^rMiiiifiiinii'M ; l : ■: i.i'l", :U:!.-;H: ■■•■ ■'■■'- ii.ii'il-ifiji'-i.!- ' ' '■■•Ni.'ir^i'V ' w\<< Ui^i.,"'.-' ■• • ■ . ^IHi!1!!:;::-.'----'"-.. liJ-i'ii'^iU''1 >'y.■■]''■/> ■ :.lnp;;;r.:.!::':'. ■.■!■.. ... Mm mm Wi> fifiiilffiil J* liii1-!: y«iiip: I Ifc i! W': ■[;;!?.. fill! i!(i!!i !.:i:}; ft!P(!j!ii!;«iiii:i!ii':!= ; ipiil;l!«;;iiifi!!i!ii:i Kj. Jiff US- U»! u'., , ■ NATIONAL LIBRARY OF MEDICINE NLfl DD5blflll D NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Serrice NLM005618110 THE PRINCIPLES AND PRACTICE SURGERY. BY JOHN ^SHHURST,* Jr., M.D., SURGEON TO THE EPISCOPAL HOSPITAL, SURGEON TO THE CHILDREN'S HOSPITAL, ETC. ILLUSTKATED WITH FIVE HUNDRED AND THIRTY-THREE ENGRAVINGS ON WOOD. PHILADELPHIA: H E E" B Y O. LEA. 1871. )N6 ?B1I Entered according to the Act of Congress, in the year 1871, by HENRY C. LEA, in the Office of the Librarian of Congress. All rights reserved. 1 PHILADELPHIA: COLL IK S, PRINTER, 705 Jayne Street. TO JOSEPH CARSON, M.D., PROFESSOR OF MATERIA MEDICA AND PHARMACY IN THE UNIVERSITY OF PENNSYLVANIA, AS A MARK BOTH OF RESPECT FOR HIS DISTINGUISHED PROFESSIONAL AND SCIENTIFIC ACQUIREMENTS, AND OF GRATITUDE FOR MANY PERSONAL KINDNESSES, %\U MttttU IS MOST CORDIALLY AND AFFECTIONATELY > INSCRIBED, » BY HIS FRIEND AND PUPIL, THE AUTHOR. PREFACE. The object of this work is, as its title indicates, to furnish, in as concise a manner as may be compatible with clearness, a condensed but comprehensive description of the Modes of Practice now gene- rally employed in the treatment of Surgical Affections, with a plain exposition of the Principles upon which those modes of practice are based. In carrying out this object to the best of his ability, it has been, of course, necessary for the author to have regard to the doctrines of the Masters of the Profession, in both this and other countries, and he has not hesitated, therefore, to avail himself freely of the labors both of systematic writers and of those who have illustrated particular departments of surgery by monographs and special treatises. At the same time, the author would claim for his work the character of being something more than a mere compilation from the writings of others. The modes of treatment recommended, are, in almost all instances, such as have proved satisfactory in his own hands, in the course of a not very limited Hospital experience, while, in every case, the principles inculcated and the practice recommended have been conscientiously considered and reflected upon, with such deliberation and attentive care as it has been in his power to bestow. In making use of the work of other writers, the author has endeavored, in every instance, to give due credit for what he has borrowed, and, should the proper acknowledgment have been in any case unfortunately neglected, hereby begs the reader to believe that the omission has been entirely unintentional. VI PREFACE. The general arrangement of this volume will be found to corre- spond in most respects with that adopted in Mr. Erichsen's Treatise, and in Mr. Holmes's System of Surgery, while many of the wood- cuts will be recognized as having previously appeared in the works of other writers. The original illustrations have been engraved by Mr. Sebald—from photographs, chiefly executed by Rhodes—or from drawings, many of which are by the skilful pencil of Dr. Nancrede. The representations of surgical instruments and appa- ratus, are, in numerous instances, from cuts furnished by Mr. Gremrig, Mr. Kolbe, and other well-known manufacturers. The author's thanks are especially due to Dr. "Wm. F. Norris, for valuable advice as to several portions of the volume, particularly the chapters on the Diseases of the Eye and Ear; to Dr. C. B. Nancrede, for original drawings; to Prof. Bigelow, of Boston, for permission to use several illustrations from his classical work on Dislocations and Fractures of the Hip; to Dr. Isaac Hays, and to Dr. Samuel Lewis, for the use of books; and to Dr. "W". S. Forbes, and to Dr. R. A. Cleemann, for photographs. 2000 "West DeLancey Place, Philadelphia, November, 1871. Note.—The author would acknowledge his particular indebtedness to the publi- cations of the Surgeon-General's Office, at Washington, D. C; to the systematic treatises of Erichsen, Gross, Fergnsson, and Druitt; to the excellent works of Bumstead, Hamilton, Paget, Wells, Laurence, Lawson, Toynbee, Thompson, Thomas, and Holmes; and especially to the various monographs embraced in the invaluable System of Surgery, edited by the last-named gentleman. Illustrations have been borrowed from the works of Ashton, Barwell, Bigelow, Bumstead, Curling, Druitt, Erichsen, Fergusson, Gray, Hamilton, Laurence, Liston, Mackenzie, Miller, Pirrie, Roberts, Simpson, Skey, Thomas, Thompson, Toynbee, Wales, Wells, and some others. CONTENTS. Preface ...... List op Illustrations ... Introductory Remarks ..... CHAPTER I. INFLAMMATION. Pathology of inflammation ..... Clinical view of inflammation ..... Ulceration . . . . . • . Granulation and cicatrization .... Gangrene ....... Inflammatory fever ..... CHAPTER II. TREATMENT OF INFLAMMATION. Prophylactic treatment ...... Curative treatment ...... Hygienic ....... Local ....... Constitutional ...... CHAPTER III. OPERATIONS IN GENERAL ; AN/ESTHETICS. Qualifications of surgeon ...... Circumstances influencing results of operations Causes of death after operations .... Preparation of patients for operation .... Mode of conducting an operation .... Anaesthetics ....... CHAPTER IV. MINOR SURGERY. Bandaging ....... Revulsion and counter-irritation .... Hypodermic injection ...... Vlll CONTENTS. Vaccination Bloodletting Transfusion of blood CHAPTER V. AMPUTATIONS. History of amputation . Conditions requiring amputation Instruments used in amputation Different modes of amputating . Structure and affections of stumps Mortality after amputation Causes of death after amputation CHAPTER YI. SPECIAL AMPUTATIONS Hand Wrist and forearm Elbow and upper arm Shoulder . Above shoulder Foot and ankle Leg Knee Thigh Hip SURGICAL INJURIES. CHAPTER VII. EFFECTS OF INJURIES IN GENERAL; WOUNDS. Constitutional effects of injuries Shock Traumatic delirium Local effects of injuries . Contusions Strangulation of parts Wounds . Incised wounds . Lacerated and contused ay Punctured wounds Poisoned wounds . ounds CHAPTER VIII GUNSHOT WOUNDS. Gunshot wounds ...... Amputation and excision in gunshot injuries . CONTENTS. IX CHAPTER IX. INJURIES OF BLOODVESSELS. Injuries of veins .... Entrance of air into veins Injuries Of arteries Hemorrhagic diathesis Process of nature in arresting hemorrhage Treatment of arterial hemorrhage Collateral circulation Secondary hemorrhage Gangrene from arterial occlusio Traumatic aneurism Arterio-venous wounds . Lines of incision for ligation of special arteries PAGE 169 171 173 175 176 177 191 192 194 195 196 197 CHAPTER X. INJURIES OF NERVES, MUSCLES AND TENDONS, LYMPHATICS, BURS^E, BONES, AND JOINTS. Nerves .......... 205 Muscles and tendons ........ 206 Lymphatics . . . . . • • • .207 Bursas .......... 208 Bones..........208 Joints .......... 208 CHAPTER XI. FRACTURES. Causes of fracture Varieties .... Separation of epiphyses . Symptoms Diagnosis .... Process of union in fractured bones Treatment of fractures . Simple Complicated Compound. Ununited fracture and false joint 212 214 216 217 220 221 223 223 227 228 233 CHAPTER XII. SPECIAL FRACTURES. Bones of face Lower jaw Ribs Sternum . Pelvis 237 238 239 241 242 X CONTENTS. Sacrum and coccyx Clavicle . Scapula Humerus . Olecranon and coronoid Bones of forearm Radius Bones of hand Femur Patella Tibia and fibula Bones of foot process CHAPTER XIII. DISLOCATIONS. Dislocations in general Special dislocations Lower jaw Ribs, sternum, and pelvis Clavicle and scapula Shoulder . Elbow Wrist Hand Hip Patella and knee Ankle Foot CHAPTER XIY. EFFECTS OF HEAT AND COLD. Burns and scalds Operations for contracted cicatrices Effects of cold; pernio or chilblain Frost-bite .... CHAPTER XV. INJURIES OF THE HEAD Injuries of the scalp Concussion of the brain Compression of the brain Traumatic encephalitis . Contusion of the skull . Fracture of the skull Injuries of the cranial contents Trephining in injuries of the head CONTENTS. XI CHAPTER XVI. INJURIES OF THE BACK. Injuries of the spinal cord Concussion from indirect causes Injuries of the vertebral column Treatment of spinal injuries Trephining in spinal injuries railway spine CHAPTER XVII. INJURIES OF THE FACE AND NECK. Injuries of the face Injuries of the neck Injuries of the larynx and trachea Surgical treatment of apnea Injuries of the oesophagus PAttE 322 328 329 334 335 337 341 343 348 353 CHAPTER XVIII. INJURIES OF THE CHEST. Contusions of the chest . Wounds of the chest Injuries of the diaphragm CHAPTER XIX. INJURIES OF THE ABDOMEN AND PELVIS. Contusions of the abdomen Wounds of the abdomen Abdominal fistula? Injuries of pelvic organs Injuries of male genitals Injuries of female genitals 355 356 364 365 368 371 373 374 376 SURGICAL DISEASES. CHAPTER XX. DISEASES RESULTING FROM INFLAMMATION. Abscesses Ulcers .... Gangrene and gangrenous diseases CHAPTER XXI. ERYSIPELAS. Varieties of erysipelas . Causes and symptoms Diagnosis Treatment 378 383 387 396 397 398 399 xu CONTEXTS. CHAPTER XXII. PYiEMIA. Nomenclature and pathology of pyaemia .... Morbid anatomy ........ Causes ......... Symptoms and diagnosis ...... Treatment ........ CHAPTER XXIII. DIATHETIC DISEASES. Struma ......... Tubercle ........ Scrofula ........ Rickets ......... CHAPTER XXIV. VENEREAL DISEASES. GONORRHOEA AND CHANCROID. Gonorrhoea of male urethra ...... Complications ....... Balano-posthitis, or external gonorrhoea .... Gonorrhoea of female genitals ...... Ophthalmic gonorrhoea ....... Gonorrhoea of nose, mouth, and rectum .... Gonorrhceal rheumatism ...... Chancroid ........ Complications ....... Treatment ....... Primary bubo or bubon d'emblee ..... CHAPTER XXV. venereal diseases—continued. SYPHILIS. History and causes of syphilis .... Primary syphilis . . . . . Secondary syphilis ..... Tertiary syphilis . Hereditary syphilis .... Diagnosis of syphilis .... Treatment of syphilis .... CHAPTER XXVI. TUMORS. Classification of tumors Cystic tumors .... Simple or barren cysts Compound or proliferous cysts . CONTENTS. Xlll PAQE Non-malignant solid tumors and outgrowths . . 465 Malignant tumors ...... . 478 Cancer ....... . 478 Epithelioma ...... . 490 Excision of tumors ...... . 493 CHAPTER XXVII. SURGICAL DISEASES OF THE SKIN, AREOLAR TISSUE, LYMPHATICS, MUSCLES, TENDONS, AND BURS.E. Skin and appendages ..... . 494 Areolar tissue ...... . 500 Lymphatic system ..... . 500 Muscles and tendons ..... . 501 Bursas ....... . 505 Neuritis Neuroma . Neuralgia Tetanus CHAPTER XXVIII. SURGICAL DISEASES OF THE NERVOUS SYSTEM. 507 508 509 511 CHAPTER XXIX. SURGICAL DISEASES OF THE VASCULAR SYSTEM. Diseases of veins 515 Vascular tumors or angeiomata . 519 Diseases of arteries 523 Aneurism 526 Treatment of aneurism in general 534 Treatment of particular aneurisms 545 Aortic and innominate 546 Carotid and subclavian 547 Axillary and brachial 549 Abdominal and inguinal . 550 Gluteal and sciatic 551 Iliac, femoral, and popliteal 552 CHAPTER XXX. DISEASES OF BONE. Periostitis Osteitis Osteo-myelitis Abscess in bone Caries Necrosis . Osteomalacia Tubercle and scrofula Tumors in bone . 553 554 556 558 560 562 566 567 568 xiv CONTENTS. CHAPTER XXXI. DISEASES OF JOINTS. Synovitis . Hydrarthrosis Pyarthrosis Arthritis . Hip disease Sacro-iliac disease Rheumatoid arthritis Anchylosis Loose cartilages in joints Articular neuralgia CHAPTER XXXII. EXCISIONS Excision in general Special excisions . Scapula Clavicle and ribs Shoulder-joint Humerus . Elbow-joint Radius and ulna Wrist-joint Bones of hand Hip-joint . Knee-joint Bones of leg and ankle-joint Bones of foot CHAPTER XXXIII. ORTHOPAEDIC SURGERY. Wry-neck Lateral curvature of the spine . Deformities of the upper extremity Deformities of the lower extremity Club-foot . CHAPTER XXXIV. DISEASES OF THE HEAD AND SPINE. Diseases of the scalp, skull, and dura mater Encephalocele and meningocele Paracentesis capitis Spina bifida .... Antero-posterior curvature of the spine Arthritis and necrosis of the spine 626 627 628 628 629 634 CONTENTS. XV CHAPTER XXXV. DISEASES OF THE EYE. Diseases of the conjunctiva ... Diseases of the cornea, sclerotic, and ciliary body Diseases of the iris Operations on the iris Cataract . Operations for cataract . Diseases of the vitreous humor, choroid, retina and amblyopia) Accommodation and refraction Glaucoma Affections of the entire eyeball Strabismus Diseases of the eyelids . Diseases of the lachrymal apparatus Diseases of the orbit and optic papilla (amaurosis CHAPTER XXXVI. DISEASES OF THE EAR. Diseases of the auricle . Diseases of the external meatus Diseases of the membrana tympani Diseases of the Eustachian tube Diseases of the cavity of the tympanum Various affections of the ear CHAPTER XXXVII. DISEASES OF THE FACE AND NECK. Diseases of the nose .... Rhinoplasty ..... Diseases of the frontal sinuses, and of the cheeks Diseases of the lips .... Diseases of the neck .... CHAPTER XXXVIII. DISEASES OF THE MOUTH, JAWS, AND THROAT. Diseases of the tongue . Diseases of the jaws Diseases of the palate Diseases of the tonsils Diseases of the pharynx and oesophagus Diseases of the air-passages XVI CONTENTS. CHAPTER XXXIX DISEASES OF THE BREAST. Hypertrophy of the breast and galactocele Diseases of the nipple and areola Mammitis and mammary abscess Tumors of the breast Excision of the breast Diseases of the mammary gland in the male CHAPTER XL Causes of hernia . Nomenclature Structure of a hernia Symptoms of hernia in general Treatment of reducible hernia Radical cure of hernia Irreducible hernia Inflamed and incarcerated hernia Strangulated hernia The taxis . Herniotomy HERNIA. CHAPTER XL I. SPECIAL HERNIiE. Diaphragmatic and epigastric hernise Ventral and umbilical hernise Lumbar hernia Inguinal hernia . Femoral hernia Obturator hernia . Perineal, pudendal, and vaginal hernias Ischiatic hernia . CHAPTER XLII. DISEASES OF INTESTINAL CANAL. Intestinal obstruction Malformations of the anus and rectum . Stricture and tumors of the anus and rectum Rectal fistulas Fistula in ano Fissures and ulcers of the anus Hemorrhoids Prolapsus of the rectum . Inflammation of the rectal pouches Neuralgia and pruritus of the anus 787 79o 798 801 803 805 807 813 815 816 CONTENTS, XV11 CHAPTER XLIII. DISEASES OF ABDOMINAL ORGANS AND VARIOUS OPERATIONS ON THE ABDOMEN. Paracentesis abdominis . Ovarian tumors .... C cesarean section .... Nephrotomy and excision of the kidney Excision of the spleen . Treatment of abdominal abscesses, etc. PAKE 816 817 825 82.j 825 826 CHAPTER XLIV URINARY CALCULUS. Varieties of calculus Renal calculus Vesical calculus . Litholysis, or solvent treatment of stone Lithotrity. Lithotomy Recurrent calculus Urethral calculus . Prostatic calculus Calculus in women Extra-pelvic vesical calculus 828 831 832 838 839 848 864 865 866 866 868 CHAPTER XLV. DISEASES OF THE BLADDER AND PROSTATE. Malformations and malpositions of the bladder Cystitis ......... Structural diseases of the bladder ..... Hematuria ........ Paralysis and atony of the bladder; retention and incontinence of urine Inflammatory diseases of the prostate ..... Chronic hypertrophy of the prostate . . . . . Retention of urine from prostatic obstruction .... Other diseases of the prostate ...... 868 872 874 876 877 879 887 CHAPTER XLVI. DISEASES OF THE URETHRA AND URINARY FISTULA. Exploration of the urethra Malformations of the urethra Prolapsus, inflammation, and spasm of Stricture of the urethra . Urethral fever Treatment of stricture . Tumors of the urethra . Urinary fistula in the male Urinary fistula in the female 2 893 the urethra 894 896 899 900 911 912 . 914 XV111 CONTENTS. CHAPTER XLVII. diseases of the generative organs. Male Genitals. Diseases of the penis and scrotum .... Diseases of the testis ..-••• Hydrocele and hsematocele . Varicocele ..-•••• Sarcocele and tumors of the testis Functional disorders of the male generative apparatus Female Genitals. Malformations ..••••• Surgical diseases of the vulva . Surgical diseases of the vagina . Tumors of the uterus ...-•• Index . LIST OF ILLUSTRATIONS. PIG. 1. 2. 3. 4. 5. 6. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. Corpuscles and filaments in recent lymph . Fibro-plastic and fusiform cells from lymph Pus cells .... Ideal section of a granulation Sphacelus; showing line of separation Mediate irrigation ; coil prepared for use Mediate irrigation; coil applied to head Mediate irrigation ; coil applied to leg Irrigating apparatus Ward carriage Clover's chloroform apparatus Reversed spiral bandage Figure-of-8 bandage Spica bandage Four-tailed bandage Bandage of Scultetus Application of Seutin's pliers to starched bandage Starched bandage ; trap for dressing wound Corrigan's button cautery Porte-moxa Formation of a seton Different forms of cautery iron Marshall's galvanic cautery Mechanical leech Petit's tourniquet . Spanish windlass Signoroni's tourniquet Skey's tourniquet . Lister's, aorta-compressor Amputating knife . Double-edged catlin Bistoury Scalpel Small amputating saw Bone-nippers Artery-forceps Tenaculum . Reef-knot Surgical needles Amputation'of the arm; circular method Amputation of the thigh; antero-posterior flap method Amputation of the thigh; modified circular method Amputation of the leg ; Teale's method Aneurismal varix in a stump Neuromata of stump Necrosis after amputation . Amputation of a finger Amputation at metacarpophalangeal joint XX LIST OF ILLUSTRATIONS. FWJ. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 79. 80. 81. 82. 83. 84. 85. 89. 90. 91. 92. 93. 94. 95. 96. 97. 98. 99. 100. 101. 102. 103. 104. 105. 106. 107. 108. 109. 110. Amputation of the thumb Result of partial amputation of the hand Amputation at the wrist . Amputation of forearm . Amputation at the shoulder-joint; Larrey's method Result of Larrey's amputation Amputation at shoulder-joint; Dupuytren's method Amputation of great-toe, with metatarsal bone . Amputation of metatarsus (Lisfranc's and Hey's Chopart's amputation Pirogoff's amputation Bony union after Pirogoff's amputation . Syme's amputation Flap amputation of the leg Amputation at the knee-joint Amputation at the hip-joint Mounted needle, with ligature Interrupted suture Continued, or glover's suture Twisted suture .... India-rubber suture Quilled suture .... Serre-fine ..... Nelaton's probe .... Bullet forceps .... Screw extractor .... Gunshot fracture of hip . Partial excision of radius for gunshot injury Limited torsion .... Aneurism al needle Grooved director .... Exposure and division of arterial sheath . Passage of needle and ligature Acupressure; first method; raw surface . Acupressure ; first method; cutaneous surface Acupressure; second method Acupressure; third method Acupressure; fifth method Collateral circulation in thigh Varicose aneurism . Ligation of innominate artery Ligation of carotid artery Ligation of lingual artery Ligation of facial artery . Ligation of occipital artery Ligation of temporal artery Ligation of subclavian artery Ligation of brachial, radial, and ulnar arteries Ligation of common iliac artery Ligation of external iliac artery Ligation of femoral artery Ligation of popliteal artery Ligation of anterior tibial artery Ligation of posterior tibial artery Apparatus for ruptured tendo Achillis . Partial fracture .... Comminuted fracture of humerus . Impacted fracture through trochanters . Gangrene from tight bandaging . Brainard's perforator for ununited fracture Gaillard's instrument for ununited fracture Barton's bandage for fractured jaw methods) LIST OF ILLUSTRATIONS. XXI FICr. 111. Attachments of outer end of clavicle; showing branches of coraco clavicular ligament . . 112. Oblique fracture of clavicle 113. Fox's apparatus for fractured clavicle 114. Velpeau's bandage 115. Fracture of the surgical neck of the humerus 116. Dressing for fracture of the surgical neck of the humerus 117. Fracture at the base of the condyles of the humerus 118. Fracture at the base of, and between the condyles of the humerus 119. Physick's elbow splints ■ . 120. Fracture of the radius near its lower end 121. Nelaton's splint for fracture of the radius 122. Bond's splint for fracture of the radius .... 123. Intra-capsular fracture of neck of femur .... 124. Liston's long splint for fractured thigh .... 125. Adhesive plaster stirrup for making extension in fractures of lower extremity ....... 126. Weight extension with long splints for treatment of fractured thigh 127. N. R. Smith's anterior splint for fractured thigh . 128. Compound fracture of thigh ; treatment by bracketed long splint 129. Fracture of patella ...... 130. Hamilton's dressing for fractured patella .... 131, 132. Separation of upper epiphysis of tibia 133. Fracture-box, with movable sides .... 134. Salter's cradle . . . 135. Wire rack for fracture of the leg ..... 136. Clove-hitch ....... 137. Dislocation of lower jaw ...... 138. Dislocation of acromial end of clavicle .... 139. Dislocation of humerus into axilla .... 140. Subcoracoid luxation of humerus ..... 141. Reduction of dislocated shoulder by foot in axilla 142. Reduction of dislocated shoulder by White's and Mothe's method 143. Forward dislocation of head of radius .... 144. Dislocation of elbow backwards ..... 145. Reduction of dislocated elbow ..... 146. Levis's instrument for reducing dislocations of thumb and finger 147. Anatomy of the hip-joint; the Y ligament 148. Backward dislocation of hip ..... 149. Reduction of backward dislocation by manipulation 150. Downward dislocation of hip ..... 151. Reduction of downward dislocation by manipulation 152. Application of rope windlass for backward dislocation of hip . 153. Bloxam's dislocation tourniquet applied for downward dislocation of hip 154. Pulleys applied for upward dislocation of hip 155. Angular extension in old dislocation of hip 156. Teale's operation for contraction of lower lip 157, 158. Severe scalp wound . 159. Hey's saw 160. Common trephine . 161. Different forms of elevator 162. Conical trephine . 163. Bilateral dislocation of cervical vertebra 164. Bony union of fractured vertebrae 165, 166. Fracture of vertebral body and unilateral dislocation of a lumbar vertebra ..... 167. Oblique illumination .... 168. Eversion of upper lid for detection of foreign bodies 169. Ear-scoop ...... 170. Application of the laryngoscope . 171. Throat>mirror used in laryngoscopy 172. Gross's tracheal forceps . 2* XX11 LIST OF ILLUSTRATIONS. FIG. 173. Operation of tracheotomy 174. Tracheal tube 175. Burge's oesophageal forceps 176. Horsehair probang, or Ramoneur 177. Paracentesis thoracis 178. Ventral hernia, following rupture of abdominal muscles 179. Lembert's suture .... 180. Gely's suture .... 181. Dupuytren's enterotome . 182. Enterotome applied 183. Brown's operation for ruptured perineum 184. Suction-trocar .... 185. Introduction of drainage-tube with forked probe 186. Strapping an ulcer 187. Diagram illustrating processes of thrombosis and embolism 188. Scrofulous ulcer of leg 189. Gonorrhceal epididymitis . 190, 191. Ophthalmic gonorrhoea 192. Mucous patches .... 193. Syphilitic rupia .... 194. Syphilitic temporary teeth 195. Syphilitic permanent teeth 196. Maury's fumigating apparatus 197. Contents of cutaneous proliferous cyst 198. Ulcerated sebaceous tumor 199. Structure of a fatty tumor 200. Fatty tumor, showing lobated appearance 201. Pendulous fibro-cellular outgrowth 202. Structure of fibrous tumor 203. Structure of fibro-muscular tumor 204. Structure of enchondroma 205. Large enchondroma of scapula . 206. Multiple enchondromata of finger 207. Myeloid and spindle-shaped cells . 208. Structure of myeloid or fibro-plastic tumor 209. Cancellous exostosis of femur 210. Ivory-like exostoses of skull 211. Painful subcutaneous tubercle 212. Section of scirrhous breast 213. Scirrhus of breast, in stage of ulceration 214. Secondary growths of scirrhus 215. Microscopic appearances of scirrhus 216. Medullary cancer in stage of ulceration . 217. Microscopic appearances of medullary cancer 218. Parent cells from medullary cancer 219. Microscopic appearances of melanoid cancer 220. Haematoid cancer of breast 221. Microscopic appearances of colloid cancer 222. Epithelioma of lower lip . 223. Epitheliomatous ulcer of cheek . 224. Cells from epithelioma of lower lip 225. Concentric globes of epithelioma 226. ficraseur ..... 227. Elliptical incision for removal of tumors . 228. Double S incision for removal of tumors . 229. Warts around the anus 230. Malignant onychia 231. Toe-nail ulcer 232. Hypertrophy of toe-nail . 233. Malignant warty ulcer of the leg 234. Rodent ulcer 235. Phagedenic lupous ulcer . LIST OF ILLUSTRATIONS. XX111 FIG. 236. Elephantiasis Arabum in lower extremity 237. Felon...... 238. Compound ganglion 239. Enlarged bursa over the patella; housemaid's knee 240. Formation of seton with trocar and canula 241. Bunion ...... 242. Apparatus for treatment of bunion 243. Section of a neuroma .... 244. Application of pins to varicose veins 245. Aneurism by anastomosis .... 246. Aneurism by anastomosis of a parietal bone 247. Naevus; application of quadruple ligature 248. Diagram of tied naevus .... 249. Diagram of ligature of flat and elongated nsevus 250. Diagram of tied flat and elongated naevus 251. Fatty degeneration in inner arterial coat 252. Fatty granules, etc., from atheromatous deposits in aorta 253. Atheromatous ulcer of aorta 254. Large fusiform aneurism of aorta bursting into pericard: 255. Sacculated aneurism of aorta 256. Section of aneurism undergoing spontaneous cure 257. Perforation of ribs by aortic aneurism 258. Aneurism of innominate artery . 259. Stellate rupture of aortic aneurism into pericardium 260. Diagram of Anel's operation 261. Diagram of Hunter's operation . 262. Obliteration of femoral vein by inguinal aneurism 263. Diagram of Brasdor's operation . 264. Diagram of Wardrop's operation . 265. Carte's compressor for the groin . 266. Gibbons's modification of Charriere's compressor 267. Osteoporosis of femur .... 268. Sclerosis and eburnation of femur 269. Abscess in head of tibia .... 270. Caries . . . . ... 271. Gouge-forceps . . . 272. Burr-head drill ..... 273. Central necrosis; new bone with cloacae . 274. Sequestrum forceps . ' . 275. Necrosis of femur, following gunshot fracture 276. Senile atrophy of neck of thigh-bone 277. Scrofulous osteitis . .... 278. Medullary cancer of humerus 279. Gelatinous arthritis of elbow 280. Arthritis of knee-joint in advanced stage 281. Barwell's splint for continuous extension. 282. Deformity in second stage of hip disease . 283. Deformity in third stage of hip disease . 284. Excised head and neck of femur, showing change in shape of bone in third stage of hip disease 285. Perforation of pelvic bones in acetabular coxalgia 286. Deformity from double hip disease 287. Davis's splint for hip disease 288. Sayre's splint for hip disease 289. Agnew's splint for hip disease 290. Head of femur in rheumatoid arthritis . 291. Synostosis of hip-joint .... 292. Anchylosis of knee-joint in position of over-extension 293. Chronic arthritis of knee-joint, with partial anchylosis in bad position 294. Barwell's splint for continuous extension in anchylosis of knee 295. Bigg's apparatus for contraction of the knee 296. Trochlea of humerus, with loose cartilages XXIV LIST OF ILLUSTRATIONS. FIG. 297. Fergusson's lion-jawed forceps 298. Butcher's saw 299. Chain saw . ... 300. Butcher's knife-bladed forceps 301. Excision of shoulder-joint 302, 303. Excised extremities of humerus and ulna . 304. Excision of elbow-joint .... 305. Arm after excision of elbow-joint 306. Diagram of Lister's method of excising wrist-joint 307. Splint for after-treatment of excision of wrist-joint 308. Diagram of Heyfelder's method of excising hip-joint. 309. Excised head and neck of femur . 310. Result of hip-joint excision 311, 312. Excised extremities of femur and tibia 313. Excision of knee-joint .... 314. Price's splint for excision of knee-joint . 315. Bracketed splint for excision of knee-joint 316, 317. Result of excision of knee-joint 318. Excision of os calcis .... 319. Tenotome ...... 320. Lateral curvature of spine 321. Apparatus for knock-knee 322. Talipes equinus ..... 323. Talipes varus ..... 324. Varus shoe, with jointed sole-plate 325. Talipes calcaneus ..... 326. Talipes valgus ..... 327. Spina bifida ..... 328. Antero-posterior curvature of spine 329. Caries of the vertebrae .... 330. Granular lids ..... 331. Pterygium ..... 332. Pannus ...... 333. Paracentesis cornea? .... 334. Prolapse of the iris .... 335. Abscission of staphyloma 336. Critchett's operation for staphyloma 337. Iritis; showing ciliary zone of sub-conjunctival injection 338. Lance-shaped iridectomy knife 339. Curved iris forceps .... 340. Liebreich's bandage .... 341. Tyrrell's hook ..... 342. Iridodesis ...... 343. Canula forceps ..... 344. Spatula hook ..... 345. Flap extraction of cataract 346. Cystotome and curette .... 347. Traction spoons ..... 348. Von Graefe's cataract knife 349, 350. Diagram of Von Graefe's operation for cataract 351. Von Graefe's hook .... 352. Bowman's stop-needle .... 353. Hays's knife-needle .... 354. Canula scissors . . . . 355. Liebreich's portable ophthalmoscope 356. Use of the'ophthalmoscope 357. Galezowski's strabismometer 358. Strabismus hook ..... 359. Snellen's forceps ..... 360. Entropion forceps .... 361 362. Adams's operation for ectropion 363.' Symblepharon ..... LIST OF ILLUSTRATIONS. XXV FIG. 364. Bowman's canaliculus knife 365. Toynbee's ear speculum . 366. Wilde's snare for aural polypus . 367, 368. Forceps for aural polypus 369. Politzer's method of inflating the tympanum 370. Toynbee's artificial membrana tympani . 371. Application of the otoscope 372. Catheter for Eustachian tube 373. Siegle's pneumatic speculum 374. Lipoma ..... 375. Plugging the nostrils with Bellocq's sound 376. Gooch's double canula 377. Rhinoplasty by Indian method . 378. Pancoast's tongue and groove suture 379. Diagram of Syme's rhinoplastic operation 380. Diagram of Burow's plastic operation 381. Formation of prolabium by Serres's method 382, 383. Serres's cheiloplastic operation, modified 384, 385. Buchanan's cheiloplastic operation . 386. Result of Syme's cheiloplastic operation 387, 388. Operation for restoration of upper lip and angle of mouth 389. Ordinary operation for harelip 390. Cheek-compressor for harelip 391. Malgaigne's operation for harelip 392. Double harelip, with projecting intermaxillary portion 393. Macrostoma ..... 394. Bronchocele ..... 395. Tumor of parotid region .... 396. Ranula, between floor of mouth and mylo-hyoid muscles 397. Exposure of tongue for excision . 398. Regnoli's mode of exposing tongue 399. Removal of tongue by division of lower jaw and Ecraseur 400. Epulis of lower jaw 401. Encephaloid of antrum 402-. Excision of upper jaw . 403. Disarticulation of lower jaw 404. Whitehead's gag and tongue-depressor 405. Sedillot's operation for staphyloraphy 406. Forceps-scissors for cutting uvula 407. Fahnestock's tonsillotome 408. Pharyngotome 409. Stricture, of the oesophagus 410. Epithelioma of larynx 411. Gibb's laryngeal ecraseur . 412. Simple hypertrophy of breast 413. Strapping the breast 414. Sero-cystic sarcoma of breast 415. Glandular tumor of breast 416. Excision of the breast 417. Hydrocele of hernial sac . 418. Scrotal hernia in a child . 419. Strangulated hernia ; stricture in neck of sac 420. Strangulated hernia ; gangrene of intestine 421. Herniotomy; searching for seat of stricture 422. Hernia-knife .... 423. Oblique and direct inguinal herniae 424. Hernia into vaginal process of peritoneum 425. Hernia into funicular portion of vaginal process 426. Common inguino-scrotal hernia 427. Encysted hernia .... 428. Wutzer's apparatus for radical cure of hernia 429. Agnew's instrument for radical cure of hernia XXVI LIST OF ILLUSTRATIONS. rectum FIG. 430. Incision for strangulated inguinal hernia 431. Femoral hernia .... 432. Incision for strangulated femoral hernia . 433. Internal strangulation by a diverticulum 434. Incision in left lumbar colotomy 435. Imperforate anus . 436. Imperforate rectum 437. Fibrous stricture of rectum 438. Malignant stricture of rectum 439. Rectal speculum . 440. Protruding hemorrhoids . 441. Ring forceps for piles 442. Smith's clamp for piles 443. Bushe's needle and needle-carrier 444. Partial prolapsus of rectum 445. Section of complete prolapsus of 446. Anal truss 447. Tapping the abdomen 448. Sims's uterine probe 449. Siphon trocar 450. Spencer Wells's trocar and canula 451. Spencer Wells's clamp 452. Sims's catheter 453. Uric acid . 454. Uric acid calculus 455. Oxalate of lime . 456. Mulberry calculus 457. Triple phosphate . 458. Cystine calculus . 459. Alternating calculus 460. Sound for examining bladder 461. Thompson's hollow sound, with slide and scale 462. Sounding for stone behind prostate 463. Sounding for stone above pubes . 464. Sounding for encysted calculus . 465. Weiss and Thompson's improved lithotrite 466. Fergusson's lithotrite 467. Introduction of the lithotrite 468. Position of lithotrite in crushing the stone 469. Clover's lithotritic injection apparatus 470. Urethral forceps . 471. Lithotomy staff 472. lithotomy forceps 473. Lithotomy scoop . 474. Tube for plugging wound in lithotomy 475. Position of patient and incision in lateral lithotomy 476. Deep incision in lithotomy 477. Direction of forceps in extracting stone 478. Position of finger and scoop in extracting stone 479. Physick's cutting gorget . 480. Frere CSme's lithotome cache 481. Dupuytren's lithotome cach6 482. Incision of prostate in bilateral lithotomy 483. Urethral dilator . 484. Female staff 485 486, 487. Plastic operation for extroversion of bladder 488! Polypoid tumors of the bladder . 489. Enlarged median lobe of prostate 490! Hypertrophied bladder and prostate 491. Prostatic catheters 492. Squire's vertebrated prostatic catheter 493 Catheterization in enlarged prostate LIST OF ILLUSTRATIONS. XXV11 FIG. 494. Puncture of bladder through rectum, and above pubes 495. French flexible bougie and catheter 496. Bougies a boule .... 497. Introduction of the catheter 498. Desormeaux's endoscope . 499. Stricture of urethra at sub-pubic curvature 500. Stricture of urethra near orifice . 501. False passages .... 502. Thompson's stricture expander . 503. Holt's instrument for splitting stricture . 504. Civiale's urethrotome 505. Syme's staff for external division of stricture 506. Stafford's lancetted catheter 507. Papillary tumor of female urethra 508. Urinary fistulae in the male 509. Urethroplasty by Dieffenbach's method . 510. Urethroplasty by Le Gros Clark's method 511. Duck-billed speculum for the vagina 512. Emmet's vaginal speculum 513. Knife for vesico-vaginal fistula 514. Introduction of sutures for vesico-vaginal fistula 515. Coghill's wire twister 516. Bozeman's button suture 517. Operation for vesico-uterine fistula 518. Transverse obliteration of the vagina 519. Circumcision .... 520. Reduction of paraphimosis 521. Hypertrophy or elephantiasis of scrotum 522. Epithelioma of the penis 523. Epithelioma of the scrotum 524. Strapping the testicle . 525. Hernia of the testicle 526. Tapping for hydrocele 527. Vidal's operation for varicocele . 528. Cystic sarcocele .... 529. Division of spermatic cord in castration . 530. Cylindrical speculum for the vagina 531. Cusco's vaginal speculum 532. Fibro-cellular uterine polypus protruding from vulva 533. Amputation of the cervix uteri with the ecraseur ADDENDA ET CORRIGENDA. Page 155, in seventhline from top, after "cupping-glass," insert " the application of dilute carbolic acid." Page 191, in eighth line from foot, for "Porter," read " Stokes." " 358, in the third line from top, for "emphysema,'" read "empyema.'''' " 451, in fifth line from foot, for "p. 437," read "p. 439." " 465, in twenty-ninth line from top, after "ovaries," insert "and testes." " 712, in tenth line from top, for " caused," read " covered." THE PRINCIPLES AND PRACTICE OF SURGERY. The word Surgery, or Chirurgery as it was formerly" written, is derived from the two Greek words #fip (the hand) and *pyo»< (a work). In its earliest and narrowest signification, it was therefore limited to certain manual operations, which we accordingly find that the surgeon was for- merly in the habit of executing under the direction and guidance of the physician, who was considered as occupying a higher grade in the pro- fession, and who took entire charge of, and was responsible for, the man- agement of the constitutional condition of the patient. In the modern application of the term, however, surgery embraces a far wider field ; and hence the division adopted in France, into internal and external pathology, is in some respects preferable to that into medicine and sur- gery, which is habitually used in England and in this country. The consideration of surgical affections naturally divides itself into the discussion of (1) Surgical Injuries, and (2) Surgical Diseases. These will therefore form the topics of the principal divisions of this work. As, however, the condition known as Inflammation, or the In- flammatory Process, with the corresponding constitutional state desig- nated by the term Inflammatory Fever, are common attendants upon both classes of affections, it will be convenient to consider these before entering upon the two great divisions of the subject; more especially as without definite ideas as to the course and treatment of inflamma- tion, the student can scarcely hope to pursue his further investigations into surgical science with either pleasure or profit. It will likewise be convenient, in this introductory portion of the work, to consider the subjects of operations in general and the use of anaes- thetics, together with the lesser manipulations usually classed as belong- ing to minor surgery, and the vai'ious amputations, which are applicable to so many different lesions and morbid conditions, as to entitle them to be looked upon rather as a part of general than of special surgery. CHAPTER I. INFLAMMATION. Inflammation, or the Inflammatory Process, may be considered from two points of view: the Pathological and the Clinical. In discussing it clinically, its causes, symptoms, course, terminations, and treatment will 3 34 INFLAMMATION. be successively dwelt upon ; but it will be better, in the first place, to examine briefly into what is known of its nature and pathological phe- nomena. Pathology op Inflammation. Inflammation was formerly considered as a disease, an entity, a some- thin^ superadded to the natural condition of the part. This view is now°almost universally abandoned, and authors, though differing as to the proper explanation to be given of many of the phenomena of inflam- mation, are, I think, generally agreed that those phenomena are mere modifications of the phenomena of natural textural life. These changes, which are always due to the action of an irritant, no matter whence de- rived, may be observed as affecting the phenomena respectively of func- tion, nutrition, and formation, and in each the changes are primarily in the direction of excess. Changes of Function.—Thus, as regards function, the first effect of an irritant upon muscular fibre is to produce contraction (an increased functional activity), followed by nutritive changes, and, possibly, the formation of new material, pus, etc. Irritation involving a nerve of special sense will similarly be attended in the first place by functional disturbances, flashes of light and photophobia in the case of the optic, and tinnitus aurium and increased sensitiveness to sound in the case of the auditory nerve. The application of an irritant to a secreting gland will, in the same way, cause excessive functional activity, manifested by increased secretion. The increased functional activity may in any case be succeeded by perverted or diminished action. Changes of Nutrition.—The consideration of the modified phe- nomena of nutrition which are due to inflammation, brings up the ques- tion of the share taken by the blood and its containing vessels in the process under discussion. That the quantity of blood in an inflamed part is increased, and that the size of its bloodvessels is greater than in corresponding uninfiamed structures, was so* patent as to have been the subject of early observation; and hence it is not surprising that, iu the absence of more accurate investigations, all the phenomena of in- flammation should have been attributed (as was the case for many years) to what was called an " altered activity of the bloodvessels." Modern pathology has, however, shown that nutrition and formation are due to cell-action, and that the office of the bloodvessels is purely that of a servant, to bring new material and to remove that which is effete and useless. Hypersemia.—While, as has been said, the quantity of blood is in- creased in a part which is inflamed, or in which the inflammatory pro- cess is in progress, this increase, or Hijpersemia, is not necessarily a part of, nor in any way connected with, inflammation. A simple reference to any of the erectile tissues of the body will suffice to illustrate this point. Again, there may be a true hyperemia, dependent on purely mechanical causes, such as the application of a tight bandage, the pres- sure of a tumor preventing the return of venous blood from a part, or a diminution of the natural elasticity of the walls of the bloodvessels themselves, not an unfrequent coincidence of the general loss of tone which usually attends advancing age. These forms of hyperemia, which are always passive and due to mechanical causes, are properly desio-- CHANGES OF NUTRITION. 35 nated by the term Congestion, which might well be reserved for these conditions ; the form of hypersemia which many writers have called Active Congestion being more conveniently distinguished by the name Fluxion (a term used by Billroth) or Determination. Determination is essentially an active condition. It is, as we shall hereafter see, clinically speaking, the first stage of Inflammation. A familiar example is the active hyperemia of the mammary gland which is apt to occur a few days after parturition, and which is sometimes with difficulty prevented from running into absolute inflammation of the part. While determination has been spoken of as an active condition, it is not to be looked upon as a cause of the nutritive and other changes which accompany it in the inflammatory process, but rather as caused by them. As Mr. Simon has well put it, "A part does not inflame be- cause it receives more blood. It receives more blood because it is in- flamed." The vessels of an inflamed part are then enlarged. Whether this en- largement is primary or not, has been doubted- As we have seen that the first effect of an irritant is to increase functional activity, and as contraction is the manifestation of functional activity proper to the ves- sels in a state of health, it would be natural to infer that the primary effect would be contraction. As a matter of observation, it is found that the condition varies according to the nature of the irritant employed. There are, however, as justly remarked by Dr. Packard, two elements which must not be ignored in coming to an opinion as to these appa- rently contradictory results: these are, (l)the reflex influence of the ner- vous system upon the calibre of the vessels, which cannot but be excited by the application of irritants, whether mechanical or chemical, to the nerve filaments in proximity to the arteries subjected to experiment; and (2) in the case of the application of liquid irritants, the laws of endosmosis which must be supposed to affect to a certain extent the size of the vessels under observation. When the inflammatory process is established in a part, there can be no question that its vessels are dilated. This fact, as regards the arteries and veins, has been a matter of common observation from the days of Hunter to our own, and as regards the capillaries it has been repeatedly established by the now classical microscopic observations of the web of the frog's foot or bat's wing. Not only are the arteries dilated in inflammation, thus admit- ting more blood, but they become elongated and tortuous; they have also been observed to become pouched at points, presenting at different parts of their walls aneurismal or fusifoVm dilations. The red corpus- cles of the blood likewise find their way into vessels which in the unin- flamed state were too narrow to admit of their entrance. More blood is brought to an inflamed part than the same part would receive in health, and more blood is likewise carried through it when inflamed than when health}'. This was shown by an experiment of Law- rence, drawing blood from both arms of a patient who had a whitlow on one hand and not on the other. With regard to the immediate cause of the hyperemia of inflammation, it would appear to be due to an increased attraction exerted by the tissues of the inflamed part upon the blood drculating within its minute vessels. This theoiy, the germ of which majr be found in the writings of Haller, seems more conso- nant with what is known of the textural changes which occur in inflam- mation than either the now exploded view of an increased activity or the vessels themselves, or the notion of a vis a tergo which would make the hyperemia due to increase of the heart's action, an increase which, 36 INFLAMMATION. as we shall see hereafter, is rather an effect than a cause of the inflam- matory process. Blood changes.—Besides the changes which are observed in the blood- vessels, in the course of inflammation, the blood itself undergoes certain alterations. . „ The red corpuscles adhere together by their flat surfaces, lorming ao-o-reo-ations or clusters, and tend to produce the stagnation which is observed in the capillary circulation under the microscope. In the later stages of inflammation, the number of red corpuscles falls considerably below the normal standard. . The white corpuscles appear to be increased in number in the blood of an inflamed part. It is, however, doubtful whether this increase be absolute or only relative, the number of red corpuscles, as has been seen, rapidly diminishing as the inflammation continues. The white corpuscles adhere to the sides of the vessels, and thus further increase the tendency to stagnation of the circulating fluid. The proportion of fibrin in the blood is notably increased in inflam- mation. It is estimated by Andral and Gavarret that its proportion may rise from 2£ in 1000 parts to 10 per 1000. The albumen and salts of the blood are somewhat reduced in amount, and the proportion of water somewhat increased by the inflammatory process. Owing to the changes in the constitution of the blood in inflammation, its mode of coagulation differs from that of blood in the normal state. The crassamentum or clot forms more slowly than in health, and is smaller and firmer in consistence. The slowness of coagulation and the increased cohesiveness of the red corpuscles allow the separation of the fibrin and white corpuscles to take place before the process of clot- ting is completed, and this gives rise to the peculiar appearance which is known as the buffy coat. This buffy or fibrinous coat is somewhat contracted and elevated at the sides, and depressed in the centre, whence the clot of inflammatory blood is said to be cupped. Other nutritive changes.—The modifications of the phenomena of nu- trition due to inflammation are not confined to the blood and blood- vessels. Important changes take place in the parenchymatous tissues, and it is indeed in these that, according to Virchow, the first manifesta- tions of the inflammatory process are to be traced. The parenchymatous tissues become swollen, the swelling being, ac- cording to Yirchow, due to the fact that the cells of the part become enlarged, through the absorption of new material; this power of taking up an increased quantity of material is, according to the doctrines of the cellular pathology, inherent in the cells themselves, and not depend- ent upon any previously established modification in the vascular or nervous state of the part. According to Billroth, however, the first step is a distention and increased pressure in the capillaries, a larger quantity of blood plasma than in the normal state thus passing into the surrounding tissues, the swelling of which is therefore only a secondary phenomenon. The nervous tissues, likewise, doubtless undergo modification in the inflammatory process, and by a form of reflex action, which it would be foreign to the scope of this work to consider, react in time upon both bloodvessels and parenchyma. The swelling of the parenchymatous tissue, which is, according to Virchow, at first scarcely distinguishable from a true hypertrophy,°and which may be conveniently designated as temporary hypertrophy, together FORMATIVE CHANGES. 37 with the accompanying vascular and nervous changes, correspond to what will be hereafter spoken of as the first stage of inflammation. Formative Changes; Lymph and Pus—The third series of changes to be noticed as due to inflammation, are the formative, consisting in the formation of the substances known to surgeons as lymph and pus. A microscopic examination of inflamed tissue, made at a period varying from a few to twenty-four hours after the commencement of the inflamma- tion, shows the part to be filled with a large number of cells, about ^Vo" of an inch in diameter, spherical or nearly so, pellucid, and colorless or grayish-white. The origin of these cells, which are commonly called lymph cells or corpuscles, and which form the corpuscular element of what is known as inflammatory lymph, cannot be said to be positively deter- mined. The doctrine which was generally received a few years ago, and which taught that the tymph corpuscles resulted from molecular aggre- gation, in a substance exuded from the bloodvessels in a fluid condition and subsequently coagulated, is now almost universally abandoned; and the two theories which at present chiefly divide the suffrages of pathologists are, (1) that which looks upon the new cellular elements as the result of proliferation1 of pre-existing cells, and (2) that which re- gards the cells of inflammatory lymph as identical with the white blood corpuscles and cells found in the lymphatic vessels, as identical, in fact, with the wandering cells which Recklinghausen has described as exist- ing in connection with the ordinary connective tissue corpuscles. These cells, in common with many others, possess a power of spontaneous movement which, from its resembling that of the amoeba, has been called amoeboid or amcebaform; they probably originate in the lymphatic sys- tem, from which they pass into the bloodvessels, wandering thence into the surrounding tissue, where they may become fixed, or whence they may wander back again and re-enter the circulation. The second theory above mentioned is commonly known as Cohnheim's. Inflammatory lymph, as ordinarily observed by the surgeon, is a yellowish or grayish- white, semi-solid substance, which is somewhat elastic and semi-trans- parent, resembling a good deal the buffy coat of an inflammatory clot. Chemically, it consists of fibrin with an admixture of oily and saline matters, while, when examined microscopically, it is found to contain fibrils2 and corpuscles (which have already been referred to), in varying proportion. The fibrillous, or as Paget calls it, fibrinous element of lymph, 1 It would appear from the observations of Virchow and others, that new may originate from previously existing cells, by one of two processes, viz., (1) division, and (2) endogenous growth or the formation of new cells within the cavity of the old. The first process, or that of simple division, is much the more common, and is that to which the term proliferation is habitually applied. The first thing observed in this process is the enlargement of the nucleolus, Avhich subsequently becomes constricted in the middle, and finally divides into two. Afterwards the nucleus, and finally the cell itself, undergo similar changes, and thus from one, two or more new cells are developed. The second process, that of endogenous cell- formation, is extremely seldom met with, and indeed the possibility of its occur- rence has been doubted by some writers. It is said sometimes to occur normally in cartilage, the supra-renal capsules, the pituitary body (Kolliker), and the thy- mus gland (Virchow); and has, according to Paget, been met with in certain encephaloid and epitheliomatous tumors. 2 Paget speaks of fibrinous and corpuscular lymph, this division corresponding pretty closely to that of Williams and others into plastic and aplastic, and to that of Rokitansky into fibrinous and croupous lymph. Inflammatory lymph is, how- ever, essentially the same under all circumstances, though the relative proportion of its constituents may vary in different cases. 38 INFLAMMATION. is, according to that author, probably exuded from the capillary blood- vessels in a fluid state, and subsequently coagulated ; that there is in inflammation an exudation from the capilla- Fig. 1. ries into the surrounding tissue, is, as we have already seen, in accordance with the doctrines of Billroth and other modern Ger- man pathologists ; and it is to this exuda- tion that the characteristic succulence of inflamed parts is due. It cannot, however, I think, be considered as established that this exudation takes any direct part in the formation of lymph. According to Billroth, during the active cell-wandering which has already been described as taking place in an inflamed part, the filamentary intercellular t substance of the connective tissue itself Corpuscles and filaments in recent , _________ , 1 ^ gradually changes to a homogeneous gela- tinous substance.1 Hence it would appear not improbable that both elements of inflammatory lymph may originate in pre-existing structures, the corpuscular from an increase in the number of wandering cells, from proliferation of the ordinary connective tissue cells, or from both sources, and the fibrinous element from a transforma- tion of the filamentary intercellular substance. Lymph is said to be absorbed, to be developed into new tissue, or to undergo various forms of degeneration. In some cases where absorption of lymph is supposed to have taken place, it is probable that the true pathological condition has been rather the temporary hypertrophy before referred to, due to the nutritive changes introduced by inflammation, without anjr lymph having been really produced. There can be no doubt, however, that lymph can actually disappear by a process which may be properly called absorption, as is not unfrequently seen in cases of iritis. When tymph is absorbed, the lymph corpuscles ma}' be gradually utilized in the normal nutrition of the part, being converted into ordinary con- nective tissue corpuscles, or may possibly resume their migratory habits and re-enter the circulation. In the development of lymph into new tissue, it passes through the fibro-cellular condition, beyond which, indeed, it frequently does not advance. It is this material which con- stitutes the adhesions, bands, etc., which are so frequently met with after the inflammatory process has subsided. Lymph that undergoes develop- ment" becomes vascular: new vessels appear in it, apparently originating from those in the surrounding tissues, and form a capillar}' network through which the circulation is carried on. It is somewhat doubtful as yet whether any production of nerve-fibres takes place in lymph that has become developed into new tissue. The lymph corpuscles during the process of development pass through the forms which have been variously designated as plastic cells, fibro-cells, fibro-plastic or caudate cells, etc. (see Fig. 2). Lymph may undergo various forms of degeneration, as the calcareous, fatty, or granular (the degenerated lymph cells forming the so-called granule or granular cells, inflammatory globules, etc.); it may become the seat of pigmentary deposits, or, when exposed to the air, may form shrivelled and horn}r masses of effete material. ' Virchow also refers to this liquefaction (as he calls it) of the intercellular substance of connective tissue, as accompanying proliferation. FORMATIVE CHANGES. 39 Fig. Fibro-plastic and fusiform cells from re- cent lymph on the pericardium. Simi- lar cells are found in granulations. Finally (a frequent change), lymph may be transformed directly into pus; the second stage of inflammation, that of lymph formation (lymphi- zation, lymphogenesis), then passing into the third stage, or that of pus formation (pyogenesis). Pus is a creamy, whitish-yellow fluid, sometimes having a greenish tinge, thick, opaque, smooth, and slightly glutinous to the touch, with a faint odor and slightly sweetish taste. It is of variable specific gravity, ranging from 1.021 to 1.042, and is neutral or slightly alkaline in its reac- tion. This description is to be understood as applying to what is called healthy or laudable pus, derived from an ordinary suppurating wound in a person of good constitution. Besides this form, surgeons speak of sanious pus (mixed or tinged with blood), ichorous pus (when it is thin and acrid), and curdy pus (when it contains cheesy-looking flakes). Muco-pus and sero-pus are of course pus mixed respectively with mucus and serum. Chemically, pus contains water, albumen, pyine (which appears to be almost identical with fibrin), fatty matters, and salts. When formed in connection with diseased bone, pus has been found to contain 2^ per cent, of the granular phosphate of lime, and Mr. Coote, in Holmes' System of Surgery, quotes from a paper by Dr. Gibb, of Canada, ten cases in which pus presented a blue1 color from containing the cyanuret of iron. Under the microscope, pus is found to consist of corpuscles floating in a homogeneous liquid (liquor jmj-is). These corpuscles, which Fig- 3. are variably termed pus corpus- cles, pus globules, or pus cells, have a diameter ranging from 3oV otn t0 3oVotn °f an inch' They usually contain several nuclei, which become apparent upon the addition of acetic acid. With these pus corpuscles there are commonly found granular matter, shreds of fibrin, and disintegrated lymph corpuscles. The above description applies to what must be called dead pus cells, the living cells possessing the power of active amoeboid movement, and corresponding in every respect with the wandering cells already referred to. It is even more difficult to speak positively of the origin of the pus cell than of that of the lymph corpuscle. In many cases (as in abscesses) the former seems to originate directly from the latter by a simple lique- faction of the gelatinous intercellular substance of lymph (p. 38); but in other instances the pus cell appears to have a different source. Virchow and other observers believe that pus corpuscles originate from rapid proliferation (luxuriation) of connective tissue and other nu- 1 Billroth and others speak of blue suppuration, resulting from the development of small vegetable organisms in the pus of a wound, but the coloring matter (which, according to Sedillot, pertains not to the pus cells but to the liquor puris, and may also be found in the serum of the blood), has been isolated in a crystalline form by Fados, who calls it pyocyanine; it is believed by Roucher and Jacquin to be of vegetable origin. Healthy pus cells. 6. Treated with acetic acid. Magnified 800 diameters 40 INFLAMMATION. cleated cells, while Cohnheim1 on the other hand maintains that the sole origin of the pus corpuscle is the migration by amoeboid movement of the" white blood corpuscle through the vascular walls.'2 Finally, Dr. Strieker and his able co-laborers, while acknowledging the origin of pus cells from both these sources, have shown that the pus corpuscles themselves divide and multiply, and that in profuse suppurations this is probably the chief mode of pus formation. [See a review of Strieker's work by Dr. J. C. Reeve, in Am. Journ. of Med. Sciences for July, 1870, p. 163.] Destructive Changes due to Inflammation.—We have now traced inflammation through its nutritive and formative changes, con- sidering in succession the temporary hypertrophy from cellular enlarge- ment, and the development of lymph and of pus, both forms of new material derived from pre-existing elements in the part inflamed. We have next to consider the inflammatory process as affecting already formed tissue in another way, namely, by degeneration or liquefaction. The application of an irritant, such as a blister, excites the inflammatory process, causing the formative changes which have been described, to occur beneath the cuticle. But the cuticle itself undergoes a change, and is thrown off as effete material, leaving a raw surface or abrasion. If the irritant act with greater intensity (as in the case of a burn), the destructive effect will be greater, the superficial tissues being thrown off in larger or smaller masses, and an ulcer being left. When the process is accomplished by the death of visible particles, it is called sloughing or gangrene, and the separated parts are called sloughs; when the particles thrown off by the destructive action are indistinguishable to the eye, the process is called ulceration. Ulceration and gangrene cannot be looked upon as essential parts of the inflammatory process; they are indeed often regarded as terminations or effects of inflamma- tion rather than as themselves parts of the process in question. Pathological Summary.—Let us now, before entering upon the clinical study of inflammation, briefly recapitulate what has been said as to its pathological phenomena. The inflammatory process, according to the degree of irritation present, modifies the phenomena of natural textural life as regards function, nutrition, and formation: in each case the modification is primarily in the direction of excess. As regards function, there is first increased activit}', followed by perversion, and eventually, perhaps, by diminution or even total abolition. The nutritive changes are shown in an altered state of the vascular system of the part (hyperemia, determination); in an altered state of the blood itself; in an altered condition of the parenchyma (temporary hypertrophy); and in a change as regards the neurotic condition, which doubtless 1 Mr. William Addison, more than a quarter of a century ago, maintained "that pus corpuscles of all kinds are altered colorless blood corpuscles • and that no new elementary particles are formed by any inflammatory or diseased action '*' [See his "Experimental Researches," etc., in Trans. Prov. 'Med and Sura Assoc vol. xi. pp. 247-2.)8.] Dr. Augustus Waller, also, in 184G, described the passaee of white blood corpuscles through the walls of the capillaries. 2 A recent writer, however, Dr. Richard Caton, concludes from observations on the frog, fish, and tadpole, that (1) the migration of white corpuscles is due not to amoebaform movements, but to congestion, as in the case of the escape of red cor puscles, and that (2) suppuration may exist without migration (."auswanderuno") and, on the other hand, migration may exist without suppuration (Journ of \,Jt and Physiol., Nov. 1870). CLINICAL VIEW OF INFLAMMATION. 41 reacts upon both vessels and parenchyma. The formative changes consist in the production of lymph and of pus. There may be also a destruction of existing tissue, resulting in its being thrown off as effete material, by the processes of ulceration or gangrene. Clinical View op Inflammation. In the clinical study of inflammation, there are to be considered suc- cessively its causes, its symptoms, its course, its terminations, and its treatment in its various stages and conditions. Causes.—The causes of inflammation may be divided into the pre- disposing, and the exciting or determining causes. The predisposing causes may be said, in general terms, to be any circumstances which impair the general health of an individual, or which render his tissues less capable of resisting the injurious influences to which they majT be subjected. Thus the various conditions of a person's life, the nature and amount of food which he consumes, the thermometric and other meteoric conditions to which he is subjected, the nature of his occupation, his having been affected with various diseases at previous periods of life, even his age, temperament, etc., may all be considered at times as causes predisposing to the development of the inflammatory process. The exciting or determining causes are usually said to be either local or con- stitutional, arising either from without or from within. I think, however, that it is more correct to look upon the determining causes of inflamma- tion as alwaj^s local or external, those which are commonly considered as acting constitutionally, being really either predisposing causes, or else properly to be termed local, though acting from within the body, and therefore, in that sense of the word, internal. The determining causes of inflammation are either mechanical or chemical. Among the mechanical causes are to be enumerated the results of external violence, blows, cuts, wounds of all kinds, fractures and dislocations (in these cases acting from within the body), the pres- ence of foreign bodies, whether introduced from without or originating internally (as a renal calculus), distention of parts, as in the cutaneous inflammation which often accompanies dropsy of the lower extremities, and compression, whether from without or from within. Among the chemical causes may be classed heat and cold, the application of acids or alkalies, poisoning of the blood by septic matters, various forms of contagion, as of gonorrhoea or chancre, etc. Certain forms of nerve lesion may probably be considered determining causes of inflammation. It has long been known that injuries or diseases of nerves may act as predisposing causes, by. diminishing the natural power of the tissues to resist the external influences to which they are constantly and unavoid- ably subjected; thus after spinal injuries, sloughing of the paralyzed parts may be produced by circumstances which would have no per- ceptible influence in a state of health, and carbuncle, a disease in the progress of which inflammation plays a prominent part, appears to be often in some way associated with diabetes, which there are strong reasons for believing to be an affection of the nervous system. Some experiments, however, recently made by Dr. Meissner, would appear to show further that certain nerve fibres exercise a peculiar " trophic" func- tion, and that a lesion of such fibres may be the immediate and deter- mining cause of an inflammatory condition of the parts supplied. [See 42 INFLAMMATION. upon this point, Holmes' Syst. of Surgery, 2d edit., vol. i. pp- 40-41, and Paget's Surgical Pathology, 3d edit., p. 36.] It is sometimes said that certain abnormal properties of the circulat- ing blood are to be considered as determining causes of inflammation; but from what has gone before, I think it will appear that this is incorrect. Either a plethoric or an anoemic condition of the blood may indeed act as a predisposing cause, by impairing the general health; or the blood may carry in its course through the system septic or other morbid elements derived either from within or without, but in this case its function is ministerial merely, and those morbid elements themselves are to be looked upon as the determining causes of the inflammatory process, not the blood which is simply their vehicle of transmission. Symptoms.—We have next to consider the symptoms1 of inflamma- tion. These may be distinguished into the local, and the constitutional or general symptoms. The latter will be treated of on a subsequent page, under the heading of symptomatic or inflammatory fever. The local symptoms of inflammation may be classified under six heads, viz.: (1) alteration of color, (2) alteration of size, (3) alteration of tempera- ture, (4) modification of sensation, (5) modification of function, and (6) modification of nutrition. One or more of these symptoms may exist in a part without that part being inflamed, and it is only when they are present in combination, that the diagnosis of the inflammatory process can properly be made. The phenomena of the erectile tissues furnish a familiar example. Again, certain nervous lesions give rise to a combination of these symptoms so striking as to have been con- sidered by many excellent observers to indicate a true inflammatory condition (the so-called neuro-paralytical inflammation), and, indeed, this state is one that can be converted into true inflammation by the action of very slight external causes. The degree in which any one of these symptoms is manifested depends, in a great measure, upon the nature of the tissue in which the inflammatory process is goino- on. Thus in the case of the skin or of mucous membranes, a change of color is the most prominent symptom. Inflammation of the connective or areolar tissue is particularly distinguished by the swelling b}r which it is attended. In the fibrous tissue, pain is the best marked"symptom. Conjunctivitis or a superficial burn, inflammation of the subcutaneous fascia, and periostitis, may be taken as illustrations of these proposi- tions. Again, modification of function is more prominent in an inflam- mation involving the eye, than in one affecting a much larger area of the skin or of the alimentary canal, while in some tissues, cartilao-e for instance, almost the only change that can be recognized' after a° loner duration of the inflammatory process, is an alteration in the nutrition of the part involved. Redness, the first of the symptoms made classical by the description of Celsus*, is perhaps the most noteworthy of all the si Fayrer has particularly insisted upon the frequency of death after operations from the formation of fibrinous coagula in the right side of the heart and bPlSvM that a malarious state of the blood acts as a predisposing cause of such coagulation I PREPARATION OF PATIENTS FOR OPERATION. 69 having escaped the surgeon's notice when the force of the circulation was depressed; hence, if there has been much shock, or if the operator has been unable to detect the mouths of vessels which yet he knows must have been divided, it is well to postpone the final closure of the wound until after complete reaction. Secondary hemorrhage may come on at any period between the occurrence of reaction and the ultimate healing of the wound; it may result from the premature detachment of ligatures, either from their having been in the first place insecurely applied or from subsequent inflammatory changes in the coats of the vessels, or it may be due to the occurrence of sloughing, opening vessels which had not been divided, or at a part higher than the point of liga- tion. The treatment of surgical hemorrhage will be described when considering wounds of arteries. A patient may die after an operation, from the violence of the inflam- mation or of the accompanying traumatic fever which, except in slight cases, necessarily ensues. The symptoms and treatment of these con- ditions have been sufficiently discussed in Chapters I. and II., and need not be again referred to here. A patient may die after an operation from causes previously in exist- ence which the operation has not been able to remove, or which it has unavoidably aggravated; as an instance of the former contingency, I may refer to the deaths from hectic and suppurative exhaustion which follow excisions of joints; of the latter, death from pre-existing peri- tonitis after the operation of herniotomy. Finally, patients after operation are frequently carried off by various affections, which, while not necessarily dependent on the performance of an operation, yet follow the use of the knife with sufficient frequency to entitle us to consider the operation as their exciting cause. These are chiefly erysipelas, pyaemia, hospital gangrene, diffuse inflammation of the areolar tissue, and, more rarely, tetanus; these will all be referred to in their proper place, and are mentioned now merely to complete this view of the subject. An operation wound, as any other wound, may become the seat of diphtheritic deposit, accompanied by low constitu- tional symptoms, and must be treated on the same principles which guide the practitioner in treating a case of diphtheria occurring under other circumstances. Preparation of Patients for Operation.—In view of the great dangers which are thus seen to accompany every operation, it certainly behooves the surgeon, whenever it is practicable to do so, to take measures as far as possible to avoid those dangers; and hence the importance of attending to the preparation of a patient for operation. In many cases, unfortunately, there is but little time offered for pre- paration ; a patient with a severe compound fracture requiring imme- diate amputation, or one who is suffocating with pseudo-membranous croup, cannot wait for any course of preparatory treatment, but must take the chance, if an operation be deemed proper, without regard to the state of his general health; 3ret even under the most unfavorable circumstances, the morale of the patient may often be improved by a few soothing and encouraging words, while, if there be much physical depression, a warming and stimulating draught may suffice to render him better able to submit to the ordeal of the knife than he would be otherwise. Consent of Patient.—A very important question, and one which ad- mits of grave doubt, is as to how far a surgeon may be justified in 70 OPERATIONS IN GENERAL. assuming the responsibility of operating, when a patient is unwilling to give his assent. Of course no one would think of performing any opera- tion of complaisance without the full consent of the patient, but where an operation is immediately necessary to save life, as in a case of stran- gulated hernia or of injury requiring primary amputation, the surgeon's position is one of great perplexity. If the patient be a child, the consent of the parents is quite sufficient; if an adult, but unable from intoxication or other cause to judge for himself, the consent of a near relation or friend who is competent to decide the matter should be obtained; in the absence of the parents or other relatives, the surgeon must place himself as it were in loco parentis, and do fearlessly what he thinks best for his patient. If, however, an adult in full possession of his faculties refuse an operation, or if, in the case of a child, the parents refuse for him, I cannot think it the duty of the surgeon to persist in operating under such circumstances; he should remember that spontaneous recoveries do occasionally occur in the most unpromising cases, and that, on the other hand, death may very likely follow the most eligible and best executed operation ; and when the true state of the case and the imperative necessity (humanly speaking) of the operation have been clearly and fully explained, I can- not think that the surgeon should be held responsible for the consequences of obstinate refusal on the part of the patient or his friends. Preparatory Treatment.—The requisite consent having been obtained, in any case that admits of a short delay, it will be desirable to occupy a few days in preparatory treatment. I do not consider it ever necessary to deplete a patient, whether by bleeding or violent purging, before an operation. The diet should be regulated, such articles as are known to be irritating and difficult of digestion being avoided, while the intesti- nal and other secretions are brought into a healthy condition by the use of mild laxatives, etc. In the case of hospital patients, who are often brought from a considerable distance to undergo an operation, it is proper to wait until they have rested from the fatigues of travelling, and have become somewhat accustomed to their new quarters and the new faces that surround them; as they are frequently in a state of debility, it is often essential to put them upon a course of tonics, with nutritious food, and even free stimulation, before they can be brought into a condition for operation. It is always proper, the night before an operation, to administer a mild cathartic, such as a dose of castor oil, and the next morning to empty the lower bowels by an enema; this is especially important in case the rectum or adjoining parts are to be involved in the operation, but is desirable under all circumstances, as it obviates the need of a fecal evacuation for some days afterwards, and thus saves a good deal of fatigue and exposure which is always undesirable and occasionally very prejudicial. In the case of a woman, the operation should not be done during a menstrual period or during pregnancy, if the exigencies of the case admit of postponement. The patient should be loosely clad aud if much bleeding be anticipated, should wear an additional garment which can be removed after the operation. No solid food shouldlbe v8emia orrnr« ,i;c™,^♦„„„'„„„., such an idea. pyaemia occurs discountenances INSTRUMENTS. 95 circulation may not be controlled, though the instrument be applied as tightly as possible. Hence, as a rule, the tourniquet plate should go im- Fie. 26. Fig. 27. Spanish windlass. Signoroni's tourniquet: a, the point of counter- pressure ; b, the pad which acts directly on the vessel. mediately over the artery: where this is not practicable, as in the case of the axilla or the popliteal space, it should be placed at a point diametri- cally opposite. Fig. 28. Fig. 29. Skey's tourniquet. Lister's aorta-compressor applied. Various other forms of tour- niquet have been devised, but none of them approach in value to that of Petit. The ordinary field tourniquet, as it is called, consists merely of a strap and buckle with a pad to go over the vessel: it is no better than the 96 AMPUTATIONS. common garrot, or Spanish windlass (Fig. 26), made with a stick and handkerchief. Other forms are the horseshoe or SignoronVs tourniquet (Fig. 27), Skeffs tourniquet (Fig. 28), and the various artery compressors, which are designed so as not to control the smaller vessels; however useful these may be for cases of aneurism or accidental hemorrhage, they are not, I think, as good as Petit's instrument for employment in ordinary amputations. In certain special operations, however, these are very valuable; thus hip-joint amputation is shorn of half its terrors by the use of Skey's tourniquet or Lister's aorta-compressor (Fig. 29). Amputating Knives.—Formerly surgeons used for the circular opera- tion a knife with but one edge and a very heavy back, shaped somewhat Fig. 30. Amputating knife. like a sickle; the modern amputating knives, however, which are adapted for either the circular or the flap operation, have a sharp point, and are Fig. 31. Fig. 32. Fig. 33. Catlin or double-edged knife. usually double-edged for an inch or two at the extremity. The length of the knife should be about one and a half times the diameter of the limb to be removed, and its breadth from three-eighths to three-quarters of an inch. Thus, a knife with a cutting edge eight or nine inches lone will answer for most amputations of the thigh, while one with an ed^e of six or seven inches will do for smaller limbs. Double-edged catlins (Fig. 31) are used principally for the leg and fore- arm, and are convenient in freeing the interosseous space for the application of the saw; their width should not exceed three-eighths of an inch. Be- sides the ordinary amputating knives, the surgeon should have at hand one or two strono- scalpels or bistouries (Figs. 32 and 33), about three inches long, while for smaller amputations, as of the fin- gers, a very slender knife with a heavy back will be found convenient. The blade of such a knife should be about two inches long and an eighth of an inch wide. The measurements which 1 have given are rather smaller than those usually di- rected, but are, I think, such as will be found satis- factory in most cases; for my own part, I much prefer a small knife to a large one, and am, indeed, in the habit of using a three-inch blade for the largest limbs, having found it quite ample even for amputation at the hip-joint. The handles of am- putating knives should be of rough ebony, which is less likely to slip when bloody than either bone or ivory. Bistoury. Scalpel, INSTRUMENTS. 97 Saivs.—The amputating saw should be about ten inches long by two and a half wide; it should be strong, with a heavy back so as to give additional firmness, and the teeth not too widely set, but just enough to prevent binding. For operations about the hand or foot, a small saw with a movable back (Fig. 34) will often be found useful. Bone-nippers or Cutting Pliers may be used in amputating the pha- langes, or for smoothing off any rongh edges left by the saw in larger Fig. 34. Small amputating saw. operations. Ten to twelve inches is a good length, of which the blades should not occupy more than two inches; the blades, which are sharp, should be set at an obtuse angle with the handles, which must be very strong and roughened to prevent the hand slipping. Fig. 35. rjiss! Artery forceps closing by their own spring. Fie. 37. Bone-nippers. Artery Forceps and Tenacula are used in taking up the vessels; the best form of forceps is essentially that invented by Liston, and known as the "bull-dog forceps;" the blades should be ex- FiS- 36- panded a short distance above the points, that the ligature may easily slip over without includ- ing the instrument itself in the knot; they may be made to fasten with a catch, or, which I think is better, be provided with a spring which keeps them closed except when opened by pressure of the surgeon's fingers. The tenaculum or sharp hook must be of sufficient size and but slightly curved; it is not as good an instrument as the forceps for most cases, but is sometimes useful, especially where the parts are matted together by in- flammation, and the artery cannot be separated by the forceps; some- times it is necessary to take up a little mass of muscle or areolar tissue with two tenacula, and throw a ligature around the whole. Though I have never seen any harm result from this ligature en masse, it should not be practised when it can be avoided, and, as far as possible, each vessel should be drawn from its sheath and tied separately. 7 Tenaculum, or sharp hook, whereby the arterial orifice is picked out. 98 AMPUTATIONS. Ligatures may be made of a variety of materials, such as catgut, horsehair, iron or silver wire, or more commonly, and I think better, of fine whip-cord or strong sewing-silk. The silk should be cut into lengths of about eighteen inches, and must be well waxed to fit it for use. The ordinary skein of silk contains about six yards, and is thus sufficient for twelve ligatures. In ordinary amputations the number of vessels requiring ligature is about six or seven, but if there has been inflamma- tion, causing enlargement of the small arteries, as many as twenty or twenty-five ligatures may be necessary. The artery having been drawn out of its sheath by the forceps or tenaculum, the ligature is thrown around it and secured by what is called the Fig. 38. reef-knot, the peculiarities of which can be better understood from the annexed cut than from any description. It is usual after tightening the knot to cut off one end of the ligature, allowing the other to hang out at the wound. It is convenient to retain both ends of the ligature which surrounds the main artery, knotting them together for purposes of distinction. Short-cut ligatures were very highly commended by Hennen and others at the beginning of this century, but are now, I believe, generally abandoned. I have occasionally used them, but have rarely found any benefit from their employment, the knot almost never becoming encysted, but coming away sooner or later as a foreign body. Their use has, however, recently been successfully revived by Prof. Lister and Mr. Maunder, in connection with the anti- septic method of the former; they have thus secured such large arteries as the external iliac and the common carotid. Some surgeons apply a single knot only to small vessels. I see no advantage in this plan, which is certainly not so safe as the use of the common reef-knot. Acupressure ma}' be used to secure arteries after amputation, as may various ingenious modifications of acupressure, in which a wire is used instead of a needle; these will be considered in the chapter on wounds of arteries. The Retractor consists of a piece of muslin six to eight inches wide, one end of which is split into two tails for the thigh or arm, and into three for the leg or forearm. It is applied around the bone or bones to keep the soft tissues from being injured by the saw, and to prevent bone dust from being caught among the mus- Zg^* cles, an occurrence which would greatly interfere with the rapidity of the healing process. ______ The Sutures may be applied -=—* with the ordinarj' " surgeon's surgical needles. needle," which for use in stumps should be large, strong, and but slightly curved; or, if the flaps be very thick, a needle, mounted in a handle and with the eye near the point, such as is used in the operation of strangulating a naevus, will be found convenient. The best material for the suture is, I think, lead wire, though this is a matter which may be safely left to the fancy of the operator. /^\ OPERATIVE PROCEDURES. 99 Scissoi°s are used to cut the ligatures and sutures, or to retrench any projecting nerves, tendons, or masses of fascia. Operative Procedures.—The various modes of amputating may be considered as mere modifications of the^ two original forms of the operation, the circular and the flap; thus the oval operation, or that of Scoutetten, is based upon the circular, while the different methods of Yermale, Sedillot, Teale, Lee, etc., are but varieties of the flap operation. Circular Method.—An amputation by the circular method is thus performed: Anaesthesia having been induced, and the seat of operation washed and shaved, the patient is brought to the side or the foot of the operating table, so that the limb to be removed projects well over the edge. The circulation should be controlled by means of a tourniquet or by manual pressure exercised by an assistant, while another assistant holds the affected limb in such a position as is convenient for the operator. The latter should stand so that his left hand will be towards the patient's trunk; thus, in amputating the right leg the surgeon stands on the patient's right side, while in removing the left leg he stands between the patient's limbs. The surgeon then, steadying and drawing upwards the skin with his left hand, slightly stoops, and carries his right hand, which Fig. 40. imputation by circular method. holds a knife of sufficient length, around the patient's limb, so that the back of the knife is towards his own face. Pressing the heel of the knife well into the flesh, he makes a circular sweep around the limb, rising as he does so, and thus being enabled to complete the whole or at least the greater part of the cutaneous incision with one motion; a few light touches of the knife will now allow considerable retraction of the skin, and, if the limb be slender, this degree of retraction may be sufficient. The first incision must completely divide all the structures down to the muscles. If the skin have not retracted sufficiently, the surgeon now, either with the same knife or with an ordinary scalpel, rapidly dissects up a cuff of skin and fascia, about half as long as the limb is thick. In doing this, care must be taken to cut always towards the muscles; neglect of this rule will cause division of the cutaneous vessels and consequent sloughing of the part. Having done this, the operator grasps the cuff of skin with his left hand, and, with the large knife, makes another circular cut at the point of the cuff's reflection, through all the muscles and down 100 AMPUTATIONS. to the bone. A wide gap is usually immediately produced by the retrac- tion of the .cut muscles; if it be not sufficient, however, the surgeon quickly separates the muscular structures from their periosteal attach- ments with the finger or the handle of a scalpel, pressing them back and thus cleaning the bone for the space of about two inches. If the limb contain two bones, the interosseous tissues must be divided with a double- edged knife or with the ordinary scalpel. The retractor being applied and firmly drawn upwards, the bone is now to be sawn at the highest point exposed. It is well first to divide the periosteum with a knife, and to use the saw lightly at first, so as to avoid splintering. The saw should be held vertically, and if two bones are to be divided, they should be sawn together. The assistant who holds the limb must exercise care to keep it in such a position as neither to interfere with the action of the saw nor to allow the bone to break before the section is completed. As soon as the limb is removed the surgeon secures the vessels, momentarily loosening the tourniquet, if necessary, that the gush of blood may indi- cate the position of the smaller arteries, and, when all bleeding is checked, proceeds to dress the stump. If any projecting spiculae have been left by the saw, they must be removed with strong cutting pliers, and any tendons or nerves that hang out from the stump should be cut short with sharp scissors. The skin cuff is then brought together with sutures, so as to convert the circular into a linear incision, its direction being horizontal, vertical, or oblique, according to the fancy of the operator. It is well to apply a bandage with circular turns from above downwards, to the stump, so as to prevent spasm or subsequent muscular retraction. Sometimes great difficult}^ is experienced in turning up the skin cuff, from the conical shape of the limb. In such cases the surgeon may slit the cuff at one or both sides, thus converting the procedure into a modi- fied flap operation. Flap Method.—Amputation by the flap method is susceptible of an almost infinite number of variations. Thus there may be only one flap, more commonly two, or even a larger number. The flaps may be cut antero-posteriorly, laterally, or obliquely; they may be made by trans- fixing the limb and cutting outwards, or may be shaped from without inwards, or one may be made by transfixion and the other from without. They may include the whole thickness of tissue down to the bone, or merely the skin and superficial fascia, or they may embrace the super- ficial muscles, while the deeper FiS- 41. layer is divided circularly (Sedil- lot). Finally, they may have a curved outline, or they may be rectangular. In practising the ordinary double-flap amputation, the sur- geon stands as for the circular amputation, and grasping and slightly lifting the tissue which is to form the flap, enters the point of the long knife at the side nearest himself; then pushing it across and around the bone with a decided but cautious motion, and slightly raising the handle when the bone is passed, he brings Amputation by autero-posterior flap operation. the point Ollt diametrically OD- OPERATIVE PROCEDURES. 101 posite its place of entrance. Holding the blade in the axis of the limb, he then shapes his flap by cutting at first downwards, with a rapid saw- ing motion, and then obliquely forwards. Turning up the flap, he re-enters the knife at the same point as before, carries it on the other side of the bone, brings it out with the same precautions as at first, and cuts his second flap. He then applies the retractor, makes a circular sweep to divide any remaining fibres, and saws the bone as in the circular operation. In many situations, as in the front of the leg where the bone is super- ficial, it is impossible to make a flap by transfixion, and in any part, if the limb be large, the flap thus made is unwieldy, the skin retracting more than the muscles, which project and interfere with the closure of the wound. Hence it is often better to make at least one flap by cutting from without inwards, dividing the skin and superficial fascia by the first incision, and the muscles by a second, at a higher point. In view of the wasting and gradual disappearance of muscular tissue, which always take place in a stump, some surgeons think to save time and trouble by making flaps of skin only ; but, apart from the danger of sloughing, which always attends these long skin flaps, unsupported by muscle, the resulting stump is not so serviceable, for though the true muscular structure does indeed disappear, the fibrous sheath of the muscle remains, becoming condensed into a thick pad which forms a very necessary covering for the bone. In making antero-posterior flaps by transfixion, the anterior one should be cut first; if the flaps are shaped from without inwards, the lower should be formed first, as otherwise the blood from the first incision would ob- scure the line of the second. In making lateral flaps, the outer should be the first cut, and, generally, it may be stated that that flap should be first formed which does not contain the principal artery. I have advised that for the flap as well as for the circular operation the surgeon should stand with his left hand towards the patient's trunk. Many authors, however, including Mr. Liston and Mr. Erichsen, direct that exactly the opposite posture should be assumed, with the left hand on the part to be removed (see Fig. 41). I have no doubt that every one will find that position most convenient to which he is most accustomed; but consider that which I have recommended to be the best, as enabling the operator to have more control over hemorrhage, in case of sudden slipping of the tourniquet or relaxation of his assistant's grasp. Oval Method.—The oval amputation in its simplest form may be con- sidered as a circular operation, in which the cuff of skin has been slit at one side, and the angles rounded off. In this form it is used for disarticu- lation at the metacarpo-phalangeal joints, and, with a slight modification, constitutes Larrey's well-known method of amputating at the shoulder- joint. Another form of the oval operation, which in this case should rather be called elliptical, is particularly adapted to the knee and elbow-joints, though it is applied by the French to other parts as well. The incision in this form of amputation constitutes a perfect ellipse, coming below the joint on the front or outside of the limb; the resulting flap is folded upon itself, making a curved cicatrix and furnishing an excellent covering for the stump. Modified Circular Operation.—This plan seems to have been indepen- dently suggested about the same time, by Mr. Liston and Mr. Syme. It may be regarded as the ordinary circular operation, with the skin cuff slit on both sides and the angles trimmed off'. It is done by cutting with a suitable knife two short curved skin-flaps, and dividing the muscles 102 AMPUTATIONS. with a circular sweep of the instrument: it is particularly adapted to amputations through very muscular limbs. /i'^jr Flaps iu Teale's amputation. Modified circular amputation. TeaWs Method by Rectangular Flaps.—This operation, which was in- troduced and systematized by Mr. Teale, of Leeds, about fifteen years ago, undoubtedly furnishes a most Fig. 43. elegant and serviceable stump. There are two flaps of unequal length,the shorter always con- taining the main vessel or ves- sels of the limb. The flaps are of equal width, but while one has a length of half the cir- cumference of the limb at the point where the saw is to be applied, the other is but one-quarter as long (i. e. one-eighth of the cir- cumference). The lines of the flaps should be marked with ink or crayon before beginning the operation, as otherwise, especially in dealing with a conical limb, it is almost impossible to cut the long flap of the requi- site rectangular shape. Both flaps are to embrace all the tissues down to the bone, and the long flap, which is in shape a perfect square, is, after sawing the bone, folded on itself, and attached by points of suture to the short flap. The advantages of this mode of amputating are that it se- cures a good cushion of soft parts over the end of the stump, and that the resulting cicatrix is entirely withdrawn from the line of pressure, in adapting an artificial limb : its disadvantage is that if used upon a mus- cular limb, it requires the bone to be divided at a much higher point than would otherwise be necessary, and thus, in the case of the thigh at least, adds much to the gravity of the operation. Hence it has been suggested by Prof. Lister to alter the relative dimensions of the flaps, making the longer of just sufficient size to bring the cicatrix out of the line of pres- sure, while its diminished length is compensated for by increasing that of the short flap. I have myself employed this modified form of Teale's operation (keeping, however, the rectangular shape of the flaps), and have found it to answer quite as well as the original. DRESSING OF THE STUMP. 103 Relative Merits of the Different Methods.—I do not purpose to enter into a discussion of the supposed advantages of one method of amputa- ting over another, believing that excellent results may be obtained by any of these plans, and that the difference in the results of amputation in the hands of various operators is not so much due to the particular pro- cedure employed, as to the judgment displayed in selecting cases for opera- tion, and the care manifested in conducting the after-treatment. When I began to operate, I practised one or other form of the flap amputation almost exclusively, having a prejudice against the circular method, which is certainly less easy of execution and less brilliant than the other. Dur- ing late years, however, my views upon this point have undergone some modification, and I now prefer the circular operation in certain localities. The surgeon should not, I think, confine himself to any one method exclu- sively, but should vary his mode of operating according to the exigen- cies of the particular case. If any general rule were to be given, I should say that the circular incision or Teale's method gives the best stumps in the forearm, the modified circular in the upper-arm and the upper part of the thigh, the common double-flap operation immediately above and below the knee, the circular or lateral-flap in the lower part of the leg, and the oval operation at the joints. The points to be con- sidered in choosing an operation for any particular part of the body will be referred to in discussing the special amputations. Simultaneous, Synchronous, or Consecutive Amputation.— It occasionally becomes necessary, in cases of severe injury, to remove two or more limbs by primary amputation at the same time. Sometimes this has been done by two surgeons operating simultaneously, but it is better for one to do both amputations consecutivel}', beginning with the limb that is most severely hurt. Though the prognosis of these double ampu- tations is always unfavorable, yet recoveries have followed with sufficient frequency to justify the surgeon in having recourse to the knife, when the condition of the patient will at all permit it. If the hemorrhage can be effectually controlled by tourniquets, it is better to remove both limbs before stopping to take up any vessels; though if the first amputation have produced much depression,it maybe necessarj7-to pause and admin- ister restoratives before proceeding to the second. Perhaps the most remarkable case of synchronous amputation on record is that done by Dr. Koehler, of Schuylkill Haven, Pennsylvania, who thus removed both legs and one arm from a boy of thirteen, the lad making an excellent recovery in spite of this severe mutilation. Dressing of the Stump.—After an amputation, the stump should not be dressed until all hemorrhage has ceased. Sometimes after all the recognizable vessels have been secured, a troublesome oozing continues from the face of the stump; this is usually venous bleeding, and will commonly cease of itself when the tourniquet is removed. If it do not, it may probably be checked by elevating the stump, and pouring over it a stream of cold water, or of diluted alcohol.1 Bleeding from the me- 1 Under the name of parenchymatous hemorrhage, Dr. Lidell has described (fol- lowing Stromeyer) a general capillary oozing, due to dilatation of the capillary vessels, either by the inflammatory process, or as the result of obstruction of the principal veins from thrombosis. The treatment recommended in the former case consists in the application of the persulphate or perchloride of iron, hot water, or the actual cautery; in the latter, ligation of the main artery, or amputation at a higher point ( U. 8. San. Commission Surgical Memoirs, vol. i. pp. 237-230). 104 AMPUTATIONS. dullary cavity of the sawn bone may be stopped by inserting a piece of dry lint, a plug of wood, or better, a pellet of previously softened white wax; the latter has the advantage of being perfectly unirritating, so that, if necessary, it may be allowed to remain when the flaps are brought together. If the surgeon have any reason to fear consecutive hemor- rhage, the stump should not be finally closed for some hours, or until complete reaction has occurred, a piece of lint, dipped in olive oil, being meanwhile laid between the flaps (as suggested by Mr. Butcher), to pre- vent their adhering, and the sutures left loose until the surgeon is ready for the final dressing. The ligatures are to be brought out at one or both angles of the wound, as may be most convenient; it has been sug- gested to bring each one through the face of the flap by a separate punc- ture, but such a plan seems to me more adapted to delay union by producing increased irritation, than to promote quick healing. The edges of the amputation wound are to be brought together, not too tightly, by the use of sutures, and the flaps, if heavy, may be additionally supported by the use of adhesive strips. It is a great mistake to hermetically seal a stump; there is always a considerable flow of serum for some hours after an amputation, and if this fluid be not allowed to escape from the stump, it inevitably decomposes and produces irritation. Various modes of dressing a stump have been employed; Mr. Teale directed what has been called dry-dressing, which was, in fact, no dressing at all, the stump being simply laid on a pillow (which was covered with gutta-percha cloth), and protected by throwing over it a piece of thin gauze. Sir J. Y. Simpson highly commended the exposure of both amputation and other wounds to the air, calling the scab produced by this exposure a " natural wound lute." MM. Guerin and Maisonneuve have, on the other hand, devised ways of treating stumps in exhausted receivers, giving their respective plans the euphonious titles of " pneumatic occlusion" and "continuous aspiration." The "antiseptic method" of Prof. Lister has been quite extensively used in the treatment of stumps, and, I doubt not, answers a very good purpose. The dressing which I myself prefer, consists of a piece of sheet lint soaked in pure laudanum, covered with oiled silk or waxed paper, and secured in place with a light recurrent bandage; the local use of the narcotic is soothing to the patient, while the styptic and antiseptic properties of the alcoholic menstruum are often use- ful. In military practice cold water is the most convenient application to a recent stump, and, if not too long continued, answers very well. What- ever dressing is used, the stump should not be disturbed 'for forty-eight or seventy-two hours, by which time suppuration will usually have begun; the wound may then be dressed with diluted alcohol, with lime- water, or with any other substance that the condition of the part may indicate. If organic sutures have been used, they should be removed about the third or fourth day; metallic sutures may remain longer, and need not usually be taken away until firm union has occurred, and until they are therefore of no further use. The ligatures may be expected to drop from the smaller vessels after the fifth or sixth day; from the larger arteries after the tenth or twelfth. The ligatures should always be allowed to drop of themselves; but when the time usually requisite for their separa- tion has elapsed, the surgeon may at each dressing gently feel them to ascertain if they are loose. If acupressure has been employed, the pins or needles from the smaller vessels may be removed on the second dav; that on the main artery on the third or fourth, according to the extent AFFECTIONS OF STUMPS. 105 of the clot formed, which may be estimated by the point at which pulsa- tion in the flap ceases. Structure of a Stump.—A stump continues to undergo changes in its structure for a long while after cicatrization is completed; the muscular substance wastes, and the muscles and tendons become con- verted into a dense fibro-cellular mass, which surrounds the bone; the bone itself is rounded off, and its medullary cavity filled up ; the vessels are obliterated up to the points at which the first branches are given off, firm fibrous cords marking their place below; the nerves become thickened and bulbous at their extremities, these bulbs being composed of fibro- cellular tissue, with numerous nerve fibrils interspersed. Upon the firm- ness and painlessness of a stump, depend greatly the facility and comfort with which an artificial limb can be worn. In the case of the upper ex- tremity, there is comparatively little difficulty, and very ingenious and serviceable arms and hands are now supplied by the manufacturers. In the lower extremity, it is found that very few stumps will bear the entire pressure produced by the weight of the booty, in walking upon an arti- ficial limb, and hence a portion at least of the pressure should be taken off, by giving the apparatus additional bearings upon the neighboring bony prominences; thus for an amputation of the leg, the artificial limb should bear upon the knee, while in the case of a thigh stump, the tuber ischii and hip should receive the principal pressure. Affections of Stumps.—Aivv one of the constituents of a stump may give trouble after an amputation, and the treatment of the morbid conditions of a stump is a very important matter for the surgeon's con- sideration. 1. Spasm of the muscles often occurs and causes much suffering a few hours after an amputation; it is best treated by the use of a moderately firm bandage around the part and by the exhibition of anodynes. 2. Undue retraction of the muscles may occur and continue for days or even weeks after an amputation, interfering with cicatrization, and giving rise to a very intractable form of ulceration, or even going so far as to produce what is called a conical or sugar-loaf stump. The me- chanical ulcer, as it is called, of stumps, requires the limb to be firmly bandaged with circular and reversed turns from above downwards; the action of the muscles is thus restrained, and the soft parts coaxed down- wards, as it were, and enabled to heal while the tension is removed. There is, however, another cause for the production of conical stumps, in cases of young persons, apart from muscular retraction or wasting by suppuration ; this is a positive elongation of the bone by growth subse- quent to amputation. This is chiefly seen in the leg and upper arm, and its occurrence in these situations, rather than in the thigh or forearm, is easily accounted for by remembering the physiological fact, that the upper extremity grows principally from the upper epiphysis of the humerus and the lower epiphyses of the radius and ulna, while the lower extremity grows chiefly from the lower epiphysis of the femur and the upper of the tibia. Hence, in amputations of the thigh or forearm, the principal source of growth for that particular member is taken away; while in the upper arm or leg, it remains, and is liable to cause subsequent protrusion of the bone through the soft parts. To whatever cause the existence of a conical stump be traceable, if the stump will not heal over the bone, or if, though a cicatrix form, it be thin, tender, and constantly liable to reulcerate, there is but one remedy, which is to resect the projecting end 106 AMPUTATIONS. of the bone ; this is fortunately a proceeding which is attended with but little risk, and its results are usually satisfactory*. 3. Erysipelas or diffuse cellular inflammation may attack the tissues of a stump; and either constitutes, under these circumstances, a very serious affection. All sutures should be at once removed, soothing and emollient dressings applied, and the general treatment adopted which will be described when speaking of those diseases. 4. Secondary hemorrhage may occur from the vessels of a stump, at any time before complete cicatrization has taken place. If it be not pro- fuse, elevating the part, and the application of cold, or pressure, will often be sufficient to check the bleeding; if it continue, or recur, more decided measures must be adopted, which will be discussed in the chapter on wounds of arteries. 5. Aneurismal enlargement of the arteries of a stump occasionally occurs; the annexed wood-cut, from Mr. Erichsen's Surgery, illustrates a Fis. 44. Aneurismal varix in a stuiup. case of aneurismal varix occurring after amputation through the ankle- joint. 6. Neuroma, or painful enlargement of the nerves of a stump, occa- sionally occurs. When it is possible to Fig. 45. detect any distinct tumor connected with a nerve, it would be proper to cut down and remove it; under other cir- cumstances a reamputation may be per- formed, though unfortunately this is by no means an infallible remedy; Dr. Xott gives a case in which a man submitted to three reamputations and three nerve excisions for neuralgia of a stump, deriv- ing at last only questionable benefit from this large, experience in operative surgery. As a palliative remedy, the application to the stump of the strong tincture of the root of aconite is occa- sionally useful, or hypodermic injections of morphia may be used, as in other cases of neuralgia. 1. The tendons in the neighborhood of a stump may become contracted and cause troublesome deformity; thus, after Chopart's amputation on the foot, the natural arch of that organ being destroyed, the tendo Achillis may be drawn up by the powerful muscles of the calf, and a painful form of club-foot result, the cicatrix being thrown against the ground in walking. The occurrence of this condition should, if possible be pre vented by the use of appropriate splints and bandages, and it' may be Neuromata of stump, afier amputation of the arm. A large neuromatous mass at a ; opposite 6, the tumors are more denned. MORTALITY AFTER AMPUTATION. 107 Fig. 46. sometimes even necessary to resort to tenotomy when milder measures will not suffice. 8. Periostitis, Osteitis, and Osteo-myelitis, one or all, may occur in a stump, and may defeat the surgeon's anticipations of a successful issue. If acute and extensive, these affections endanger life, and, especially in the femur, are apt to terminate fatally. The diffuse suppurative form of osteo-myelitis is especially apt to occur when the division of the bone has exposed the medullary cavity, and is almost sure to end in pyaemia and death; the only mode of treatment is reamputation at the nearest joint, and this is of course an almost desperate remedy. Less violent forms of bone inflammation result in the oc- currence of— 9. Necrosis, which may likewise be produced by injury from the saw, at the time of operation. The treatment of this condition consists pretty much in waiting for the nat- ural separation of the necrosed part, which will then be exfoliated as a ring of dead bone, or as a long conical sequestrum. I do not believe that anything is to be gained, under these circumstances, by interference with the slow but safe processes of nature; in the case, however, of the occurrence of acute necrosis, as it is sometimes called, or more properly diffuse subperiosteal suppuration, it may be necessary to reamputate to save life, just as it would be under the same circumstances occurring elsewhere than in a stump. 10. Caries may occur in the bone of a stump. I have seen benefit result in such cases from the injection of the preparation introduced by M. Notta, under the name of Liqueur de Vitiate. [R. Zinci sulphatis, Cupri sulphatis, aa gr. xv; Liq. plumbi subacetatis f3ss; Acid. acet. dilut. vel. Aceti alb. f 3iijss. M.] 11. Finally, an adventitious bursa may be formed over the bone of a stump, as in any other part subjected to much pressure. If this bursa become painful, the artificial limb should be altered so as to relieve it from pressure; if this be not sufficient, an effort may be made to obliter- ate the burs by the introduction of the tincture of iodine or by estab- lishing a small seton, or the bursa itself may be excised. Necrosis of the bone after ampu- tation. Mortality after Amputation.—The results of amputation depend on a variety of conditions. Some of these are common to this as to other serious operations, and have mostly been sufficiently referred to in the chapter on operations in general; the most important circumstances coming into this category are the age and the constitutional state of the patient, and the hygienic conditions to which he is subjected before, at the time of, and after the amputation. The relation between the baro- metric condition of the atmosphere and the mortality after amputation has been particularly investigated by Dr. Addinell Hewson. He finds that, at the Pennsylvania Hospital, the mortality varied from 11 per cent, with an ascending, to 20 per cent, with a stationary, and 28 per cent, with a falling barometer. While the column of mercury was rising, the average duration of life, in fatal cases, was only seven days, but was thirteen while the column was falling; and of all the cases that died within three days, over 75 per cent, proved fatal while the barometer was rising. " Surely," he adds, " these figures need no commentary as to how well they sustain the idea that the results of operations are 108 AMPUTATIONS. materially influenced by the weather, and that the risks from shock arc increased by opposite conditions" (Penna. Hosp. Reports, vol. ii. p. 34). The most recent statistics as to the influence of the age of patients upon the results of amputation have been collected by Mr. Holmes, of St. George's Hospital, who finds that " the risk of amputation is con- stantly rTsing throughout life, and at any given period after thirty years of age the risk is more than twice as great as it was at the same period after birth" (St. George's Hosp. Reports, vol. i. p. 300). Besides the circumstances which have been referred to, there are others which affect the result of amputation, and which are peculiar to this as distinguished from other operations ; these are now to be considered. 1. Locality.—The part of the body at which an amputation is per- formed exercises an important influence on the result;. amputations of the lower extremity are more apt to prove fatal than those of the upper, and in the same limb the rate of mortality varies directly with the proximity to the trunk of the point of amputation. These facts will appear from the following table, which I have prepared from the published statistics of French,1 British,2 and American3 hospi- tals, and from those of our late war,4 together with those of the war in the Crimea.5 Table showing Mortality of Amputations in Different Parts of the Body, for Traumatic Causes, in Civil and in Military Practice. Civil Hospitals. American and Crimean Wars. Aggregates. Locality. Cases. Deaths. Mortality, per cent. Cases. Deaths. Mortality, per cent. Cases. Deaths. Mortality, per cent. Thigh.. Leg .... Arm.... Forearm 269 476 256 197 143 216 67 25 53.16 45.38 26.17 12.69 3516 3278 3091 1046 2715 1089 973 301 77.22 33.22 31.48 28.78 3785 3754 3347 1243 2858 1305 1040 326 75.51 34.76 31.07 26.23 Totals.. 1198 451 37.65 10,931 5078 46.46 12,129 5529 45.58 In amputations of the thigh, the mortality varies according as the operation is done in the upper, lower, or middle third. The following are the percentages given respectively by Legouest and Macleod, both referring to the British army in the Crimea, though for different periods of the war. XT ,, . , Legouest. Macleod. Upper third.......87.2 86 8 Middle third.......58-5 55 3 Lower third.......55-0 50 0 2. The part of the hone which is divided in an amputation influences the result, the mortality being greater when the medullary cavity is opened than when only the cancellous structure at the end of the bone is involved. This appears to be owing to the greater probability of 1 Malgaigne (Arch. Gen. de Med., Avril, 1842) « St. George's Hosp. Reports vol. i.; Med. -Chir. Trans., vols. xlii. and xlvii.; and Guy's Hosp. Reports, 3d s., vol. xv. p. 630. ' 3 Am. Journ. Med. Sciences, vols, xxii., xxvi., n. s. xvi., xxi xxviii lv • p,>nna Hosp. Reports, vol. i.; and Trans. Am. Med. Assoc vol iv ' * Circular No. 6, S. G. O., Washington, 1865. 5 Legouest, Chirurgie d'Armee, pp. 722-735. MORTALITY AFTER AMPUTATION. 109 pyaemia supervening under the former circumstances. Of 295 cases of amputation which were followed by pyaemia during Our late war, 155, or 52.5 per cent., were through the shaft of the femur (Circular No. 6, S. G. 0., 1865, p. 43). 3. The nature of the affection for which an amputation is done, exercises a most important influence upon the result; thus amputations for injury are much more fatal than those for disease; the removal of a limb for cancer is more likely to be followed by death than the same operation if practised for caries or a chronic joint affection; while amputations of complaisance or expediency (as for deformity) are less successful than those for other pathological conditions. The relative mortality of am- putations for injury and disease, as exhibited by the published reports of hospital practice in various countries, is shown in the following table. Amputations for Injury. For Disease or Deformity. Totals. Place of observation. a. Mortality, per cent. <6 o ft Mortality, per cent. Cases. Deaths. Mortality, per cent. French hospitals1.... English hospitals2-.. American hospitals3. • 652 537 751 378 209 215 57.98 38.92 28.63 947 955 278 406 197 51 42.87 20.63 18.35 1599, 784 1492' 406 1029 266 49.03 27.21 25.85 1940 802 41.34 2180 654 30.00 41201456 35.34 The mortality which attends amputations of expediency has been particularly investigated by Mr. Bryant, of Guy's Hospital, who finds it to be (in that institution) 30.3 per cent., as compared with a death- rate of 12.57 per cent, for other pathological causes; or, if the lower extremity alone be considered, the former class of cases gives a mortality of 40 per cent., and the latter of 15 per cent. (Med.-Ghir. Trans., vol. xlii. p. 86). 4. In amputations of the same category, the time at which the opera- tion is done exercises an important influence over the result; thus, amputations for acute affections of the bones or joints are much more fatal than those for chronic diseases of the same parts. Amputations for traumatic causes are usually divided by surgical writers into pri- mary or immediate, and secondary or consecutive. Primary amputa- tions are such as are done before the development of inflammation, a period rarely exceeding twenty-four hours, though, if there have been much shock, it may reach to forty-eight hours, or possibly still longer, from the time at which the injury was received. Military writers make a third class, the intermediate, which embraces all operations done during the existence of active inflammation, reserving the term secondary for such as are done after the subsidence of inflammatory symptoms, and when the condition of the part somewhat assimilates the case to one of amputation for chronic disease. It is now, I believe, universally acknowledged among military sur- geons that primary amputations (except of the hip-joint and the upper 1 Malgaigne (loc. citat., Avril et Mai, 1842), and Trelat (Legouest, op. citat., p. 707). 2 St. George's Hosp. Reports, vol. i.; Med.-Chir. Trans., vols. xlii. and xlvii.; Guy's Hosp. Rep., 3d s., vol. xv.; and Erichsen's Surgery. 3 Am. Journ. Med. Sciences, vols, xxii., xxvi., n. s. xvi., xxi., xxviii., and lx.; Penna. Hosp. Reports, vol. i.; and Trans. Am. Med. Association, vol. iv. 110 AMPUTATIONS. part of the thigh) do better than others; of those which are not primary, the secondary do better than the intermediate. It is, however, com- monly said that in civil practice secondary amputations are more suc- cessful than primary, and this difference has been accounted for by the different hygienic circumstances by which soldiers and civilians are respectively surrounded. I believe that the usual statement upon this point is erroneous, and that a careful collation of statistics will show that in both civil and military practice, primary amputations are fol- lowed by better results than others. To illustrate this point, I have drawn up the table which follows, and in which the results of primary amputations, or those performed in the pre-inflammatory stage, are com- pared with those of all others for traumatic causes.1 Primary. Secondary and Observations from Civil Hospitals. Intermediate. >>~ >;- — a — c in Js ^

Uma! a?d ^"f JoLaite,s Retrospect, July, 1869, p. 109. 3 Brit. Med. Journal, Jan. 14, 1871. l LACERATED AND CONTUSED WOUNDS. 151 Prof. Lister has recently substituted oakum, or what he suggests as a substitute, several la}^ers of muslin gauze dipped in a mixture formed by melting together 16 parts of paraffin, 4 of resin, and 1 of crystal- lized carbolic acid. During the dressing of a wound a "cloud of spray of 1 to 40 carbolic lotion" should be thrown over the part by means of an atomizer, and all instruments employed should be smeared with an oily solution of the acid, 1 part to 10. As has already been said, the merits of the antiseptic method cannot yet be considered as positively determined. Failure on the part of other surgeons to attain the expected results, is attributed by the advo- cates of the plan to some mistake or neglect in the application; and such may doubtless be the case. But it is obvious that any mode of treatment which is so intricate and complicated as to elude the skill of such excellent surgeons as have failed with the antiseptic dressing, is not likely ever to be adapted for general emplo}Tment. Amputation in Lacerated and Contused Wounds—In many of the worst cases of lacerated and contused wound no treatment will avail, short of removal of the injured limb. Thus, if an arm or leg be en- tirely torn awa}T, or if all the soft parts and bones be crushed together into a pulp-like mass, there can be no question as to the propriety of amputation. Those cases, however, in which the soft tissues are alone involved, the bones escaping injury, present more difficulty; there is a popular notion that cases of this kind do not require amputation; it is a mere flesh wound, it is said, and the surgeon ought to be able to cure it. I am well convinced, however, that when the skin and muscles are extensively torn and separated, even if the bone be whole, especially in the lower extremity, amputation is more often necessary than is com- monly supposed. It must be remembered that the appearance of the skin often gives an imperfect idea of the amount of injury beneath; I have not unfrequently found the skin apparently healthy and uninjured, ' when, by insinuating the finger beneath the surface, all the deeper-seated tissues, muscles, vessels, and nerves, were found pulpefied as it were, and crushed into an almost indistinguishable mass. If amputation be required, it should be done as soon as sufficient reaction has occurred; the advantages of primary over secondary amputation were fully considered in Chapter V., and need not be referred to here. If an attempt be made to save the limb, however, secondary amputation may become necessary from the occurrence of hemorrhage, or from the onset of one of the forms of gangrene described on page 148. If the true traumatic gangrene should occur, amputation must be at once performed, though the chances of a successful issue are, it must be confessed, under these circumstances, very doubtful. It is, perhaps, scarcely necessary to give the caution not to be deceived into amputating for a mere superficial slough, an error which can be avoided by carefully watching the case for a few hours, when, if mortification have really taken place, the occurrence of putre- factive changes in the part will sufficiently clear up the diagnosis. When amputation is resorted to under these circumstances, it should be done at a point sufficiently removed from the seat of gangrene, to avoid, if possible, the recurrence of the disease in the stump. Brush-burn is a name used by Mr. Erichsen for the form of contused wound which is produced by violent friction. It is frequently caused in manufacturing districts, by portions of the body being caught by rapidly revolving straps of leather or other material. Brush-burn may vary in severity from a mere superficial abrasion to absolute destruction of the skin and subjacent tissues. It is a very painful injury, but not 152 EFFECTS OF INJURIES IN GENERAL. dangerous, unless very extensive and severe, and it presents no peculiar indications. The part is to be protected from the air, the separation of sloughs promoted by poultices, etc., and the resulting ulcer treated on general principles. Gunshot wounds will form the subject of the next chapter. Punctured Wounds.—These, as their name implies, are such wounds as are inflicted with the point, rather than with the edge, of a weapon. If the point be sharp, the wound approaches somewhat the character of an incised wound; if dull, the injury more resembles a con- tused wound. Punctured wounds are always painful, and are apt to be followed by a good deal of swelling and inflammation. If deep, and es- pecially if they penetrate an important cavity, they are attended by much risk of life. The form of punctured wound most frequently met with in civil practice is that produced by the common sewing-needle, which easily penetrates the flesh, and then is broken off, the point remaining in the tissues. These wounds may be met with in any part of the body, but are, for obvious reasons, most often found in the hands, feet, knees, and buttocks. If the surgeon see such a case shortly after the intro- duction of the needle, he should, if possible, at once remove the foreign body. Its position can usually be detected, even if it cannot be seen, by a sensation of limited resistance offered to the surgeon's fingers on careful palpation. If it be necessary to cut down upon the needle, the incision should be made somewhat obliquely to the position of the foreign body, so that it may be reached with suitable forceps a short distance below the point at which it is broken ; it is occasionally more convenient to push the needle onwards, thus making its point emerge by a counter-opening at a little distance. If the case be not seen for some hours after the introduction of the needle, when swelling has already occurred, or if unskilful efforts at extraction have only served more deeply to imbed the foreign body, it is often impossible for the surgeon to satisfy himself as to the position of the needle. In such cases it is usually better to wait until the establishment of suppuration has dislodged the foreign body, when it will gradually work its way towards the surface. The presence or absence of a needle might, in case of doubt, be determined by the magnetic test of Mr. Marshall, holding a powerful magnet upon the part for fifteen or twenty minutes, so as to influence the fragment, the presence of which would then be revealed by the deflection of a polarized needle delicately suspended above it. Very serious consequences sometimes result from the prick of a needle; I have known necrosis of the entire shaft of the humerus, due to a wound of the periosteum thus inflicted. After the removal of the foreign body, cases of needle wound are to be treated on general principles'. If an important part, such as the knee-joint, is involved, entire rest and the local use of dry cold will be particularly indicated. Bayonet Wounds form almost the only class of punctured wounds now met with in civilized warfare. They are very rare, only 143 cases being re- corded in Circular Xo. 6, S. G. 0., 1865, compared with over 85,000 wounds of other descriptions; of these 143, only six proved fatal. Formerly when duelling was very frequently resorted to by soldiers, the sraail- sword was the weapon usually employed, and punctured wounds were thus constantly inflicted; they were treated by the drummers of the regiment, who sucked the part dry from blood, and then applied a piece of chewed paper or wet cloth to the wound, which frequently healed under this treatment in a remarkably short space of time. This mode PUNCTURED WOUNDS. 153 of practice is said by Percy and Laurent to have originated among the Romans (who employed suction as a remedy for poisoned wounds), and to have been introduced into military surgery by Cato, who would not allow doctors in his army, disliking them because they were usually of Grecian birth. Arrow Wounds are frequently met with on our western border in con- flicts with the Indians. They are very serious injuries, being particu- larly fatal when they involve the abdominal cavity. The following tables, taken from an excellent paper, by Dr. J. H. Bill, in the American Journal of the Medical Sciences for October, 1862, show the relative fatality of arrow wounds in different parts of the body, and the causes of death in fatal cases :—■ Head. o I. u B "a a e. w Chest. Abdomen. 1 a> P. P. & 1 OP O h3 ■a 2 = « "£ o 1* ■a a to a a © 3* ■a ° a o 5* Total. No. of cases saved... No. of cases died.... l 2 2 1 2 2 4 9 2 15 3 31 27 1 5 1 51 29 Total............... 5 1 2 15 2 21 28 6 80 Cause of death. to 03 ■If ■3 o 5 s '3 o p., a o $ a" £"3 BS o 9 ce o o> S P. E w si a .2 'a o a a a Oh o| a 2 a 2 ° Pi **"5 » a Total. 7 13 2 2 1 1 1 1 1 29 The great danger in cases of arrow wound is, as shown by Dr. BilL from the head of the weapon becoming detached from the shaft, and remaining in the wound as a foreign body of the worst description. Hence, the importance of not hastily pulling the shaft away while leav- ing the head, and the equal importance of careful but persistent efforts to remove the latter. This may often be done by catching the head of the arrow in a strong wire loop, as recommended by Dr. Bill, or it may be sometimes better to make a counter-opening, and in case of a chest wound, if necessary for this purpose, even to cut through the rib with a trephine. It is commonly believed that the Indian tribes make use of poisoned arrows: it would appear, however, from the reports of Dr. Bill and other army surgeons, that in reality this is very seldom done; I am, however, informed by Dr. Schell, who was stationed for some time at Fort Lar- amie, that it is the universal custom to dip the arrows in blood, which is allowed to dry on them, and it is not improbable, therefore, that septic material may thus be occasionally inoculated through a wound. Tooth Wounds.—Quite severe injuries are occasionally inflicted by bites, even when there is no evidence of the introduction of any morbid poison. Prof. Gross has met with several cases in which extensive inflam- 1 One of these perished from a gunshot wound. 15i • EFFECTS OF INJURIES IN GENERAL. mation and great suffering followed abrasions of the hand received in striking another person on the mouth. The treatment of punctured wounds consists in the use of simple ano- dyne dressings, and in the adoption of means to prevent the develop- ment of excessive inflammation. Poisoned Wounds.—The Stings of Insects are seldom productive of serious- consequences, in this country at least. In tropical climates the insects appear to be more venomous, and, according to the reports- of African and other travellers, death not unfrequently results from such a cause. Even in this part of the world, however, death, sometimes preceded by gangrene, has occasionally resulted from the sting of a bee or the bite of a mosquito, probably owing to idiosyncrasy on the part of the patient. The pain of a sting may be relieved by the application of spirit of hartshorn (liq. ammonia?), and the subsequent inflammation should be treated on general principles. Snake Bites are often productive of serious symptoms, and not unfre- quently of death. All snakes, however, are not venomous ; and even in the case of those which are known to be poisonous, if by the action of biting a few times they have exhausted their stock of venom (which in the instance of the rattlesnake is contained in a small pouch under the upper jaw), the wounds which they can then inflict, until the venom reaccumulates, may be no more serious than other punctured wounds of similar characters. The bite of the rattlesnake is usually attended with much pain, though this is not always the case; there is sometimes free external bleeding, and always rapid interstitial hemorrhage, causing great swelling of the affected part, which is usually one or other extremity. In cases which terminate unfavorably, the swelling rapidly ascends the limb, which is deeply discolored; vesications make their appearance, and the part falls into a gangrenous condition. In favorable cases, the swelling and other local symptoms disappear almost as rapidly as they came. The constitutional symptoms of rattlesnake poisoning are those of extreme prostration, the mind often remaining clear until within a few minutes of the fatal issue. Death may take place in a very short time (forty minutes only in a case reported by Dr. Shapleigh), from the direct effect of the poison on the nervous system, or after the lapse of several days or weeks, from extensive sloughing and suppuration resulting from the local injury. The coagulability of the blood appears to be much impaired by the effect of the poison, this fact accounting for the great interstitial hemorrhage, and consequent swelling and discoloration? Various substances have been proposed as antidotes to snake poison, those which have attained most reputation being the eau de luce (con- taining ammonia), the Tanjore pill (of which arsenic is a principal ingre- dient), and Bibron's antidote (containing corrosive sublimate, bromine, and iodide of potassium) ; still more recently, Prof. Halford, of Austra- lia, has proposed the direct injection into the veins of dilute liquor am- monia?, and has reported several cases in which the treatment was fol- lowed by recovery. The use of ammonia in this way might doubtless prove efficient as a cardiac stimulant, but the treatment has completely failed in the hands- of Prof. Fayrer, and there seems to have been a doubt as to the venomous nature of the snakes, in some of those cases in which success followed the use of the remedy. There is no evidence of advantage from the use of any of the antidotes above mentioned in cases of rattlesnake poisoning; the remedy attri- POISONED WOUNDS. 155 buted to Prof. Bibron, which was highly esteemed a few years ago, is now, I believe, abandoned even by those who most highly extolled its virtues. The treatment recommended by Dr. S. W. Mitchell, who is one of the highest living authorities on this subject, consists in the internal administration of alcoholic stimulus, of course not pushed to the point of producing deep intoxication, with suction by means of a cupping-glass, and the local use of the intermittent ligature. The inter- mittent ligature consists of a tourniquet applied above the injured part, so as to interrupt the blood current, except when momentarily relaxed by the surgeon; by the use of this means a small portion of the venom can be admitted at a time into the general circulation, and the enemy, as it were, met and fought in detachments. The warmth of the body should be kept up to the normal standard, by the use of external heat; and, should it be found impossible to produce sufficient stimulation through the stomach, the inhalation of the fumes of warm alcohol, or even of ether, might be resorted to. Bites of Rabid Animals, especially cats and dogs, sometimes prove fatal through the occurrence of Hydrophobia. The peculiar poison which produces this frightful affection appears to be communicated by means of the saliva, though whether it originate in that secretion or be merely mixed with it, coming from other structures of the mouth, is uncertain. The proportion of cases of hydrophobia to the number of persons bitten bj' dogs or other animals supposed to be mad, is very small, only 71 deaths from this affection having occurred in London in twent}r-nine years, an annual average of less than 2j. After the reception of a bite, the poison may remain latent for a variable period, the limits of which have been placed at as short a time as one day, and at an interval as long as forty years. The truth appears to be that the stage of incubation may vary from about four weeks to eleven months, sometimes, however, undoubt- edly surpassing the latter limit. This difference is supposed, by Mr. Forster, to depend on the part bitten, and the circumstances under which the bite is received. If the face be the seat of injury, the period of latency will probably not exceed four or five weeks, and if the disease have not appeared in that time, the patient may be considered safe. When the hand is the part affected, the period of latency varies from five weeks to a year; and when the clothes have been bitten through before the skin is injured, several years may elapse before the development of the disease.1 The wound is usually healed long before any manifestations of hydrophobia occur, and the invasion of the latter is often unattended by local symptoms, though occasionally shooting pains and twitchings are felt at the seat of original injury. The development of hydrophobia is usually preceded for some days by a feeling of general malaise, to- gether with chills, flushes, and giddiness. The most characteristic spe- cial symptoms of the disease, and those which Mr. Forster considers in themselves sufficient for diagnostic purposes, are intense pain and cutaneous sensibility, and spasm of the pharyngeal muscles, rendering it almost impossible to swallow anything, but especially liquids. To these there is usually added a feeling of great anxiety and a sense of impending danger, together with delusions alternating with the wildest delirium. There may be general convulsions, while there are almost always spasmodic movements of the mouth and of the laryngeal muscles, with expectoration of viscid and very tenacious mucus and saliva; hence the popular notion that the patient barks and tries to bite. Hjdro- phobia is, I believe, invariably a fatal affection. Death may occur in 1 Guy's Hosp. Reports, 3d s., vol. xii. p. 20. 156 EFFECTS OF INJURIES IN GENERAL. one day, or life may be prolonged for nearly a week. As a preventive measure, excision of the part bitten is usually recommended. Mr. Youatt had great confidence in cauterization with nitrate of silver, and I may add, that I was told by a negro, who was for many years chief "dog- catcher" in this city, that he himself had been bitten many times by dogs suspected of being mad, and had never suffered any unpleasant consequences, having always used this remedy. I am disposed, how- ever, to question (with Mr. Forster) whether either of these plans is really productive of benefit; the immense majority of bites will not be followed by hydrophobia under any circumstances, and, on the other hand, hydrophobia has occurred even after free excision of the injured part. When the disease occurs, the patient must be kept quiet in a darkened room, and free from all avoidable sources of irritation; his strength must be supported by such concentrated food and stimulus as can be taken, or by nutritious enemata, while an ice-bag may be placed to the spine, as recommended by Dr. Todd and Mr. Erichsen, and the violence of the spasms relieved by the inhalation of ether. The only post-mortem appearance which can be considered as characteristic, is, according to Mr. Forster, dilatation of the pharynx. Dissection Wounds are less frequently productive of unpleasant conse- quences at the present day, when anatomical subjects are prepared with antiseptic agents, than formerly; it is indeed much oftener from making autopsies, especially in cases of erysipelas, puerperal peritonitis, etc., than from the dissection of ordinary subjects, that this form of poisoned wound is met with. Even in performing surgical operations, surgeons are occasionally exposed to this form of injury; witness the melancholy case of the late Mr. Collis, of Dublin, who died from the effects of a slight wound received in excising an upper jaw. A cut re- ceived in dissecting or in operating may act merely as any other wound, producing an inflammatory condition, which will of course be aggra- vated if the person be in a depressed state of health when the injury is inflicted. Under such circumstances, the wounded part will swell, be- coming hot and painful, and the neighboring lymphatics will probably become involved, with enlargement of the axillary glands, and a condi- tion of general febrile disturbance. The inflammation may end in reso- lution, or may run on to suppuration, pursuing very much the same course as a severe whitlow. In other cases there is a positive inocula- tion of septic material, followed by diffuse cellular inflammation, or by phlegmonous erysipelas, involving a considerable part of the body, and attended by extensive suppuration, and perhaps sloughing; the o-eneral symptoms are those of extreme depression, and the patient dies of pyaemia or septicaemia, or recovers after a long and tedious convalescence, with his health, perhaps, permanently impaired. The first symptom of this more serious form of the affection is usually a small vesicle, which appears at the seat of the injury, sometimes within twelve hours, but usually on the second or third day. • If a wound is received in dissecting, it is proper to tie a ligature around the part to encourage bleeding, and to wash the wound thoroughly with soap and water; after which suction should be practised, provided there is no abrasion about the mouth. The benefit of cauterization in these cases is somewhat doubtful, but if it be thought proper to employ it, strong nitric acid or the acid nitrate of mercury will probably prove the best agent. If, in spite of these precautionary measures, the wound give further trouble, the treatment must vary according to the form which the symptoms assume. The simple inflammatory affection which CHARACTERS OF GUNSHOT WOUNDS. 157 was first described, should be treated on general principles, poultices or other soothing applications being made to the injured part, and laxa- tives and diaphoretics administered internally. In the more serious form, in which there is evidence of blood-poisoning, more active measures must be adopted: the vesicle and adjacent parts should be freely incised, and the wound washed with diluted tincture of iodine. Anodyne fomen- tations may be then applied, and the strength of the patient must be kept up by the free use of stimulants and food, with quinia, camphor, and ammonia. If abscesses form, they should be opened as soon as fluctuation is detected. The proportion of recoveries from this form of the affection is stated by Travers to be but one in seven: if the case terminate favorably, the patient should be sent as soon as possible to the country, to recruit his shattered health by change of air and scene. CHAPTER VIII. GUNSHOT WOUNDS. It is not my intention, nor, indeed, would it be possible, within the limits of this chapter, to attempt a full description of gunshot injuries, and of their modes of treatment. American surgeons have had ample opportunities for the study of this class of injuries during the last ten years—more ample, it is to be hoped, than will again be afforded for a very long period; still, injuries from firearms are often enough met with in civil practice to render it important for every surgeon to be familiar with their more prominent features and peculiarities, and to be pre- pared to perform any of the operations which their treatment especially demands. Characters of Gunshot Wounds.—These vary according to the nature of the projectile by which the wound is inflicted, and the force with which it produces its effect. The momentum of a gunshot projec- tile is an important matter for the surgeon's consideration. This de- pends upon two factors—the mass or weight of the projectile, and the velocity which it possesses at the moment of striking the body ; thus, if a cannon-ball and a musket-ball, moving with the same velocity, strike at the same moment, the cannon-ball, from its greater mass, will have a greater momentum, and will produce the greater injury. A charge of powder alone, without any ball, or the wadding of the gun, if the latter be fired at short range, may produce a serious or even fatal injury, the great velocity making up for the slight mass. A charge of small shot, if the gun be discharged in close proximity to the person struck, may enter the body en masse, as it were, and pro- duce a large, ragged wound; or if the hand be struck, as occasionally happens to sportsmen from the premature discharge of a fowling-piece, may absoluteJ3rblow off a portion of the member, as effectually as would be done by a piece of shell or a round shot, fired at a greater distance. When small shot scatter before they strike, they produce slighter wounds, though even then a single shot may destroy the eye, or cause fatal hemor- rhage by wounding a large artery or vein. 158 GUNSHOT WOUNDS. Bullet wounds have increased greatly in severity since the introduc- tion of rifled muskets and of conoidal balls. The old round musket-ball. fired from a smooth bore, produced a comparatively slight wound ; thus I have on several occasions seen patients who had what might be called "button-hole fractures" of the tibia, caused in this wajT; simply a round aperture in the front of the bone, the ball sometimes lodging, and some- times going completely through the limb, but causing no splintering, and no great laceration of the soft tissues. The peculiar shape of the modern conoidal ball causes it to meet with much less resistance from the air, while the spiral rotatory motion which is imparted to it by the grooves of the modern rifled firearm enables it to retain much more of its initial velocity, and thus to strike with much greater momentum than the old form of musket-ball; moreover, from its centre of gravity not coinciding with its centre of figure, in its passage through the air it acquires a peculiar dip, causing it to strike obliquely, making a large wound, ploughing and tearing up the soft parts, and splintering the bones in all directions. Thus, it is not uncommon for a long bone, such as the tibia or humerus, when struck by a conoidal ball, to be splintered and split both upwards and downwards, to the epiphyseal lines, or even into the adjoining articulations. Round shot or cannon-balls, unless moving with very slight velocity, are apt to tear off an entire limb, or whatever part of the body they may happen to strike ; even when almost spent, and rolling along the ground with no more apparent force than a ten-pin ball, they are capable of pro- ducing most frightful injuries, as it is said foolhardy soldiers have oc- casionally learnt to their cost, in attempting to stop such a spent ball with the foot. The reason is obvious: though the velocit}' is slight, the mass and therefore the momentum are very great. On account of the great elasticity of the skin, it will occasionally escape injury from the blows of spent shot, while the parts beneath, bones, muscles, ves- sels, and nerves, may be frightfully torn or completely pulpefied. Such are the injuries which used to be attributed to the effects of the windoi a ball, passing close to, but apparently not coming in contact with, the person wounded. These injuries are apt to be followed by gangrene, which often seems to be due to rupture of the main artery, at a point higher than the seat of apparent lesion. Shell wounds are among the most fatal injuries met with in modern warfare. The explosion of a single shell may kill or mortally wound quite a number of persons; the injuries most analogous to. these which are met with in civil life, are such as are produced by accidents in blast- ing and mining, portions of metal or of stone, or splinters of wood, being hurled violently by the force of the explosion against the bystanders, and often inflicting most serious and even fatal lacerations. Nature of Gunshot Wounds.—In whatever way inflicted, -• 168 GUNSHOT WOUNDS. In the case of the separate bones of the forearm, however, most ex- cellent results may be obtained by excision. I have myself twice excised considerable portions of the ra- dius, in cases of gunshot fracture, one being a primary (Fig. 76), and the other a secondary opera- tion ; both patients made good re- coveries. Of 1689 completed cases of gun- shot fracture of the humerus, re- corded in Circular No. 6, " ampu- tation or excision was practised in 996, and conservative treatment was adopted in 693, with a ratio of mortality of 21 per cent, in the former, and 30 per cent, in the latter." These statistics are as yet incomplete, but, even taking them as they now stand, they show that in the upper extremity, gunshot fracture may often, though in a minority of cases, be recovered from without operation. In the lower extremity, the case is some- what different. The mortality of gunshot fracture of the upper third of the thigh is, indeed, less when treated by expectancy than after amputation, which, in this situation, is an extremely fatal operation; in the middle of the thigh, the mortality is about the same under either mode of treatment; but in the lower third, or in gunshot injury of the knee-joint, amputation gives much the best results. These points will appear from the following table, condensed from one in Circular No. 6:— Statistics of Gunshot Fractures. Mortality per cent. Upper third of femur..... Middle do. ..... Lower do. ..... Wound of knee-joint, with or without fracture Result of partial excision of radius for gunshot injury. (From a patient at the Episcopal Hospital.) Amputation. Expectation. 75.00 71.81 54.83 55.46 46.09 57.79 73.23 83.76 In gunshot fracture of the leg, if the splintering of the bones be not very great, and if the vessels and nerves have escaped injury, an attempt may be made to preserve the limb, the mortality, according to Circular No. 6, being but 24 per cent, under all modes of treatment. Remote Consequences of Gunshot Injury.—There are certain indirect or remote consequences of gunshot wounds which may demand the attention of the surgeon. These are principally manifested in the bones, the vessels, and the nerves. Bones.—The vitality of a bone may be seriously impaired by a gunshot wound, which, at first, is supposed to have inflicted no injury upon it. The subjects of contusion, and of contused wounds of bone, have been ably investigated by Dr. John A. Lidell, formerly surgeon in the U. S. INJUEIES OF VEINS. 169 Volunteer Corps, who has published his views in an elaborate paper in the American Journal of the Medical Sciences for July, 1865. Dr.Lidell has traced seven distinct conditions, which may result from contusion of bone, and each of which is fraught with more or less danger to the patient; these are: 1. Ecchymosis of the osseous tissue; 2. Ecchymosis of the medullary tissue; 3. Simple osteo-myelitis (attended with production of new bone, both from the periosteum and from the medulla); 4. Necrotic osteitis or an inflammation of bone, so severe in character as to terminate in necrosis; 5. Suppurative osteo-myelitis; 6. Gangrenous or septic osteo-myelitis (both this and the last-named condition are almost certain to terminate fatally); and 7. Necrosis produced directly by the con- tusion of bone, without the intervention of either ecchymosis or inflam- matory irritation. If the bone which is contused, be in the neighborhood of an articula- tion, the latter may undergo serious or even fatal disorganization; or if an important organ, as the brain, be adjacent, secondary visceral disease may ensue. Vessels—Traumatic aneurism of the circumscribed variety, occasion- ally, though rarely, follows a gunshot injury: the diffused traumatic aneurism is a more frequent result of these wounds, and constitutes a most serious affection. I have seen one case of arterio-venous wound, resulting in aneurismal varix, produced by a musket-ball passing directly between the femoral artery and vein. Nerves—Very curious nervous affections are occasionally observed as consequences of gunshot wounds. These affections may consist of para- lysis of either motion or sensation, or both, of hyperaesthesia, of choreic movements, etc. This subject has been particularly investigated by Drs. Mitchell, Morehouse, and Keen, of this city, whose labors in this depart- ment will be again referred to in a subsequent chapter.1 Encysted Balls.—Balls sometimes become encysted, that is, sur- rounded by a layer of dense cellular tissue, within which they may remain without producing any irritation, for a very long period. There are well-attested cases on record, in which encysted balls have remained harmlessly in the tissues for forty or even fifty years; in other cases, again, after a variable interval, they excite inflammation by acting as foreign bodies, and may produce serious or even fatal consequences. Especially when lodged in the lung or pleural cavity is this apt to be the case, so that it is given as a rule by many authorities, that any gun- shot wound of the thoracic cavity, in which the ball remains lodged, will sooner or later cause death. CHAPTER IX. INJURIES OF BLOODVESSELS. Injuries op Yeins. Subcutaneous Rupture of Veins occasionally occurs as a con- sequence of external violence, and is manifested by the extravasation 1 See also a remarkable case reported by Dr. J. H. Brinton, in Am. Journ. of Med. Sciences, Oct. 1870, p. 435. 170 INJURIES OF BLOODVESSELS. of a laro-e quantity of blood, which is, however, usually absorbed again in the course of a few days; or the blood may coagulate, the clot subsequently exciting suppuration, or possibly becoming organized, as pointed out in Chapter VII. More rarely, the blood may become en- cysted in a fluid state, constituting what is sometimes called a venous aneurism. Open Wounds of Veins are not unfrequently met with in civil practice, and occasionally give rise to the most serious consequences. Hemorrhage from a Wounded Vein is marked by the even and rapid flow, and the dark color1 of the effused blood. In certain situations, as at the root of the neck, or under peculiar circumstances, as when veins are affected by varicose disease, the hemorrhage may be so profuse as to endanger life. Wounds of the internal jugular vein are indeed extremely fatal accidents, eighty-five cases collected by Dr. S. W. Gross having been followed by death in no less than thirty-seven instances. Hemorrhage from superficial veins can usually be readily controlled by pressure, or even by position. Thus the most profuse bleeding, from rupture of a vein in a varicose ulcer of the leg, may often be checked, simply by elevating the limb. The large superficial veins on the back of the hand are often wounded by accidents from broken glass; in such cases I have found it a good plan to transfix both ends of the bleed- ing vessel with a metallic suture, thus arresting the hemorrhage and closing the wound at one and the same time. In any case in which pressure cannot conveniently be applied, the surgeon should not hesi- tate to use a ligature. There was formerly a great prejudice against the practice of tying veins, from the supposition that it was liable to induce pyaemia, but now that modern researches have shown that there is no necessary connection between that process and inflammation of the veins or phlebitis, the theoretical grounds for opposition are removed, and it is established by clinical observation that the risks of tying veins are much less than was formerly believed. The lateral ligature, which was first practised by Mr. Travers in a case of wound of the femoral vein, consists in pinching up the bleeding orifice, and throwing around it a delicate ligature, so as not to obliterate the calibre of the vessel; this plan, which has theoretical merits, is found in practice to be very apt to be followed by secondary hemorrhage, so that it is now generally abandoned, the vein being tied as an artery, above and below the bleed- ing point. The process by which nature arrests bleeding from a vein is essentially that which will be presently described in speaking of wounded arteries, a clot forming in the vessel, and the cut edges subse- quently uniting through the development of local inflammatory changes. After ligation, which corrugates but does not divide the coats of the vein, a clot forms on the distal side of the ligature, which gradually cuts its way through, as in the case of an artery, though in a shorter time in proportion to the size of the vessel. Phlebitis may follow a wound of a vein, and was formerly supposed to be the cause of pyaemia, which occasionally occurs and proves fatal after such an injury: this subject will be fully discussed in another part of the volume. 1 Dr. H. A. Potter, of Geneva, N.Y., has observed in eight cases of spinal injury, that the blood drawn from a vein is of arterial hue ; this observation has, however, not been confirmed by others. ENTRANCE OF AIR INTO VEINS. 171 Entrance of Air into Veins.—The most frightful and fatal conse- quence of venous wounds, though fortunately one which is rare, is the entrance of atmospheric air, and its transfer to the heart. This accident is principally met with in cases of wound of the internal jugular, or of the other large veins situated at the root of the neck, or in the axilla, and this part of the body is accordingly often spoken of by surgeons as the " dangerous region." It has, however, occurred in other parts of the body: thus, in a case of the late Prof. Mott's, serious though not fatal symptoms followed the entrance of air into the facial vein where it crosses the lower jaw, while this accident occurring in the femoral vein is supposed to have been the cause of death in a case of thigh amputation during the Crimean war.1 The mode in which air is pumped into the veins is easily understood: during the act of inspiration, a vacuum is created in the thorax, to supply which air rushes through the trachea or through any other opening into the interior of the chest; thus, in the case of wounds of the pleura, air is sucked in during inspiration, to such an extent as often to induce collapse of the lung and pneumothorax, and in the same way, if a large vein in the neighborhood of the thorax be wounded, and be prevented from collapsing by the natural connections of the part, by the position of the patient, or by a structural change in the vessel itself (to which the French give the name of canalization), the act of inspiration will mechanically and necessarily pump air into the open vein, precisely as it does through any other aperture into the chest. The local sigjis of entrance of air into a vein, consist in a peculiar sound, variously described as of a hissing, gurgling, sucking, or lapping character, and in the appearance of frothy bubbles in the wound. The constitutional symptoms are equally well marked. The patient cries out, impressed with a sense of certain and rapidly impending death, and falls almost instantly into a semi-collapsed state, moaning and perhaps struggling; the pulse is almost imperceptible, the action of the heart tumultuous but feeble, and the respiration difficult and oppressed. Death may occur immediately, but more commonly after an interval varying from a few minutes to an hour or more; or, if the quantity of air introduced be but small, recovery may gradually ensue, partial paralysis sometimes continuing for several hours or even a much longer time subsequent to the accident. The cause of death in these cases is somewhat obscure; Mr. Erichsen believes it to be the frothy condition of the blood, produced by the action of the heart, which prevents the due transfer of the circulating fluid through the pulmonary tissue, and thus secondarily causes a deficient supply of blood to the brain and nerve centres, inducing death by syn- cope. Sir Charles Bell believed that death was caused by the direct transference of air to the base of the brain, and, in confirmation of this view, Prof. Gross's observation may be referred to, viz., that animals may be rapidly killed by the injection of air into the carotid artery. Mr. Moore maintained that death was due to the entrance of air to the heart, impeding the action of the cardiac valves and thus stopping the circulation; while Dr. Cormack attributed the fatal result directly to paralysis of the right side of the heart from gaseous distention. Treatment.—As a preventive measure, the surgeon should exercise extreme caution in all operations about the root of the neck, or deep in 1 It is probable, also, that the entrance of air into the uterine veins is an occa- sional cause of sudden death after delivery, and after various operations upon the womb. (See an able paper by Dr. Greene, of Dorchester, in Amer. Journ. of Med. Sciences for Jan. 1864, pp. 38-65.) 172 INJURIES OF BLOODVESSELS. the axilla, using as much as possible the handle instead of the blade of his knife. It might also be desirable to have the large veins compressed by an assistant, or protected by serre-fines, between the seat of the ope- ration and the heart, and care should be taken not to place the veins in such a position as will prevent them from collapsing if wounded, whether by stretching the patient's head to the opposite side, by hastily elevating the shoulder, or by incautiously lifting a tumor from its bed. Mr. Erichsen recommends that the patient's chest should be swathed by a firm and broad bandage, as a precautionary measure, so as to limit as far as possi- ble the depth of the inspirations. Should a large vein in the "dangerous region" be wounded during an operation, or should the surgeon find such a wound in a case of cut-throat, etc., measures should instantly be taken to prevent the entrance of air, by the application of ligatures above and below the aperture. When this alarming accident has actually oc- curred, the first indication for treatment is obviously to prevent any further ingress of air, by making instant compression and then quickly applying a ligature. The subsequent treatment must consist chiefly in endeavoring to keep up the action of the heart by appropriate means. Of these, the most promising appear to me to be artificial respiration and the administration of stimulants. The patient should be in the re- cumbent position, and the extremities elevated so as to retain as much blood as possible in the central organs; to accomplish the same purpose, Mercier advised the application of tourniquets and compression of the abdominal aorta. Artificial respiration may be practised with suitable bellows, or simply by the surgeon's mouth. Sylvester's or Hall's method would scarcely be applicable in these cases, on account of the situation of the wound. Various other plans have been suggested, among which may be mentioned—(1) an attempt to suck out the air by means of a canula introduced into the wounded vein, into the right jugular vein, or even into the heart itself; (2) bleeding from the right jugular vein or from the temporal artery; (3) tracheotomy; and (4) the injection of warm water into the heart. I am not aware, however, that there are any cases on record which prove the efficiency of any of these methods. Galvan- ism might rationally be applied to the cardiac region, though I should be disposed to trust more to the use of stimulants and to artificial res- piration. Remote Consequences of Injuries of Veins.—A clot may form in a vein as the result of injury (thrombosis), and may subsequently undergo disintegration, the fragments being carried to the right side of the heart and thence to the lungs, plugging the minute pulmonary arteries (embolism), and thus giving rise to the formation of what are commonly but incorrectly called metastatic abscesses. This condition, which is in no degree necessarily connected with phlebitis, will be again referred to in the chapter on pyaemia. On the other hand, a clot in a vein may undergo a process of gradual contraction, induration, and decolorization, becoming finally calcified, and constituting what is called a phlebolite, or vein-stone. These phle- bolites, however, usually result from clots due to stagnation, without external violence, and are consequently chiefly met with in the veins of the pelvis, genital organs, and lower extremities. INJURIES OF ARTERIES. 173 Injuries of Arteries. Contusion of an Artery may exist, without giving at first any evidence of its occurrence. The secondary results of arterial contusion depend upon the severity of the injury; if this have been very great, a portion of the wall of the vessel may slough, and cause secondary hemor- rhage or extravasation; if the violence have been less, the vessel may undergo obliteration, or in very slight cases may recover without evil consequences. The obliteration of an artery, occurring some hours or days after the reception of an injury, is usually attributed to the effect of inflammation; I believe, however, that it is more commonly due to the plugging of the vessel, either by embolism (fragments of clot being carried from another part of the circulation), or more rarely to an actual thrombosis in situ, clotting taking place in the injured vessel itself. As a result of this obliteration, or infarctus, as it is called by French writers, gangrene or serious visceral degeneration may occur, according to the size and situation of the vessel. Thus, in two cases of injury in the lumbar region, Dr. Moxon found complete thrombosis of the renal arte- ries, with corresponding incipient degeneration of the kidneys. Rupture or Laceration of an Artery may be either partial or complete; partial laceration generally occurs without external wound, and involves the two inner coats of the artery, the elasticity of the outer coat preserving it from injury. This accident may form the starting- point for the development of an aneurism at a subsequent period^; or the torn inner coats of the vessel curling upon themselves, may furnish a nidus for the occurrence of coagulation, which, as in the case of contu- sion, may cause gangrene of the part below the seat of injury; or, again, the lacerated inner coats may turn downwards, and by their mechanical valvular action produce gangrene, by directly interfering with the circulation. Complete rupture of an artery may occur subcu- taneously, or in an open wound. In the latter case, the nature of the accident may be obvious from the profuse arterial bleeding, though in other instances, if the coats of the vessel are twisted upon themselves, there may be scarcely any hemorrhage, the artery, perhaps, hanging out of the wound and pulsating, and yet no blood escaping. When an artery is torn across subcutaneously, there may be wide-spread extrava- sation, or the development of one or other form of traumatic aneurism, according to the size and position of the vessel. Wounds of Arteries.—Non-penetrating wounds of arteries occa- sionally, but very rarely, occur. In these, the external coat is divided, with, perhaps, a portion of the middle coat. There is no primary hemor- rhage in these cases, but the inner coat almost invariably yields after a few days, when fatal bleeding may ensue. Hence, a partially divided artery should always be ligated, as a precautionary measure. Penetrating wounds of arteries, if very small (consisting of a mere puncture with a fine needle), may not be productive of evil consequences; but if the puncture be larger, as with a tenaculum, secondary if not primary hemorrhage will almost certainly follow. Incised wounds of arteries bleed more or less freely, according to the size and direction of the wound: thus, a longitudinal wound will, in consequence of the ana- tomical arrangement of the arterial coats, gape less, and consequently bleed less than one which has an oblique direction, while a transverse wound will bleed more than either. An artery which is completely cut 174 INJURIES OF BLOODVESSELS. across bleeds less, other things being equal, than one which is only partially divided; for the complete section of the vessel allows partial retraction and contraction to occur, and thus measurably lessens the size of the stream. A wound of an artery at the bottom of a narrow and tortuous passage through muscular or other tissue, approaches to the nature of a subcutaneous laceration, and extensive extravasation may then occur with very little external bleeding; or the outer wound may actually heal, while the opening in the vessel remains patulous, in which case a form of traumatic aneurism may be developed. Hemorrhage from a Wounded Artery may usually be recog- nized by the bright vermilion hue of the effused blood, and by the fact that it is thrown out in jets corresponding to the pulsations of the heart, and does not flow in an even stream, as in cases of hemorrhage from veins. To this rule there are, however, exceptions; the blood from the proximal end of a divided artery, always, I believe, presents the characters which have been described, but from the distal end, for at least an hour after the infliction of the wound, or until the collateral circulation has been established, the flow of blood resembles that from a wounded vein. In other cases, however, if the anastomosis be very free, as in the palmar arch, both ends of the cut vessel will bleed in jets, and pour out blood of a bright red color. The force of the jet varies with the size and position of the artery, and the strength of the heart's action. A small branch wounded in close proximity to a main trunk, may bleed more furiously than a larger vessel divided at a more distant point, and, in general terms, the nearer a cut vessel is to the centre of circulation, the more profuselj' will it bleed. As the pulsations of the heart become weaker, the jet of blood has less force, and may finally cease with the occurrence of syncope, or may be arrested by the natural processes of contraction and retraction, which are set up in the wounded vessel. As already indicated, there may be profuse bleeding without any ex- ternal loss of blood. When bleeding occurs into one of the cavities of the body, as the peritoneal, it constitutes internal or concealed hemor- rhage; when into the areolar tissue of a part, it is known as extravasa- tion. Extravasation may prove directly fatal, by the amount of blood abstracted from the general circulation, may cause gangrene by pressure, especially upon the neighboring venous trunks, or, if circumscribed, may give rise to a form of traumatic aneurism. Constitutional Effects of Hemorrhage.—These are the same in kind, though differing in intensity, whether the bleeding proceed from arteries or veins, and whether the hemorrhage be apparent or concealed. The first effect of profuse hemorrhage is shown in the blanching of the surface; the cheeks and lips become pale, and the conjunctiva unnatu- rally white. The pulse becomes small and rapid, the heart endeavoring by increased action to compensate for diminished power. The patient feels languid; the respiration assumes a sighing character; the senses of sight and hearing are perverted, being sometimes preternaturally acute, but more often dulled; the temples throb, the skin becomes cold, and at last, rather suddenly, the patient faints. During the state of syncope, the heart's action is very feeble, and the breathing almost entirely dia- phragmatic. Death may occur in this condition from a continuance of the hemorrhage, but more commonly coagulation takes place in and around the mouth of the wounded vessel, and when consciousness returns, the bleeding is found to have spontaneously ceased. Vomiting frequently HEMORRHAGIC DIATHESIS. 175 occurs as syncope passes off. All the tissues of a patient who has lost much blood, appear soft and flabby, probably from the loss of the natural fluids of the part, which are rapidly absorbed into the depleted blood- vessels. Profuse or repeated hemorrhage, besides the symptoms which have been above described, often gives rise to distressing nervous phe- nomena, such as amaurosis, delirium, convulsions, or even hemiplegia: I have known death attributed to a cerebral clot, which the autopsy showed did not exist, the fatal result being simply and altogether owing to profuse and repeated secondar}^ hemorrhages. In recovering from the effects of loss of blood, the patient sometimes passes through a condition of constitutional irritation, with extreme restlessness and delirium, to which the name of "hemorrhagic fever" has been not in- aptly applied. The amount of blood which can be lost without serious consequences ensuing, varies greatly in different individuals. Infants and very old persons are, as a rule, more injuriously affected by hemorrhage than those in middle life. The amount of blood lost in ordinary childbirth might produce serious consequences under different circumstances, while, on the other hand, the mental state of a patient, as of one who has attempted suicide, or who believes himself to be bleeding to death, may actually cause a fatal result after the loss of a really insignificant quantity of blood. Habitual or Periodic Hemorrhage may be met with in either sex. In the female it may take the place of, or alternate with, the natural men- strual flow, when it constitutes what is called vicarious menstruation. In the male sex, bleeding from the hemorrhoidal veins sometimes occurs at certain periods of the year, and seems to be occasionally beneficial by relieving a state of plethora. Some persons bleed habitually from the nose, without any apparent solution of continuity having taken place; and Mr. Moore mentions an apparently authentic case, in which a young woman had severe spontaneous hemorrhages from the skin of the finger. In these cases the blood seems to ooze from numerous minute orifices, and subsequently to collect in the form of drops, which then flow over the surface. Hemorrhagic Diathesis.—This is the name used in England and in this country for the remarkable affection which the French call He- mophylie, and the Germans Hamophilie or Bluterkrankheit. Its chief manifestation, and that from which its name is derived, is a disposition to profuse bleeding, which may be spontaneous, or may follow upon the slightest wounds. It is often hereditary, and those in whom it exists are in childhood often subject to affections of the joints, and to inflam- mations of the lungs. The disease appears to depend on a peculiar condition of the blood (not mere want of plasticity, for it coagulates readily when removed from the body), and on a defective contractility of the arteries and capillaries. According to Wachsmuth, the spon- taneous hemorrhages may often be averted by smart purging with Glauber's salts, and, when they occur, may best be arrested by the ad- ministration of an infusion of arnica, or ergot in doses of five grains every half hour. The hemorrhages which follow wounds do not yield so readily to constitutional measures, and in these cases long-continued pressure, and the use of the actual cautery, appear to be the most prom- ising modes of treatment. The existence of the hemorrhagic diathesis would of course be a contra-indication to the performance of any opera- tion involving the use of the knife; it is somewhat remarkable, however, 176 INJURIES OF BLOODVESSELS. that cases which have proved fatal, from this cause, have almost inva- riably been those of trivial accidental wounds, or of such slight surgical procedures as the extraction of a tooth, or lancing the gum,—the onfv recorded instance, so far as I know, of the hemorrhagic diathesis having caused death after an important operation, being in a case of lithotomy reported by Mr. Durham. Process of Nature in Arresting Hemorrhage.—Before entering upon the subject of the treatment of arterial hemorrhage, it will be necessary to consider briefly the process adopted by nature in closing wounds of these vessels, a process which the surgeon endeavors to imitate by the appliances of art. The natural means by which arterial wounds are healed have been experimentally and very thoroughly investigated by Dr. J. F. D. Jones, whose monograph on the subject was published about sixty years ago, since which time very little if anything has been added to our information concerning the matter. The temporary means employed by nature to arrest hemorrhage are twofold: (1) the forma- tion of a clot, and (2) the contraction and retraction of the cut end of the vessel itself. The formation of a clot, which is greatly facilitated by the diminished force of the heart's action (one of the constitutional effects of hemorrhage, as we have already seen), was first noticed and its importance pointed out by the celebrated French surgeon Petit, in 1731. This distinguished writer described an external clot which he called couvercle, and an internal clot which he called bouchon. The in- ternal clot is somewhat conical in form, its base adhering to the sides of the vessel near its cut extremity, and its apex reaching upwards usually as high as the origin of the first anastomosing branch. It is formed gradually, and having served its temporal purpose, undergoes contrac- tion and partial absorption, and eventually appears to form a portion of the fibrous cord into which a closed artery is converted. The contrac- tion of a divided artery, and its retraction within its sheath, begin im- mediately upon its division ; this step of the process was first indicated by Morand in 1736, who did not deny, as some of his followers have done, that the formation of a clot is of temporary utility, though he clearly declared his conviction that the permanent closure of the vessel must depend upon the cicatrization of the artery itself. The retraction of the vessel within its sheath allows the blood to come in contact with the irregular surface of the latter, and thus facilitates the formation of the external coagulum, while its contraction as regards its calibre di- minishes the size of the stream, and thus tends to assist the formation of the internal clot, of which it likewise determines the shape. This contraction, as shown by Kirkland, extends to the origin of the nearest anastomosing branch. The permanent means by which a divided artery is closed, consist in the union of the cut edges by the development of local inflammatory changes, the continued contraction of the walls of the vessel upon the internal coagulum, and the final conversion of the lower end of the vessel into a dense, fibrous, impervious cord, into the construction of which a certain portion of the internal clot appears usually to enter. The exact mode in which the cicatrization of the cut extremity of the vessel is effected, is variously described by authors, ac- cording to the several views entertained as to the nature of the inflam- matory process (see Chap. I.). Most surgical writers, following Dr. Jones, have attributed the healing of divided arteries to the effusion of plastic matter from the vasa vasorum; the advocates of the cellular path- ology consider the process to be one of cell proliferation from the ves TREATMENT OF ARTERIAL HEMORRHAGE. 177 sel's walls; Prof. Beale and Mr. Lee consider the union to be due to the development of germinal matter, derived from the white corpuscles of the blood, while Billroth (practically returning to the old doctrine of Petit), attributes the healing of wounds of both arteries and veins to the or- ganization of the internal coagulum, through the multiplication of the white blood-corpuscles, aided perhaps by the entrance of wandering cells from the surrounding tissues. Without entering into a discussion of this question, which must be considered to a great degree one of purely theoretical interest, I may say that whatever be the method by which injuries of other tissues are repaired, by the same method, in all probability, are wounds of arteries united; and this method, as I have endeavored to show in previous chapters, is in all cases by means of that natural process which, for want of a better name, we call inflammation. We ma}', however, from what has been said, derive this practical lesson : that as the repair of an artery after injury appears to require the co-operation both of the walls of the vessel and of the contained blood, no means of arresting hemorrhage can be looked upon as philosophical, which ignores the efficiency and attempts to dispense with the aid of either of these agents. The appli- cation of this remark will be seen directly, when I come to speak of the local means of treating arterial hemorrhage. The changes which have been above described are best marked in the closure of the proximal or cardiac end of a divided artery. Those which take place in the distal extremity are the same in kind, though less in degree; especially is this the case as^-regards the internal coagu- lum, which in the distal end of the vessel is smaller than in the proxi- mal, and indeed in some cases entirely deficient; a circumstance which, as pointed out by Guthrie, may probably account for a fact which has long been recognized by surgeons, that secondary hemorrhage usually occurs from the distal extremity of a wounded vessel. In the case of partially divided arteries, the process is essentially the same; a clot forms between the sheath and the vessel itself, and com- presses the latter; this pressure may likewise be aided by the formation of a clot in the external wound. The permanent closure of the arterial incision is effected, as in the case of complete division, by the inflam- matory process. Very slight wounds, especially if longitudinal, may close without the calibre of the artery being obliterated; if, however, the size of the wound be equal to one-fourth of the circumference of the vessel, the latter will almost inevitably be converted into an impervious cord at the seat of injury, and it is probable that, in these cases, the healing process is assisted by the formation of an internal, as well as an external coagulum. When such a wound heals without the obliteration of the calibre of the artery, the inner coats of the latter do not unite very firmly, and an aneurism is apt to be subsequently developed. In an artery as large as the axillary or femoral, it may be stated, in general terms, that a wound of one-fourth of the circumference of the vessel will, if untreated, either cause death by hemorrhage, or give rise to a traumatic aneurism ; in the rare instances in which neither of these con- sequences ensues, the vessel will, in healing, be converted into an imper- vious fibrous cord. Treatment op Arterial Hemorrhage. The treatment of arterial hemorrhage should be both local and con- stitutional. The constitutional treatment consists in keeping the 12 178 INJURIES OF BLOODVESSELS. patient quiet in a recumbent position, and in avoiding any sudden ele- vation of the head or of the arms, which might induce fatal syncope. Food and stimulants should be cautiously administered in small quanti- ties at a time, and, if there be vomiting, may be given by enema. Opium should be freely used, and is a most valuable remedy in these cases. Drugs adapted to increase the plasticity of the blood, such as the muri- ated tincture of iron or the acetate of lead, may be administered, or ergot may be used, as recommended by Wachsmuth in cases of the hemorrhagic diathesis. As a last resort, transfusion of blood should certainly be tried, in the manner and with the precautions recommended in Chapter IV. The statistics of this operation in cases of hemorrhage, as given by Landois, are very favorable, 99 cases having afforded not less than 65 recoveries, while 11 of the 31 fatal cases (the result in 3 was doubtful) were moribund at the time transfusion was practised. For the anaemia left after recovery from the primary effects of hemorrhage, a long course of tonics, and especially of the preparations of iron, may be re- quired. The loss of blood in some cases is never entirely repaired during life, the patient remaining permanently blanched, though other- wise apparently in good health; or the debility resulting from hemor- rhage may act as a predisposing cause for the occurrence of tuberculosis or other morbid condition. The local treatment of arterial bleeding consists in the adoption of various measures, which may be either of a temporary, or of a permanent nature. Hemorrhage from a wounded artery may be temporarily checked by pressure. This maybe applied directly at the seat of injury, or indirectly upon the main artery of the part, at a point between the wound and the centre of the circulation. In the latter case compression is usually best exercised by the applica- tion of the tourniquet, the various forms of, and the modes of using which instrument have been sufficiently described in a previous chapter. In dealing with certain arteries, as the subclavian, to which a tourniquet cannot be applied, effectual pressure may be made with the handle of a large key (previously wrapped, so as to protect the skin), or other suitable implement; or if the clavicle be much displaced—as by an aneurismal tumor—Syme's plan might be employed, which consists in making an incision in the line of the artery, upon which direct pressure is then made by introducing the finger through the wound. For the permanent arrest of arterial hemorrhage, the surgeon ma}' have recourse to the use of—1, cold; 2,position; 3,pressure; 4, styptics; 5, cauteriza- tion; 6, torsion; 7, ligation) or 8, acupressure. 1. Cold is an efficient means of arresting hemorrhage from many vessels of small calibre. In some cases the presence of clotted blood in a wound appears to encourage further bleeding by acting just as a warm poultice would do, and the surgeon often finds that, upon sweeping away the clots and exposing the wound to the air, the hemorrhage ceases spontaneously. Hemorrhage from small vessels may often be arrested by pouring a stream of cold water over the part, or if the bleeding come from one of the mucous outlets of the body, as the mouth, nostrils, rectum, or vagina, by introducing small pieces of ice. Care must be taken, however, in the use of cold, not to continue its application too long, lest injurious depression or even sloughing should ensue. 2. Position may often be usefully employed to arrest, or, at any rate, to assist in arresting arterial hemorrhage. If the wound be in the lower limb, the part should be elevated by means of pillows or an inclined plane, so that, by the laws of hydraulics, the force of the circulation in PRESSURE AND STYPTICS. 179 the injured part may be diminished, and an opportunit}- given for the occurrence of the natural processes of repair. The same plan may be adopted for wounds of the upper extremity; while in treating wounds of the arteries of the "forearm or of the palmar arch, it will be found advantageous to forcibly flex the elbow—a modification of Hart's method of treating aneurism, which has afforded good results on more than one occasion. 3. Pressure, which, as we have seen, is the common mode of tempo- rarily checking hemorrhage, may be also efficiently used for its permanent arrest. It may be applied directly to the bleeding point by means of the graduated compress, or by the use of serrefines,or of small forceps; or indirectly, by bandaging the limb and flexing the proximal joint over a roller, or in the case of bleeding from cavities, by plugging the part with lint or compressed sponge. Sometimes pressure may be efficiently applied by means of a weight, as a bag of shot, or even loose shot, as was done in Dr. Smyth's remarkable case of successful ligation of the inno- minate artery, which will be again referred to. The graduated compress is made by laying together a number of pledgets of lint of gradually increasing dimensions, so that when completed the mass has the form of an inverted cone about an inch in height; the apex of this cone is ap- plied directly upon the bleeding point, all clots having been previously removed from the wound, and the compress is held in place by adhesive strips, while firm pressure is made upon it by means of a piece of cork or metal, secured with a bandage. In positions where the proximity of a bone gives a firm substance against which the vessel may be com- pressed, as in the case of wounds of the temporal artery, this will be found a very efficient mode of controlling hemorrhage. 4. Styptics.—These agents, when employed alone, are not of much use except in checking capillary oozing or the bleeding from very small vessels. The simplest and most convenient is ordinary diluted alcohol, the employment of which in operations has already been adverted to. The styptic of Pagliari, which has a good deal of reputation, particularly among French surgeons, contains alum and benzoic acid, and certainly seems in some cases to answer a very good purpose. Among the more powerful styptics may be especially mentioned the perchloride of iron, in substance, in solution, or in the form of the muriated tincture, and the persulphate, or Monsel's salt. The latter, in particular, is undoubt- edly a very powerful agent, and, when properly used, capable of serving a very good end; its indiscriminate employment in all cases of surgical hemorrhage has, however, been productive of a great deal of harm, not only on account of its effect in hindering primary union, but because the rapidity of its action, and the facility with which it can be applied,. have often induced inexperienced practitioners to neglect less eas}' but more trustworthy means of suppressing arterial bleeding. In conjunction with pressure, styptics are more valuable than by themselves; by applying the styptic upon the apex of the graduated compress, or, in the case of hemorrhage from deep fistulous wounds or from the mucous outlets of the body, by plugging the cavity with lint or sponge soaked in the styptic, a very powerful impression may be pro- duced. In a very interesting if inconclusive paper, published in the American Journal of Medical Sciences for October, 1865, Dr. J. M. Hol- loway advocates the employment of styptics, with pressure, in cases of consecutive hemorrhage from gunshot wounds, as often preferable to the 180 INJURIES OF BLOODVESSELS. use of the ligature; and though, of course, a practice founded on uni- versal experience is not to be revolutionized hy the record of a few ex- ceptional cases met with by any individual, still the instances mentioned by Dr. Holloway are of much interest, as showing that these means may occasionally prove successful even in dealing with such a large artery as the axillary. 5. Cauterization with a hot iron was, until within a comparatively short period, the principal means of arresting arterial bleeding at the command of the surgeon. Although the ligature was re-invented and powerfully advocated by the illustrious Pare, in the middle of the six- teenth century, it was not generally adopted for a long time subsequently, and we learn from the writings of Sharpe, of Guy's Hospital, only a little more than one hundred years ago, that even in his time the cautery and styptics were still preferred to the ligature, by many surgeons not only on the Continent, but even in some parts of England. Although no surgeon at the present day, probably, would use the hot iron in any case in which a ligature could be applied, there are some circumstances under which the cautery must still be resorted to; in some operations about the jaws, and in other cases in which, from the position of the bleeding vessel, or from the condition of the surrounding tissues, other modes of controlling hemorrhage are not available, or fail upon trial, the hot iron is a valuable application. The various forms of the cautery have already been described and figured in the chapter on Minor Surgery, and it will be sufficient to add here that when used for hemorrhage, as it is the co- agulant and not the destructive effect that is needed, the temperature of the iron should not be raised above a black heat. 6. Torsion, as a means of controlling the hemorrhage from cut arte- ries, was known to the ancients, but subsequently passed through a long period of oblivion, having been revived in the early part of this century, principally by the efforts of French and German surgeons, among whom may be specially named Amussat, Velpeau, and Fricke. Since then torsion has been occasionally used by surgeons, generally in dealing with small -arteries ; but the practice has within a very few years received a fresh impulse, and is now strongly advocated by several writers as a mode of treatment applicable to vessels of all sizes ; this movement has been most actively participated in by Prof. Syme, of Edinburgh, Prof. Humphrey, of Cambridge, and Messrs. Bryant and Forster, of Guy's Hos- pital, London. Torsion may be practised in several ways: Syme and Humphrey, following Amussat, draw the extremity of the artery out from its sheath, and twist it until it is twisted off; the surgeons of Guy's Hospital, on the other hand, adopt Velpeau's plan of leaving the twisted end attached, that it may give additional security by acting as a mechanical plug. Free torsion (that is, with a single pair of for- ceps) is recommended by Bryant for vessels of moderate size, and for all vessels in the extremities; limited torsion (in which the vessel is grasped with one pair of forceps and twisted with another, as shown in Fig. 77), for such arteries as are large and loosely connected. When it is not intended to twist off the end of the vessel, the number of turns should vary from six to eight, according to the size of the artery. The mechanism of torsion is as follows : the inner and middle coats are lace- rated and curl upon themselves, forming a nidus for the coagulation of blood, just as after ligation, or in the ordinary natural process of repair already described; the external coat is twisted into a cord, which serves LIGATION. 181 temporarily as a mechanical plug, and is eventually surrounded by bymph and incorporated with the adjoining tissues, or more commonly separated and thrown off by sloughing, just as the end of a vessel which has been submitted to the ligature. The artery is permanently closed by the in- Fig. 77. Limited torsion. flammatory process, at the point at which the middle and inner coats have given way. Torsion has now been so often successfully applied, even to large vessels, that it cannot, I think, any longer reasonably be doubted that it is an effectual mode of controlling hemorrhage; it is, according to Forster and H. Lee, even more applicable to large vessels than to small. I do not see, however, that it is at all a better mode than liga- tion, nor, I think, does it equal the latter in safety ; this point will be again referred to after I have described the remaining modes of con- trolling hemorrhage, ligation, and acupressure. A modification of the ordinary mode of effecting torsion has been recently suggested by Dr. S. Fleet Speir, of New York, who employs an instrument which he calls the "artery constrictor"; its action somewhat resembles that of the ecraseur, and it is designed to sever the internal and middle coats of the artery, thus allowing their invagination within the external coat, which is corrugated but not divided. The instrument is removed as soon as this has been accomplished. 7. Ligation.—The use of the ligature, though apparently known to the ancients, was afterwards completely forgotten, so that its introduc- tion into surgery by Pare*, in the sixteenth century, has all the merit of an original discovery. It was not, however, until long after Pare's time that the use of the ligature became universal, or indeed general; and the reason for this appears to have been not so much on account of innate obstinacy on the part of surgeons, as because the natural process by which hemorrhage is arrested not being understood, and ligation being conse- quently practised in a very defective manner, its results were corre- spondingly unsatisfactory. The ligature, as now used, is, I believe, when applicable, the very best method of checking arterial hemorrhage. The form and structure of the ligature, and its mode of application to the open ends of vessels, have already been described (page 98), and need not be again adverted to. When it is necessary to secure an artery in its con- tin uit}-, the ligature may be most conveniently passed beneath the vessel by means of an aneurismal needle (Fig. 78), or even an ordinary curved needle, or an eyed probe. The mechanism of the ligature in controlling hemorrhage is now well understood (thanks to the investigations of Dr. Jones), and the rules for its application thoroughly established. The illustrious John Hunter, even, did not appreciate the mode of action of the ligature, and accordingly we find that in his operations for aneurism 182 INJURIES OF BLOODVESSELS. he did not draw the noose tight, fearing to weaken the coats of the vessel—thus, as Dr. Jones subsequently showed, defeating the very object sought to be attained. The ligature should be applied with suffi- cient force to divide, smoothly and evenly, the inner and middle coats of the artery, while the outer coat is constricted within the noose. In tying the larger vessels, the giving way of the inner tunics of the artery is sometimes distinctly perceptible to the surgeon. The divided inner coats curl upon themselves, and assist the formation of an internal co- agulum, while the artery is permanently sealed by the occurrence of Fig. 78. Aneurismal needle, armed with a ligature. inflammatory changes, just as in the natural haemostatic process already described. The noose of the ligature is gradually loosened by ulcera- tion, and finally cuts its way through, or comes out bringing with it the constricted portion of the external arterial coat. The clot which is formed on the distal side of the ligature is usually smaller than that on its proximal side; in some cases one or even both clots maybe absent, and yet the artery be securely closed, which shows that the for- mation of a clot, though of great assistance, is not in all cases absolutely essential for the success of the ligature. Dr. B. Howard, of New York, has published some experiments to show that it is not invariably neces- sary to draw the ligature so tight as to divide the inner coats, but that mere narrowing of the arterial tube with a loose ligature, is suffi- cient sometimes to secure obliteration of the vessel. This (which is a revival of the teaching of Scarpa) was indeed known from the cases of Hunter, who, as We have seen, did not tighten his ligatures in operating for aneurism ; but I am not aware of any clinical facts which show that a loose ligature has any superiority over a tight one, while the universal experience of surgeons is that it is less safe, and has the additional disadvantage of not coming away so readily as one which is tightly drawn. The best material for a ligature is, as has been already said, ordinary fine whip-cord or silk. Various attempts have been made from time to time to substitute other materials which it has been supposed would produce less irritation and might become encysted or absorbed. Thus Sir Astley Cooper and Dr. Physick made use of animal ligatures, catgut or some similar substance,and this practice has since been occasionally adopted by other surgeons. Metallic ligatures were employed in a series of experi- ments on the lower animals by Dr. Levert, of Alabama, about forty years ago, and since then have been occasionally used in operations on the human subject. Dr. Levert found that wire ligatures tightly secured around the arteries of dogs, produced obliteration of the vessels, and that when both ends of the ligature were cut short, the loop became encysted, and remained in the wound an indefinite time without producing irrita- tion. Similar results have been since obtained by Sir J. Y. Simpson and RULES FOR LIGATING WOUNDED ARTERIES. 183 others. Dr. Howard, on the other hand, finds that wire ligatures, if drawn tight, produce marked inflammation and suppuration around the seat of ligation, and therefore recommends the use of loose wire ligatures. Metallic ligature threads have now been used a sufficient number of times in operations on the human subject, to warrant the belief that they are safe agents, and may properly be applied in cases in which it is desirable to leave the noose in situ and close the wound over it, as in certain operations upon the abdominal cavity: even in these cases, however, it is doubtful if the antiseptic short-cut ligature of Prof. Lister would not answer a still better purpose. Rules for Ligating Wounded Arteries.—In the application of ligatures to wounded arteries, there are certain rules which should be indelibly impressed upon the surgeon's mind: these are— 1. In cases of primary hemorrhage, no operation should be performed upon an artery, unless it is at the moment actually bleeding. In cases . of secondary hemorrhage, a different practice should be adopted, as will be presently seen: but in dealing with a recently wounded artery, if hemorrhage have ceased, the surgeon as a rule should not interfere, because (1) there is a fair prospect that the bleeding will not return; (2) the probability of discovering the source of hemorrhage is much less, when there is no stream of blood to point the surgeon's way, and (3) the incisions and manipulations which would be necessary in searching for the arterial wound would be a positive injury which would more than counterbalance any benefit that might probabl}r be obtained. In certain exceptional cases, however, the surgeon should not hesitate to apply a ligature even under these circumstances; for instance, if an artery were seen pulsating in a wound, it would be right to tie it even though it did not bleed, for in such a case the ligature could do no harm, and might prevent a great deal of subsequent mischief; again, if a patient were likely, for any reason, to be subjected to unusual risk of secondary hemorrhage, as, for instance, if it were necessary for him to be trans- ported to a distance, or if he were threatened with the invasion of de- lirium tremens, it might be proper to choose the lesser evil, and search for the wounded vessel, that it might be secured by a ligature. Under any circumstances the patient should be constant^ watched, and if the wound were in an extremity, it would be right to apply a provisional tourniquet, so that in case of secondary hemorrhage, all unnecessary loss of blood might be prevented. 2. In applying a ligature to a wounded artery, the surgeon should cut down upon it directly at the point from which it bleeds, and secure the ves- sel in the wound. This rule and the next were clearly laid down by John Bell, and most powerfully enforced by Guthrie, and yet, it is to be feared, are, even at the present day, too often practically ignored by operators. There are two principal reasons why this rule should be considered invari- able : (1) because it is often impossible to tell what vessel is wounded, until it is exposed in the wound itself; arid (2) because, even if this point could be determined, ligature of the main trunk above the wound would, in a vast number if not in the majority of cases, fail to arrest the bleeding. Thus it has happened that the superficial femoral artery has been tied for arterial hemorrhage from a wound of the thigh, and, bleeding continuing or recurring, it has been subsequently discovered that it was a branch of the profunda that was wounded; or the subclavian has been tied for sup- posed wound of the axillary artery, when the hemorrhage really came from the long thoracic. Again, if the main trunk be tied, the collateral 184 INJURIES OF BLOODVESSELS. circulation being quickly established, secondary hemorrhage is extremely apt to occur from the distal side of the arterial wound; or if there be collateral branches given off between the point of ligation and the wound, bleeding may occur even from the proximal side of the latter, when, if a second ligature be applied in the wound, the double obstruction will (at least in the lower extremity) almost invariably cause gangrene of the limb. Still further, deligation of the main trunk exposes the patient some- times to additional danger; thus, Liston having tied the external iliac for wound of a small branch of the common femoral, the patient died of peritonitis, a cause of death, it will be observed, which was directly con- nected with the operation, and entirely independent of the original injury. For these reasons, then, viz., that by this method only can the actual source of hemorrhage be determined; that thus only can probable secu- rity be afforded against secondary bleeding; that if secondary hemor- rhage should occur, this plan does not put out of the question further treatment; and that this plan does not entail any additional risk upon the patient, the rule should be invariable, that, whenever practicable, a bleed- ing artery should be directly cut down upon, and tied where it bleeds. In doing this, the surgeon should usually take the original wound as the guide for his incisions; should, however, the wound be very deep, it may be more convenient to reach the source of hemorrhage by making a counter- incision in the course of the vessels, cutting upon the end of a probe introduced to the bottom of the wound. Hemorrhage during the opera- tion should be guarded against by the use of a tourniquet, where this in- strument is applicable, or by pressure made by an assistant on the main trunk; in situations where this is impracticable, the surgeon should in- troduce one or two fingers into the wound, so as to compress the bleed- ing vessel while making the necessary incisions. This rule of tying an artery where it bleeds holds good for both primary and secondary hemor- rhage ; no matter what the condition of the wound may be, so long as there is a wound, it should be freely enlarged, and the vessel secured at the point whence the blood issues. This is often a difficult and tedious proceeding, particularly in wounds that are swollen and granulating, but it is a proceeding that the surgeon should consider imperative, when the occasion arises; and it is surely very reprehensible for any operator, in view of the vast accumulation of recorded experience on the subject from both civil and military practice, to persist in cases of arterial hemorrhage in tying the main trunk of a limb, merely because it is easier than to tie the vessel in the wound, or, still worse, because it enables him to perform what is considered a more important operation. 3. A third rule, and one closely connected with the preceding, is that two ligatures should be applied, one to each end of the artery if it be completely divided, and one on each side of the wound, if the latter have not completely severed the coats of the vessel. The reason for this rule is obvious: in many parts of the body the arterial anastomosis is so free that a ligature to the proximal side alone will not even tempo- rarily arrest the bleeding, the current of blood being immediately carried around to the distal extremity; in other cases, though a proximal liga- ture may serve to check the hemorrhage for a short time, as soon as the collateral circulation is fully established, bleeding will again be°in from the distal end of the vessel. If, as sometimes happens, the distal ex- tremity of the vessel be so retracted and surrounded by the adjoining tissues, that it cannot be found even after long and careful search the surgeon may plug the wound with a graduated compress, the apex of which is imbued with the solution of the persulphate of iron, and good LIGATURE IN THE CONTINUITY OF ARTERIES. 185 results may be hoped for from this proceeding; but, whenever it is practicable, the distal, as well as the proximal end of the vessel, should unquestionably be tied. If a large arterial branch be wounded immedi- ately below its origin, it is safer to regard the injury as one of the main trunk, and apply ligatures immediately above and below the origin of the branch, as well as on the distal side of the wound in the latter; so, on the other hand, if a large branch be given off immediate^ above or below an arterial wound, it is proper, after tying the injured vessel in the usual way, to apply an additional ligature to the branch. If this should not be done, there would be risk of secondary hemorrhage from deficiency of the internal coagulum, which, as has been mentioned, ex- tends only as far as the nearest anastomosing vessel. There are, it is true, a certain number of cases on record, in which the proximal ligature alone, or even the ligature of the main trunk at a distance from the wound, has arrested hemorrhage, which has not re- curred; but such cases are quite exceptional, and in no degree invalidate the force of this and the preceding rule of treatment, which might well be called golden rules. 4. However desirable it may be to tie a bleeding vessel in the wound, in certain situations it is impossible to do so; thus, in the case of wounds which penetrate the floor of the mouth, dividing branches of the external carotid, or in cases of hemorrhage into the mouth from the internal carotid, or within the pelvis from branches of the internal iliac, it is mani- festly impossible to reach the seat of the wound, and the surgeon's only resource is to tie the main trunk. Again, in cases of secondary hemor- rhage from wounds of the palmar arches, it may be necessary to deviate from the ordinary rule, and tie either the brachial, or the radial and ulnar arteries. Application of Ligatures in the Continuity of Arteries.—In apply- ing a ligature in the continuity of an artery, whether at the seat of wound or at a higher point, or in the Hunterian operation for aneurism, the surgeon is guided in making his incisions by the lines which he knows to correspond with the general course of the vessel. If there be a "wound, that should, of course, be the starting-point for the incision, but in other cases the operator must rely upon the pulsation of the vessel if that can be felt, and if not, upon his general anatomical know- ledge as to the course of the artery. It is well, especially when the Fig. 79. Grooved director. artery lies deeply, to make the incision, as recommended by Hargrave and Skey, somewhat obliquely to the course of the vessel, which can thus be more readily found than if the incision were directly in its line. The skin and superficial fascia may be divided by the first stroke of the knife, but afterwards the surgeon should proceed with great caution, taking up each successive layer of tissue with delicate forceps, and making a slight notch for the introduction of a grooved director (Fig. 79), upon which the layer is then carefully divided from below upwards. When the sheath of the vessel is reached, the surgeon picks it up in the same way with 186 INJURIES OF BLOODVESSELS. Exposure and division of the arterial sheath. forceps (Fig. 80), and makes an opening just sufficient to allow the passage of the needle which bears the ligature. This is then delicately introduced between the artery and vein, and very cautiously brought around the former so as to include no- Fig- 80- thing except the vessel itself. The point of the needle, which must be well ground down and rounded, is then teazed through the opening in the sheath (Fig. 81), a process which may be facilitated by a gentle touch with the knife, one end of the ligature drawn out, and the other drawn backwards with the needle, which must be withdrawn as gently as it was introduced. The operation is completed by tying the artery firmly and tightly with the reef- knot, and bringing both ends of the ligature out at the wound, which is closed with sutures and lightly dressed. If any small arterial branch should be cut during the operation, it should be twisted or tied, taking care to secure both ends; the chief precautions to be observed in passing the needle are not to wound the vein, and not to include the latter or any portion of it, or a nerve, in the noose of the ligature. Entanglement FiS- 81- of the vein would be very apt to cause phlebitis or gangrene, while ligature of the nerve would at least give unnecessary pain, and might possibly expose the patient to the risk of tetanus. It would likewise cause paralysis of the parts below, which in some situations might be productive of very grave conse- quences. If, in passing the needle, there should be a gush of blood, more in quantity than could be accounted for by the separation of the sheath, making it probable that the vein had been punctured, the surgeon should either suspend the operation and apply pressure, or should ex- tend his incision and reapply the ligature at a higher" point. To allow a ligature to remain which passed partially through a vein, would be equivalent to forming a seton through that vessel, and would certainly expose the patient to the risks of phlebitis, thrombosis, gangrene, and, possibly, embolism and secondary pyaemia. It is almost needless to say that the surgeon should be careful not to miss the artery, and tie instead a nerve or even a portion of condensed fascia, an accident which has occasionally happened in the hands of the most skilful operators. If the artery be very superficial, the surgeon should be correspondingly careful not to go too deeply in his first incision, which some operators, indeed, Passage of the needle and ligature. ACUPRESSURE. 187 prefer to make by pinching up a fold of skin, transfixing, and cutting from within outwards. In dividing the deeper structures the side of the knife should be used rather than the point, and the edge should always be directed away from the artery. After tying an artery in its continuity, the limb below should be kept warm until the collateral circulation is fully established ; the ligature will usually drop between the first and third weeks, according to the size of the vessel; should it remain too long, gentle traction and twist- ing may be practised, as in the case of ordinary ligatures on the cut ends of vessels. 8. Acupressure.—Acupressure, or the means of controlling arterial hemorrhage by pressure with a needle or pin, was first introduced to the notice of the profession by Sir J. Y. Simpson, in December, 1859. Tt has since then been employed more or less extensively by a great num- ber of surgeons, and after having been alternately extolled and con- demned, and having excited in the city of its birth one of the most virulent professional controversies of modern times, is now gradually assuming its proper place as one of the modes, and, under certain circum- stances, one of the best modes by which arterial bleeding can be arrested. Acupressure may be practised in several different ways, of which Prof. Pirrie and Dr. Keith, who have published a monograph on the subject, enumerate seven ; though for practical purposes the number might be reduced to four. In the first two of Pirrie's and Keith's methods, the vessel is compressed between a pin or needle and the soft tissues of the part; in the third, fourth, and sixth, between a pin or needle and a loop of fine flexible wire ; in the fifth (or Aberdeen method), the pressure is made by passing a pin or needle beneath the artery, which is then twisted upon itself by a quarter or half rotation of the pin; and in the seventh, the vessel is compressed between the pin and any bony prominence which may be conveniently situated. The first method is thus described by Simpson: " It consists in passing a long needle twice through the flaps or sides of a wound, so as to cross over and compress the mouth of the bleeding artery or its tube, just in the same way as in fastening a flower in the lapel of our coat, we cross over and compress the stalk of it with the pin which fixes it, and with this view pass the pin twice through the lapel.....When passing the needle in this method, the surgeon usually places the point of his left forefinger or of his thumb upon the mouth of the bleeding vessel, and with his right hand he introduces the needle from the cutaneous surface, and passes it right through the whole thickness of the flap till its point projects for a couple of lines or so from the surface of the wound, a little to the right side of the tube of the vessel. Then, by forcibly inclining the head of the needle towards his right, he brings the projecting portion of its point firmly down upon the site of the vessel, and after seeing that it thus quite shuts the artery, he makes it re-enter the flap as near as possible to the left side of the vessel, and pushes on the needle through the flesh till its point comes out again at the cutaneous surface. In this mode we use the cutaneous walls and component substance of the flap as a resisting medium, against which we compress and close the arterial tube." The exact mechanism of the first method can be readily understood from the accompanying wood-cuts (Figs.82, 83). In the second method, "a common short sewing- needle, threaded with a short piece of iron wire, for the purpose of after- wards retracting and removing it, is dipped down into the soft textures 188 INJURIES OF BLOODVESSELS. a little to one side of the vessel, then raised up and bridged over the artery, and t then finally dipped down again and thrust into the soft Fig. 83. Acupressure ; first method ; raw surface. Acupressure ; first method; cutaneous surface. tissues on the other side of the vessel" (Fig. 84). In the third method (Fig. 85), " the point of the needle is entered a few lines to one side of the vessel, then passed under or below it, and afterwards pushed on, so that the point again emerges a few lines beyond the vessel. The noose Fig. 84. Fig. 85. Acupressure ; second method. Acupressure; third method. Fig. 86. or duplicature of wire is next thrown over the point of the needle; then, after being carried across the mouth or site of the vessel, and passed around the eye end of the needle, it is pulled sufficiently tight to close the vessel; and lastly, it is fixed by making it turn by a half twist or twist around the stem of the needle." The fourth method is identical with the third, except that a long pin is substituted for the needle, the head of the pin remaining outside of the wound; while the sixth differs from the fourth merely in the way of fixing the wire, the ends of which are, in this method, " crossed behind the stem of the pin so as to embrace the bleeding mouth between them, . . pulled sufficiently tight to arrest the hemorrhage, thereafter brought forward by the sides of the pin—one on each side—and finally fixed by a half twist in front of and close down upon the pin" (Pirrie and Keith, Acu- pressure, p. 44). The fifth, or. "Aber- deen method," consists in passing a pin or needle through the soft tissues close, to the artery, giving the instru- ment a quarter or a half rotation, by which the vessel is twisted upon itself, and then fixing the pin or needle by thrusting its point deeply into the tis- sues beyond (Fig. 86). This method seems to me the best and most generally applicable ; additional security may be given by superadding the use of a wire loop, as in the preceding methods. The seventh and last method consists, according to Prof. Pirrie, "in passing a long needle through the cutaneous surface, pretty Acupressure ; fifth method. ACUPRESSURE, TORSION, AND LIGATURE. 189 deep into the soft parts, at some distance from the vessel to be acu- pressed—making it emerge near the vessel—bridging over and compress- ing the artery, dipping the needle into the soft parts on the opposite side of the vessel, and bringing out the point of the needle a second time through the common integument. In this method the soft parts are twice transfixed, and the artery is compressed between the bone and the middle portion of the needle in front of the integument, between the first point of exit and the second point of entrance." Mode of Repair of Arteries after Acupressure.—This subject has re- cently been investigated by several writers, the results of whose observa- tions may be stated as follows: there is no direct adhesion of the apposed walls of the vessel, as believed by Dr. Hewson and others, but, on the contrary, the sole process of permanent repair takes place at the cut end of the vessel; the end subserved by the needle is merely to remove the pressure of the blood current until this repair is accomplished. If, how- ever, the needle be allowed to remain so long as to destroy the structure of the lining membrane of the vessel, then closure takes place at the line of this destruction, just as after the use of a ligature. The actual repair which goes on at the cut end of the vessel is due partly to changes in the walls of the vessel itself, and partly to changes in the contained blood, in fact to the same changes which we have alread}' studied as taking place in the process of natural haemostasis. A clot forms above the needle, and rests upon without adhering to the contracted portion of the artery below. (See Hewson, Penna. Hosp. Reports, vol. i.; Lee and Beale, Med. Chir. Trans., vol.1.; Bryant, Ibid., vol. li.; Lee, St. George's Hosp. Reports, vol. iii.; and Forster, Guy's Hosp. Reports, vol. xiv.) The time during which the acupressure needle should be allowed to remain varies from twenty-four to sixty hours, according, to the size of the vessel. If it be removed before the repair of the cut end of the vessel is complete, there will be risk of dislodgement of the clot (which is not adherent), and of hemorrhage; while if it remain too long, it will excite suppuration in its track, just as any other foreign body. [On the general subject of Acu- pressure, see works by Simpson, Pirrie and Keith, and J. C. Hutchison, of New York.] Modified Acupressure.—Under the name of "artery compressor," Mr. Porter, of Dublin, has described an apparatus for the temporary occlusion of an artery in cases of aneurism. It somewhat resembles Sir P. Cramp- ton's "press-artere," and consists essentially of a bent probe and a wire, between which the vessel is compressed, and which are so arranged as to be withdrawn at will. Dr. L'Estrange's apparatus for the same pur- pose consists of a double aneurismal needle, the blades of which close like the jaws of a lithotrite. Filopressure, or compression of a vessel by means of a wire, has been practised by various surgeons, among whom may be specially mentioned Mr. Dix and Professor Langenbeck, and has been described as a modifi- cation of acupressure. It is, however, as shown by Simpson, an old mode of treatment, and, I may add, appears to be inferior to both acu- pressure and the ligature. It is practised by surrounding a vessel with a loop of wire, the ends of which are brought out separately through the flap or side of the wound, and twisted over a compress which serves to protect the skin. Comparison between Acupressure, Torsion, and Ligature.— From what has been said with regard to the mechanism by which each of these methods acts, and the pathological changes to which each gives rise, it will appear, I think, that the ligature is to be preferred, whenever the 190 INJURIES OF BLOODVESSELS. circumstances of the case allow the surgeon to choose between them. The objections urged against the ligature are, that (1) it acts as a seton, causing suppuration along its track ; (2) it confines a minute slough in the wound until it comes away itself; and (3) it may become prematurely detached and allow secondary hemorrhage. These objections, though theoretically just, seem to me to be practically of little or no value, for (1) healing without any suppuration is almost never met with (at least in this climate), in wounds of the size of those in which ligatures are used, and no trustworth}' evidence has yet been adduced to show that the use of ligatures increases the amount of suppuration; (2) the size of the slough embraced by the noose of the ligature, in cases that do well, is so minute as to be really not worth notice, and in cases where there is extensive sloughing, there is no reason to attribute that sloughing to the use of ligatures; and (3) though hemorrhage may occur upon the detach- ment of a ligature, it is (unless violence have been used in removing the ligature) due to a defect in the natural process of haemostasis, which, as we shall presently see, is quite as likely to occur with either torsion or acupressure as with the ligature. Torsion closes arteries just as tlie ligature does, and there is the same risk of hemorrhage on the separation of the twisted extremity, if it has been twisted enough to impair its vitality, as on detachment of the ligature; while if it have been insuffi- ciently twisted, there is the additional risk of the extremity of the ves- sel becoming untwisted, and thus allowing bleeding at an earlier period; if, on the other hand, the end be twisted off, the vessel is in the same con- dition as if it had been tied, and the ligature immediately removed. If the acupressure pin be removed before it produces suppuration, the sole protection against hemorrhage is an incomplete union at the cut end of the vessel, and an unadherent clot above the point of constriction ; if it be allowed to remain long enough to cause inflammatory changes in the arterial coats at the point of constriction, it defeats its own object, and acts as a ligature which has been tied and subsequently removed. That both acupressure and torsion are able to control hemorrhage from even large arteries is abundantly proved; that either does so any better than the ligature is, it seems to me, not proved; while to give the same security that is afforded by the ligature, either must be pushed so far as to be open to the identical objection which is urged against the ligature, viz., that of introducing a foreign body into the wound, and, by so doing, impeding union by adhesion. I am not aware of any sufficiently extended statistics of torsion having yet been published, to warrant a numerical comparison of the results of this method, with those of the ligature. The reports of Messrs. Syme, Humphrey, Bryant, and Forster have certainly been favorable, yet the experience of other surgeons who are equally eminent has been opposed to the general employment of torsion ; and it is to be observed that Mr. Syme only recommended it in connection with the antiseptic method of Prof. Lister, while the whole number of cases in which it has been used in the human subject is as yet very limited. As regards the statistics of acupressure, the most favorable series of cases yet pub- lished is that of Prof. Pirrie and Dr. Keith, and yet even this, when ana- lyzed, shows at least no better results than are obtained by the use of the ligature. Thus, twelve amputations reported by Prof. Pirrie gave three deaths, and yet in all but one case the operation was done for disease, and eight of the twelve patients were children. The theoretical assump- tion that acupressure guards against the common causes of death after operation is not borne out by fact,—erysipelas, sloughing, and pyaemia COLLATERAL CIRCULATION. 191 having occurred even in the very favorable experience of Messrs. Pirrie and Keith; while union by adhesion, except in Aberdeen, has been quite as rare with acupressure as with the ligature, and even in the few Aber- deen cases in which it is stated that not a single drop of pus was seen during the cure, it does not appear that the period of convalescence was any shorter than it is constantly found to be, when ligatures are used. What, then, are the real advantages of acupressure ? Simply and solely, I believe, that it is more easily and quickly applied than the liga- ture, and that^in its use the surgeon needs no assistant: hence, in cases of emergency, especially of secondary hemorrhage, it is often the sur- geon's most available resource, and as such its modes of employment should be familiar to every practitioner. Torsion, on the other hand, is confessed even by its advocates to be a more tedious and difficult pro- ceeding than the application of a ligature, and, therefore, seems to me, although possibly safer than acupressure, even less desirable for general use. Collateral Circulation.—In whatever way an arterial trunk be occluded, whether by disease or by surgical interference, the vitality of the parts below would be impaired but for the estab- lishment of the collateral circulation. The«imme- diate effect of a ligature, or other means of arterial occlusion, is to throw the force of the circulation into new channels, and, hence, though the limb below the site of ligature is for a time less full of blood, the balance is soon restored, and after a few hours the activitj^ of the capillary circulation is so much increased, that the part is not un- frequently both redder and warmer than in its natural state. The action of the capillaries is, however, but temporary, the true collateral circu- lation being established through the inosculation of anastomosing branches, derived sometimes from the affected vessel itself, but more frequently from neighboring trunks on the same side of the body. Thus, if the superficial femoral be tied, the collateral circulation is established through the branches of the profunda (Fig. 87), while after ligature of the common carotid, it is princi- pally through the inferior thyroid and vertebral arteries that the circulation is maintained. Even after occlusion of the abdominal aorta, the colla- teral circulation is established in quite a short time, pulsation in the femoral artery having re- turned in less than ten hours, in the case of liga- tion of the aorta, reported by Mr. Porter. In old persons, or in those whose arterial system is affected by atheromatous or fatty degeneration, the collateral circulation is less readily estab- lished and less perfectly maintained than in the young and healthy, the reason of this obviously being that the arteries of the latter are more elastic, and dilate with greater facility to accom- Fig. Collateral circulation shown in the thigh. At a, the femoral artery has been obliterated by ligature. 192 INJURIES OF BLOODVESSELS. modate the increased flow of blood through them. On the other hand, in cases of chronic aneurism, the obstruction has sometimes gradually caused the establishment of the collateral circulation before ligation is practised, so that under these circumstances surgical interference may be even less resented than when employed for wounds of healthy arteries. This statement would appear to be contradicted bjr the well-known fact that gangrene is more frequent after ligature for aneurism, than after that for traumatic causes, but, as will be seen hereafter, the gangrene in the former case is usually from venous, not from arterial obstruction. Not only does anastomosis take place between collateral branches, but an indirect communication is sometimes re-established between the divided ends of the obliterated trunk. Finally the fibrous cord, which connects the divided extremities of the artery, occasionally becomes itself pervious, allowing a narrow but direct channel of communication between the proximal and distal ends of the vessel. The establishment of the collateral circulation is sometimes attended with pain, apparently from pressure of the enlarging vessels upon con- tiguous nerves; this is most marked in cases of aneurism, in which addi- tional pressure is caused by the coagulation of the blood contained in the sac. Secondary Hemorrhage.—The most frequent accident after the use of the ligature or other artificial means of arterial occlusion, is unques- tionably secondary hemorrhage. This may arise from a variety of causes, some of which are local and some constitutional. Among the local causes may be mentioned, (1) imperfect application of the occluding means; as when the vessel has been tied so near its cut extremity that the noose slips off prematurely, when the knot has been carelessly made, when a large amount of extraneous tissue has been included in the noose of the ligature, so that this becomes loosened before the vessel is healed, or (which is especially apt to happen with acupressure) when the vessel has been compressed only enough to check bleeding while the force of the heart is diminished by shock or by the use of an anaesthetic, but not enough to occlude the artery when reaction has occurred; (2) the giving off of a large collateral branch either immediately above or immediately below the point of occlusion, a circumstance which, though not necessarily a cause of secondary hemorrhage, is very apt to be so, from limiting the extent of the internal coagulum in the proximal, and more especially in the distal end of the vessel; and (3) a diseased condition of the coats of the artery itself: this may cause hemorrhage directly, either by allowing the ligature to ulcerate through the vessel prematurely, or by allowing rupture to take place above the site of the ligature; or more rarely in directly, by giving rise to the formation, above the ligature, of an aneurism which subse- quently bursts and permits the escape of blood. In other cases secondary, or rather consecutive hemorrhage may occur from vessels which escape the notice of the surgeon during an operation, or (in case of ligation in the continuity) from small anastomosing branches, which, though wounded, do not begin to bleed until enlarged by the establishment °of the colla- teral circulation. The constitutional causes of secondary hemorrhage may be said to be any conditions of system which interfere with the natural processes which we have seen to be essential for the closure of wounded arteries. Thus, a want of coagulability in the blood itself, the "hemorrhagic diathesis," visceral disease (especially of the liver), an unusually severe attack of ordinary traumatic or inflammatory fever, cer- tain affections which are apt to occur after operations, especially erysi- SECONDARY HEMORRHAGE. 193 pelas, pyaemia, hospital gangrene, or even ordinary sloughing, may all be considered as causes of secondary hemorrhage. In the case of pyaemia, the hemorrhage often consists of capillary oozing—the parenchymatous hemorrhage of Stromeyer and Lidell—and is apparently due to mechani- cal obstruction, from thrombosis of the venous trunks of the part. Occasionally a single secondary hemorrhage may prove fatal, but more usually there are a number of successive gushes, of which the first may be comparatively slight, the patient being gradually reduced to a state of extreme anaemia, and dying rather from repeated losses of blood, than from the quantity lost at any one time. When hemorrhage occurs after ligature of an artery in its continuity, it is almost invariably from the distal extremity of the vessel. The reasons for this appear to be (1) that, as already remarked, the distal clot is smaller and less firm than the proximal, and (2) that, from the constriction of the ligature inter- fering more with its vasa vasorum, the distal end of the vessel is more exposed to sloughing than the proximal. Secondary hemorrhage may occur at any time after the application of a ligature, though it is most common about the period of separation of the latter; when it occurs earlier, it is usually owing to some defect in the mode of occlusion, to disease of the arterial tunics, or to some of the systemic conditions which have been referred to. Secondary hemorrhage is occasionally met with, weeks or months after the separation of the ligature; in these cases it is usually due to the occurrence of sloughing, or to the dissolution and reabsorption, under the influence of constitu- tional causes, of the coagulum and inflammatory adhesions by which closure of the vessel was effected. Treatment of Secondary Hemorrhage.—The constitutional treatment of secondary hemorrhage does not differ from that already described as appropriate to the primary affection: special care, I may add, should be taken to prevent, by the administration of suitable remedies, any strain- ing in defecation or violent coughing. The local treatment of secondary hemorrhage varies according as the bleeding proceeds from a stump, or from an artery ligated in its continuity. It should be premised that the rule not to operate on an artery which has stopped bleeding, does not apply in either of these cases. As Mr. Erichsen puts it, the surgeon in these cases may after the first, and must after the second bleeding adopt determined measures to prevent a return of the hemorrhage. 1. Secondary Hemorrhage from a Stump may, if in only moderate amount, be often checked by the judicious application of pressure, posi- tion, and cold. Should, however, these means fail, or should the bleeding be so free as to render it probable that it comes from a large vessel, the proper course to be pursued depends upon the condition of the stump itself; if the process of cicatrization in the latter is not far advanced, or, under any circumstances, if its cavity appears to be stuffed and distended with clots, the surgeon should without hesitation break up the adhesions, and search for the bleeding artery on the face of the stump itself, applying a fresh ligature to whatever vessel is found to be in fault. If, on the other hand, the stump is nearly healed, and does not appear to be stuffed with clots, it is proper to attempt to secure the bleed- ing vessel, or the artery of which it is a branch, immediately above the stump : this may be done by cutting down and applying a ligature, or, preferably, by acupressing the vessel by Simpson's first method ; this is one of the exceptional cases in which acupressure seems to be par- ticularly applicable, and there would be every reason to hope, under such circumstances, that the temporary occlusion of the artery by the 13 194 INJURIES OF BLOODVESSELS. pin would be sufficient to allow the completion of the natural process of repair at the cut extremity of the vessel. Ligation of the main artery of a limb, for hemorrhage from a stump, is in most situations a bad ope- ration, and should only be resorted to when prolonged search has failed to find the artery in the reopened wound (an event which may occur from the sloughing and disorganized condition of the part), and when the ves- sel cannot be secured immediately above the stump. The reasons for this are, that in many cases the operation would fail to check the hemorrhage, that it would expose the patient to great risk of gangrene, and that it would superadd an operation, in itself serious, to the dangers which already existed : hence, in some situations, even reamputation might be a safer and better procedure than ligation of the main trunk. In some positions, however, as after amputation at the shoulder-joint, or high up in the thigh, ligation of the main trunk may be the only resource avail- able, and in such cases the vessels to be secured are the axillary for the upper, and the external iliac for the lower extremitj^. 2. Secondary Hemorrhage from an Artery previously Ligated in its Continuity is an accident of the gravest nature. In its treatment the surgeon may properly first try the effect of pressure, adjusting accurately to the bleeding point a graduated compress, and keeping it in position with a ring tourniquet, or arterial compressor. In the case of some arteries, as the subclavian or iliacs, and generally in the case of vessels situated about the trunk, no other means are applicable, and the use of pressure should then be persevered in, though it must often prove inef- fective. In the case of the upper extremity, if pressure fail, the surgeon should treat the vessel as one primarily wounded, cutting down and tying the vessel above and below the source of hemorrhage; if hemorrhage again recur, or if the bleeding vessel cannot be found or secured in the wound, a ligature may be applied with fair hope of success to the main artery at a higher point. Should this fail, amputation at the highest point of ligature should be resorted to. In the lower extremity, the case is some- what different. If the bleeding be from the femoral artery, an attempt may be made to apply fresh ligatures in the wound, above and below the source of hemorrhage, and this course will occasionally succeed. The tibial vessels lie so .deeply that it would be almost hopeless to attempt this mode of treatment in case of secondary hemorrhage after deligatiou of one of them, though it might perhaps be tried, if the condition of the patient warranted the effort. Ligation of the main trunk under these circumstances in the lower extremity would almost inevitably cause gan- grene, and should not be attempted. Amputation at or above the site of ligature would be a safer operation, and should, I think, in this situation, undoubtedly be preferred. Gangrene after Arterial Occlusion, whether from disease or from surgical interference, is due to a deficiency in the collateral circulation; it is most often met with in the lower extremity, and in those whose arteries from age or other cause are in an inelastic condition, whether accompanied or not by positive degeneration. Among the exciting causes may be mentioned loss of blood (as from secondary hemorrhage), venous congestion (hence it is more frequent after ligations for aneurism than after those for wounds), erysipelas, the application of cold or of excessive heat, or the use of even moderately tight bandages. It is usually mani- fested from the third to the tenth day, and is commonly, on account of venous implication, of the moist variety; occasionally, however, it assumes the character of dry gangrene or mummification. These con- TRAUMATIC ANEURISM. 195 ditions have been alread}- described, in discussing the subjects of in- flammation, and of mortification as a cause for amputation, and need not therefore be again referred to. Much may be done to prevent the occur- rence of gangrene after ligation of an artery, by wrapping the limb in cotton-wool, so as to keep up its temperature and protect it from external injury, and by placing hot bottles or hot bricks under the bedclothes, though not in contact with the limb. Should there be much venous congestion, gentle but methodical friction from below upwards might be practised, so as to assist in emptying the superficial veins. Should gangrene actually occur, amputation must be practised through the site of arterial occlusion, unless, when after injury of the femoral artery, the gangrene is limited to the foot, when, as pointed out by Guthrie, amputation below the knee will usually be sufficient. (See page 92.) Remote Consequences of Arterial Occlusion.—Even when everything goes well after the ligation of a main artery, the limb is sometimes left for a long while numb and weak. In the case of the lower extremity, it is often oedematous, and apt to become inflamed from apparently slight causes. In such cases the limb should be warmly clad, and supported with an elastic bandage, while care should be taken to avoid undue pres- sure, which might give rise to ulceration, or even gangrene. Traumatic Aneurism.—Under this name are included several dis- tinct affections:— 1. The Diffused Traumatic Aneurism (so called), is, as Prof. Gross justly remarks, no aneurism at all, but merely a collection of arterial blood in the tissues of a part, differing from an ordinary case of wounded artery simply by there being no communication with the external air. This condition of affairs may result either from an originally subcuta- neous lesion of an artery, or from the external wound healing before the arterial aperture itself is closed. It not unfrequently is a consequence of gunshot injury, the arterial wall being bruised though not severed by the contact of the ball, and giving way after an interval of perhaps several weeks, during which the external wound may have completely healed. The diagnosis of this condition can usually be made with tole- rable facility; there is an oblong, somewhat pyriform swelling, more or less elastic and fluctuating, and if the arterial wound be tolerably free, accompanied by a distinct impulse, and often by a marked thrill and aneu- rismal bruit. The limb below is oedematous, and the pulse very feeble or completely absent. As the disease advances, the skin covering the tumor becomes tense, thin, and discolored, and unless efficient treatment be adopted, the limb may become gangrenous, though more commonly the tumor will suppurate and open externally, allowing profuse secondary hemorrhage to occur. The treatment is the same as for an ordinary case of wounded arter}r. The circulation being temporarily controlled by pressure applied as already directed, the surgeon la}rs open the tumor,. turns out the clots, and applies ligatures to both ends of the affected vessel; this is most conveniently done by introducing a director into the mouth of the artery, dissecting it up for about an inch, and passing , a ligature around it with an ordinary aneurismal needle. If the arterial wound be in such a situation that effective pressure cannot be made above it during the operation, the surgeon must proceed more cautiously, in the way recommended by Prof. Syme; in this case the incision should be at first merely large enough to admit one or two fingers of the left hand, which may plug the wound as they are introduced, and thus pre- vent hemorrhage, until, guided by feeling the current of warm arterial 196 INJURIES OF BLOODVESSELS. blood, they reach the aperture in the vessel; having thus control of the bleeding orifice, the surgeon may now enlarge bis incision, turn out the clots, and still keeping up pressure with the left hand, endeavor to pass a ligature with the right; in doing this, a mounted needle, eyed at the point (Fig. 65), or a short curved needle, held with suitable forceps, may prove of more service than the ordinary aneurismal needle. In some instances, especially in military practice, the safety of the patient will be more promoted by amputation, than by any attempt to secure the vessel by ligation; particularly is this the case when the brachial artery is wounded near its origin, the aneurismal tumor encroaching upon the axilla ; under such circumstances I believe amputation at the shoulder- joint to be often the best mode of treatment. 2. There is another form of traumatic aneurism, of which the pa- thology is the same as of that which has been described, but in which the extravasation is less extensive, and in which an adventitious sac has been formed by the condensation of the surrounding areolar tissue. This, which is, clinically speaking, a Circumscribed Traumatic Aneurism, commonly results from punctured wounds, and is rarely met with except in the course of the smaller arteries ; it may be treated by laying open the sac and tying the vessel above and below, or, if in a position where this operation would be undesirable, as in the palm of the hand, the main trunk may be ligated with the prospect of a favorable result. When met with in connection with a large artery, a proximal ligature may be applied as close as possible to the sac, without opening the latter. 3. Another form of circumscribed traumatic aneurism is that which has been called "Hernial," and which results from the protrusion of the inner coats of the vessel through a wound or laceration of the outer tunic. This form of aneurism is extremely rare, its existence indeed being doubted by many writers. 4. The True Circumscribed Traumatic Aneurism results from a punc- tured wound of an artery (generally a large one), which has healed, the cicatrix afterwards yielding, and a true sac being thus formed from the external coat of the vessel and its sheath. The treatment consists in compression or in ligation of the artery at as short a distance as pos- sible above the sac. Should, however (in any of these forms of cir- cumscribed traumatic aneurism), the sac burst, allowing the aneurism to become diffused, or should suppuration or gangrene appear imminent, the proper course would be to lay open the part freely, and apply liga- tures above and below, as in the case of the so-called diffused traumatic aneurism already described. Arterio-venous Wounds.—Occasionally an artery and its con- tiguous vein are simultaneously wounded, the external wound healing, but a communication remaining between the two vessels. This accident most frequently follows upon punctures, as of the brachial artery in bleeding, though it may also result from a gunshot wound, as in a case to which I have already referred. The preternatural communication .between an artery and vein may assume two distinct forms, known re- spectively as aneurismal varix and varicose aneurism. Aneurismal Varix consists -in a direct communication between an artery and a vein, part of the arterial blood finding its way into the vein, which is dilated and somewhat tortuous; the symptoms are the presence of a small, somewhat oblong, compressible tumor, with a jarring sensa- tion communicated to the hand, and a buzzing or rasping sound* rather than the ordinary aneurismal whirr. The sound is more distinct above LIGATION OF INNOMINATE ARTERY. 197 than below the tumor, and the limb is usually somewhat weaker and colder than natural. The condition is not progressive, and requires, as a rule, no treatment beyond the support of an elastic bandage: should anything further be needed, the artery must be tied above and below its aperture. Varicose Aneurism.—This consists of a circumscribed traumatic aneurism, in which the sac communicates also with a vein, which is itself Fig. 88. Varicose aneurism. always varicose. It differs from an aneurismal varix, in that the arterio- venous communication is indirect, through an interposed aneurismal sac. Its symptoms are a combination of those of aneurismal varix, and of ordinary traumatic aneurism: the tumor gradually enlarges, and becomes more solid from the deposition of fibrin, there is a distinct impulse added to the jarring sensation of the aneurismal varix, and there is an aneurismal whirr superadded to the rasping sound heard in the former affection. The sac in this form of disease has two openings, one into the artery and one into the vein, and thereby is much in the condition of the sac of a traumatic aneurism which has become diffuse by rupture; hence the proper treatment consists in laying open the tumor and tying the artery above and below; in doing this, it must be borne in mind that the first incision (which opens the dilated vein) merely exposes the ex- ternal orifice of the sac, and that this must be laid open by a second incision, when the aperture of the artery will be found more deeply seated. Lines of Incision for Deligation of Special Arteries. I have gone so fully into the discussion of the principles which should guide the surgeon in the management of arterial hemorrhage, and of the various accidents which follow arterial wounds, that I do not think it necessary or even desirable, to recur to the subject in connection with each special artery. I purpose merely, therefore, in this place, to indi- cate as concisely as possible the lines of incision to be adopted in applying ligatures to the several arteries, whether the operation be re- quired on account of injury or of disease. Innominate or Brachio-eephalic Artery.—This vessel may be reached by an incision at least two inches long, corresponding to the anterior edge of the left sterno-cleido-mastoid muscle, and extending in the form of an J across the top of the sternum, and in the line of the right clavicle (Fig. 89). Care must be taken to avoid the thyroid plexus of veins, the middle thyroid artery, and the pneumogastric and phrenic nerves. The needle should be passed behind the artery, from without inwards, so as to avoid the innominate vein which lies on its outer side. 198 INJURIES OF BLOODVESSELS. Common Carotid.—This vessel may be tied either above or below the point at which it is crossed by the omo-hyoid muscle. In either case, Fig. 89. Ligation of the innominate artery. A. Innominate. B. Carotid. C Subclavian. D. Inferior thyroid vein. E. Sterno-mastoid muscle. F. Sterno-hyoid and sterno-thyroid muscles. Fisr. 90. Ligation B. Jugular mastoid. of car vein. otid artery. A. Carotid artery. C. Descendens noni. D. Sterno- the guide to the artery is the inner edge of the sterno-mastoid muscle, the patient's head being thrown backwards, and inclined to the op- posite side. The incision for the upper operation (which is the best, when practicable) extends from near the angle of the jaw to a little below the cricoid cartilage; for the lower operation (Fig. 90), from a little above the cricoid cartilage, to about three inches downwards, along the edge of the sterno-mas- toid muscle. The ligature should be passed from without inwards, avoiding the jugular vein and pneumogastric nerve. In opening the sheath, care should be taken to avoid the " descendens noni" nerve, which, however, it is said, has been occasionally divided in this operation, without unpleasant consequences resulting. External Carotid.—This vessel may be reached by an incision parallel to, but half an inch in front of, the inner edge of the sterno- mastoid muscle, and extending from near the angle of the jaw to a point corresponding to the middle of the thyroid cartilage. Superior Thyroid.—This vessel may be reached either by an incision across the upper part of the neck, from the side of the hyoid bone, obliquely outwards and downwards to the edge of the sterno-mastoid LIGATION OF SUBCLAVIAN ARTERY. 199 muscle, or by an incision of about two inches, along the inner border of the latter muscle. Lingual Artery.—This may be tied through an incision an inch long, made in a direction downwards and forwards, immediately behind the corner of the hyoid bone (Fig. 91). The superior laryngeal nerve should be carefully avoided in passing the needle. Fig. 91. Fig. 92. Ligation of the lingual artery. Ligation of the facial artery. The Facial Artery is most easily secured where it crosses the lower jaw (Fig. 92); the Occipital, as it emerges from beneath the splenius muscle, behind the mastoid process of the temporal bone (Fig. 93); and the Temporal, immediately above the zygoma (Fig. 94). Fig. 93. Fig. 94. Ligation of the occipital artery. Ligation of the temporal artery. Subclavian Artery.—The Right Subclavian may be tied in the first part of its course, that is, between the trachea and the scaleni muscles, by the incision recommended for ligature of the innominate; on the left side the vessel is so deeply seated as to render the operation almost impracticable, though if it be attempted, the same incision (reversed) should be employed. This operation has, I believe, been performed but / 200 INJURIES OF BLOODVESSELS. once on the living subject—by Dr. J. K. Rogers, of New York. Either subclavian may be tied in the third part of its course, or exterior to the scaleni muscles, by an incision about three inches long, corresponding to the upper border of the clavicle, the shoulder being drawn down, and the head turned to the opposite side; in dividing the superficial fascia, care must be taken not to wound the external jugular vein. After Fig. 95. Ligation of subclavian artery. A. Subclavian artery. B. Brachial plexus. C. Scalenus anticus. D. Transversalis colli. E. Omo-hyoid. cutting through, if necessary, some of the fibres of the sterno-mastoid muscle, the surgeon cautiously works his way down to the outer edge of the scalenus muscle, in the angle between which and the first rib, the vessel lies: the needle should be introduced from below upwards. The artery may be tied in the second part of its course, by the same incision, the anterior scalenus muscle being cautiously divided upon a grooved director; the parts to be specially guarded from injury in this operation, are the phrenic nerve, the jugular vein, the thyroid axis, and the pleura. Mr. Skey recommends for ligature of the subclavian in its outer part, an arched incision, which " is commenced about two and a half or three inches above the clavicle, upon, or immediately on the outer edge of, the mastoid muscle, . . .' carried slightly outwards and downwards towards the acromion, and then curved inwards along the clavicular origin of the mastoid muscle." - Axillary Artery .—This vessel may be tied either below the clavicle or in the axillary space. For the former operation, an incision either straight or semilunar (in which case it must be convex upwards) is made below the clavicle from near its sternal end to near the attach- ment of the deltoid muscle. The fibres of the pectoralis major require division, and care must be taken to avoid the cephalic vein and acromial thoracic artery. The needle is passed from below upwards. To secure the artery in the axilla, an incision of about three inches is made along the border of the latissimus dorsi muscle, though many surgeons prefer an incision more oblique to the course of the vessel; the filature may LIGATION OF ABDOMINAL AORTA. 201 be passed from within outwards, between the roots of the median nerve, which, in this position, lie on either side of the artery. Brachial Artery.—This vessel may be tied in its upper part by an incision along the inner edge of the coraco-brachialis muscle, or in its middle and lower parts by an in- cision corresponding to the ulnar Fig. 96. edge of the biceps. The artery lies very superficially in its whole extent, and is perhaps more easily tied than any other in the body. The ulnar nerve lies to its inner side, while the median nerve, which above is to the outside of the vessel, crosses in front of it at about its middle. In operating upon the brachial artery, its oc- casional high division must be borne in mind. Radial Artery.—This vessel, in its upper part, lies between the supinator longus and the prona- tor teres muscles; and below, be- tween the former and the flexor carpi radialis. It may be reached in any portion of its course by an oblique incision crossing a line from the middle of the arm, at the bend of the elbow, to the ordinary place of feeling the pulse. The radial artery behind the thumb may be exposed by an incision about an inch long, across the proximal ends of the metacarpal bones of the thumb and forefinger. Ulnar Artery.--Ihe general Ligation of the humeral, radial, and ulnar arteries; COUrse Of this Vessel may be de- also of the palmar vessels. scribed by a line drawn from the middle of the bend of the elbow, obliquely inwards, to a point half-way down the forearm, and thence parallel to* the ulnar edge of the latter, but an inch to its outside. The radial border of the flexor carpi ulnaris may be considered a guide to the vessel in the middle part of its course. Abdominal Aorta.—The aorta may be reached by a curved incision on the left side of the body, convex towards the vertebrae, and extending from the cartilage of the tenth rib to near the anterior superior spinous process of the ilium, the length of the wound being about six inches. The various structures being divided down to the peritoneum, this membrane is cautiously pushed backwards, the surgeon tracing up the common iliac to its bifurcation, about an inch above which the ligature should be applied ; the needle is passed around the aorta from left to right, and from behind forwards, special care being taken not to injure the vena cava, which lies to the right, or the filaments of the sympa- thetic nerve, which lie in front of the vessel. 202 INJURIES OF BLOODVESSELS. Fig. 97. Common and Internal Iliacs.—Either of these arteries may be reached by a curved incision, five to seven inches long, passing from above the anterior superior spinous process of the ilium, about half an inch above Poupart's ligament, to the external abdominal ring; the peritoneum is carefully stripped up- wards, and the needle passed from within outwards, around whichever vessel is to be secured. In tying the internal iliac, the surgeon must be specially cautious not to wound the external iliac vein, which lies in the angle formed by the bifurcation of the common artery. Gluteal and Sciatic Arteries. —The former vessel may be reached by an incision in a line from the posterior superior spinous process of the ilium, to a point midway between the tuber ischii and the great tro- chanter ; the latter by a similar in- cision, about an inch and a quarter below the position of that already described. Ligation of the common iliac. Fig. 98. Ligation of the external iliac. to be held open. A. Artery ; B. D. Spermatic cord. The wound supposed Vein; C. Peritoneum ; External Iliac.—This ves- sel may be tied by Liston's modification of Abernethy's method, or by that recom- mended by Sir Astley Cooper. In the first operation an incision is made from about two inches within the anterior superior spinous process of the ilium, in a curved line, inwards and downwards, to an inch and a half above the middle of Pou- part's ligament; the wound, which is convex downwards, should be three or four inches long. All the tissues being carefully divided down to the peritoneum, the latter is cau- tiously pushed and held out of the way, while the artery is se- cured by passing the needle from within outwards. Coop- er's incision (Fig. 98), is about three inches long, parallel to and a little above Poupart's ligament, and reaching from near the anterior superior iliac spine, to a point above the inner border of the abdominal ring. The external oblique tendon LIGATION OF POPLITEAL ARTERY. 203 being divided, the spermatic cord ap- pears, and beneath it the artery may readily be found. The disadvantages of this operation are the risks of wounding the epigastric artery and circumflex artery and vein; hence, in most cases, Abernethy's is the best incision, especially as it can very easily be extended upwards, so as to allow the common trunk to be reached, if that should be found necessary. Femoral Artery.—The Common Femoral artery can be readily reached by an incision made vertically down- wards from Poupart's ligament, in the line of pulsation of the vessel; the ope- ration of ligation is, however, a bad one in this situation, and the external iliac should be always tied in prefer- ence to the common femoral. The Superficial Femoral artery may be tied in any portion of its course, though the operation is best done at the apex of " Scarpa's triangle," where the artery is crossed by the sartorius muscle; the incision for this operation should be three or four inches long, beginning about two inches below Poupart's ligament, midway between the ante- rior superior iliac spine and the symphysis, and carried downwards in the axis of the limb, some- what obliquely to the edge of the sartorius muscle. The femoral vein in this part of its course lies to the inside of the artery, and the needle should, therefore, be passed from within outwards. The femoral artery may also be tied at a lower point, where the sartorius muscle will still be the guide for the surgeon's incision, the vessel, which at first lies inside of this muscle, afterwards crossing beneath it, and finally being external to it. The Profunda, or Deep Femoral Artery, may be reached by an incision similar to that em- ployed for the common femoral, the latter vessel being traced down to its bifurcation, and the deep femoral tied about half an inch below the origin of its circumflex branches. Popliteal Artery.—This vessel may- be reached in its upper third by an incision along the outer border of the semi-membranosus mus- cle, and in its lower third by an incision between the heads of the gastrocnemius. The vein in the former situation lies to the outer, and in the Fis;. 99. Ligation of the femoral artery in its middle Ligation of the popliteal at its upper and lower parts, a. The popliteal vein. b. The popliteal artery, c. The posterior saphe- nous vein. The popliteal nerve, on the outside of the artery, has been omitted in the diagram. 204 INJURIES OF BLOODVESSELS. latter to the inner side of the artery; in either case the needle should be introduced between the two vessels. Anterior Tibial.—This artery may be found, in its upper third, in the space between the tibialis anticus and extensor communis muscles. The incision is made rather more than an inch outside of the spine of the tibia, and should be about three inches long. In its lower half the artery may be found just outside of the extensor proprius pollicis tendon, which, in this situation, is the guide for the surgeon's incision. Care Fig. 101. Fig. 102. Ligation of the anterior tibial at various parts. Ligation of the posterior tibial, at various parts. The wounds are supposed to be held asunder. The "wounds are supposed to be held asunder. The ligature is under the vessel. The ligature is under the vessel. must of course be exercised in passing the ligature, to avoid the vena? comites and the peroneal nerve. On the dorsum of the foot, this artery may readily be found between the tendons of the extensor pollicis and extensor brevis digitorum. Its course corresponds to the line of the first metatarsal interspace. Posterior Tibial.—This artery may be tied in the calf of the leg, or just above the ankle: in the former position, the operation should only be INJURIES OF NERVES. 205 done for hemorrhage, when the wound must be made the guide for the inci- sion, which should be in the direction of the fibres of the gastrocnemius, and about four inches long. Above the ankle, the artery may be easily reached by a semilunar incision, concave forwards, about three-fourths of an inch behind the inner malleolus, and from two to three inches in length; the needle should be passed from behind forwards, so as to avoid the accompanying nerve. Peroneal Artery.—If this vessel should require ligation, which can only be in case of wound, an incision must be made similar to that re- commended for ligation of the posterior tibial in its upper third, except that in this instance it will of course be on the outer or fibular side of the calf. The artery will be found lying in a groove between the fibula, flexor pollicis muscle, and interosseous ligament. CHAPTER X. INJURIES OF NERVES, MUSCLES AND TENDONS, LYMPHATICS, BURS^E, BONES, AND JOINTS. Injuries op Nerves. Contusions.—Nerves are frequently subjected to contusion; the effects of this injury, which is manifested by local pain and a tingling sensation (pins and needles, as it is popularly called) along the course of distribution of the nerve fibres, are commonly evanescent, though in persons of a hysterical or nervous disposition they may be more perma- nent, giving rise, in some instances, to a distressing form of neuralgia; or the neurilemma may become thickened as a consequence of the bruise, causing by pressure a form of partial paralysis, or, more rarely, a second- ary morbid condition of the nerve centres. Laceration or Rupture of nerves sometimes occurs as a subcuta- neous.injury, as in cases of dislocation, when the lesion may be a direct result of the injury, or may be caused by the force used in attempts at reduction. Paralj'sis sometimes exists in these cases from the first, or may come on several weeks subsequently and be attended with muscular atrophy; according to Duchenne, sensation is less impaired in these cases than motion. The treatment should consist in the use of elec- tricity, douches, and suitable gymnastic exercises. Punctured Wounds of nerves usually result from the pricks of needles, or of the lancet in venesection. Partial paralysis and neuralgia may result, and may affect not only the parts supplied by the injured nerve, but adjoining parts as well, as in cases recorded by Graves and others. Complete Division of a nerve causes paralysis of the parts sup- plied, with a diminution of temperature, and certain nutritive changes which have been studied by Mr. Paget, and more recently and more fully by Drs. Mitchell, Morehouse, and Keen, of this city. These nutritive changes may be classified as diminished tension with muscular atrophy 206 INJURIES OF MUSCLES AND TENDONS. and contraction ; a peculiar alteration of the skin and its appendages, manifested by a glossy appearance, loss of hair, incurvation of nails, and the occurrence of eczematous eruptions; subacute, rheumatoidal, articular inflammations; absence of perspiration from the affected part; the whole accompanied in many cases by a peculiar and very distressing burning pain. In some rare instances the temperature of the affected part is absolutely higher than the normal standard. Repair of Nerves after Division.—The divided ends of a cut nerve are observed to become bulbous, and the continuity of the trunk is ultimately restored by means of fibrous tissue, in which, according to Schwann and Hasse, nerve tubes are ultimately developed. In some cases neighboring nerves appear to act vicariously for those trunks which are divided, thus presenting a condition somewhat analogous to the collateral circulation in cases of arterial obliteration. If any con- siderable portion of a nerve be excised, there is no reproduction, and the only chance of restoration of function is in the vicarious action above alluded to. In some cases the extremity of a divided nerve, or even an undivided nerve, becomes involved in the dense tissue of a cica- trix, or in the exuberant callus produced in the repair of a fracture. A very painful neuralgic and paralytic condition may result from this circumstance, requiring surgical interference, which has been success- fully applied in such cases by Warren, of Boston, Oilier, of Lyons, and others. Treatment of Wounded Nerves.—It has been proposed to unite the cut extremities of divided nerves by means of sutures, and several cases in which this has been done have been reported in France, the alleged results being marvellously favorable. There does not, however, appear to be sufficient evidence of the success of the plan to warrant its gen- eral adoption, and the very introduction of a suture into a nerve would seem, in itself, not wholly free from risk. The pain attending nerve wounds may be alleviated by the application of warmth or cold, accord- ing to the feelings of the patient, and especially by the hypodermic use of morphia. Repeated blistering is recommended by Di\ Mitchell, and his co-laborers, for the burning pain of nerve injuries—and for the mus- cular atrophy, faradization with the electro-magnetic battery, shampoo- ing, and the alternate use of hot and cold douches. Reflex Paralysis, resulting from injuries of nerves, is a very inter- esting subject, but belongs more to the domain of physiology than to that of practical surgery; it has been specially studied oy Prof. Brown- Sequard, by Dr. Mitchell, of this city, and by Dr. Echeverria, of New York. Injuries of Muscles and Tendons. Strains and Sprains of muscular tissue are of very frequent occur- rence, and vary in severity from the slightest stretching to absolute rupture of some of the muscular fibres; the treatment consists in keep- ing the parts at rest, in the use of slightly stimulating embrocations, and in the internal administration (in cases occurring to patients of a rheu- matic tendency) of Dover's powder with colchicum or iodide of potas- sium. Corrigan's button cautery may be applied if the pain be very persistent, while the atrophy and paralysis, which sometimes result, require faradization, shampooing, etc. INJURIES OF THE LYMPHATICS. 207 Fig.103. Subcutaneous Rupture of muscles and tendons may occur either from external violence, or from the forcible contraction of the muscle itself. Thus, the abdominal muscles are sometimes ruptured during the process of parturition, while muscular rupture is a frequent attendant upon the spasms of tetanus. Rupture of tendons is apt to occur from sudden and unusual exertions, especially on the part of persons past the middle time of life; thus, the tendo Achillis has been known to give way in elderty gentle- men who indulge in the juvenile amusement of dancing. The line of rupture may be through the muscle or through the tendon, though more commonly at their line of junction; more rareby the tendon may be separated from its point of insertion. The symptoms of this accident are sufficiently evident. The patient experiences a sudden shock, attended with a sharp pain, and some- times an audible snap; the power of using the part is lost; and usually a distinct de- pression or hollow can be felt at the line of rupture. The treatment consists in placing the part in such a position as will relax the affected muscle or tendon, and allow its di- vided extremities to be approximated as closely as possible. Repair in these cases is effected, as shown by Paget and Adams, by the development of a new tissue between the cut extremities, which in the case of a tendon gradually assumes the character of the original structure, but in the case of a muscle remains permanently as a fibrous band. Rupture of the tendo Achillis may be conveniently treated by an apparatus (Fig. 103), consisting of a col- lar placed above the knee, with a cord which pulls up the heel of a slipper applied to the foot, so as to keep the gastrocnemius muscle thor- oughly and constantly relaxed. Rupture of the extensor muscles of the thigh, or of the ligamentum patella?, should be treated by keeping the limb in an extended position and somewhat elevated; after recovery, a posterior splint should be worn for some time, to prevent sudden flexion of the knee. Paralysis or atrophy resulting from these injuries requires the use of friction, faradization, etc., as already described. Open Wounds of tendons should be treated on general principles, care being taken to avoid gaping of the part by placing the limb in a suit- able position, and by the use of sutures to approximate the cut ex- tremities, if this seem necessary. Apparatus for ruptured tendo Achillis. Injuries of the Lymphatics. These present, ordinarily, no features requiring special comment; in some cases, however, in which there is a varicose state of the lymphatic trunks (a condition usually associated with one of the varieties of Ele- phantiasis Arabum), wounds of the affected part are followed by a copious and sometimes troublesome flow of a milky fluid, constituting a traumatic form of what is known as lymphorrhoea. Such wounds are 208 INJURIES OF BURS.3E AND BONES. difficult to heal, and sometimes degenerate into obstinate fistulse. Care- fully applied pressure, and the use of caustic or even of the hot iron, would seem, in such a case, more promising than any other remedy. Injuries of Bursae. These are chiefly of interest from the possibility of their being mis- taken for injuries of adjoining articulations. Wounds of bursas heal with obliteration of the sac. Should suppuration occur in a bursa, with- out external wound, the part should be freely opened, and treated as an ordinary abscess. Injuries of bursa? sometimes result in chronic struc- tural changes which will be described in another part of the volume. Injuries of Bones. Besides fractures, which will be considered in a separate chapter, bones may be subjected to contusion and to alteration of shape (bending), without solution of continuity. Contusion of bone has already been referred to in the chapter on gunshot wounds, as a consequence of which injuries it is not unfre- quently met with. It may also occur, however, as the result of acci- dents met with in civil life, and is frequently productive of very serious effects as regards the limb, or even the life of the patient. The various inflammatory conditions of bone, which will be hereafter discussed, such as periostitis, necrosis, and osteo-myelitis, may all result from contusion, while in special localities, as in the skull, serious visceral complications may secondarily ensue. In the aged, shortening and atrophy may result from bone contusion, as is often seen in the neck of the femur; this condition may be mistaken for fracture. The primary treatment of contusion of bone is to be conducted in accordance with the principles which guide the surgeon in the management of contusion of other parts. The operative measures which may be required by the after consequences of this form of injury will be referred to in another place. Bending of Bone, apart from fracture, can only be met with in very early life, or under the influence of some morbid condition which dimin- ishes the proportion of the earthy constituents of bone, as in cases of rickets or of osteo-malacia. The treatment consists in attempting to remove the deformity by the use of suitable splints and bandages. The splint may be applied to either the concave or the convex side of the limb, but in either case care must be taken to prevent sloughing at the points of greatest pressure. Injuries of Joints. Injuries of joints, apart from dislocations, which will be considered hereafter, may be classed as contusions, sprains, and wounds. Contusions of joints are of frequent occurrence as consequences of falls, blows, etc., and if not very severe, and in healthy persons, are usually readily recovered from ; in other circumstances, however, the results of these injuries may be very serious. Hip disease is not unfre- quently traced to a fall or blow upon the hip, as its exciting cause, and I have known a simple fall upon the ice, in a boy of strumous con- stitution, to be followed by osteo-myelitis of the humerus, with suppura- WOUNDS OF JOINTS. 209 tive disorganization of both elbow and shoulder joints, requiring even- tually amputation at the latter articulation. The treatment of contused joints should consist in keeping the part at complete rest, and in apply- ing cold, with leeches, if necessary; and, in the later stages, in affording support by means of an elastic bandage, and in the use of methodical friction and of the cold douche. Sprains.—A joint is said to be sprained, when, as the result of a twist or other external violence, its ligaments are forcibly stretched or torn, without the occurrence of either fracture1 or dislocation. This ac- cident may occur in any joint, though it is most frequent in the wrist, ankle,»and smaller joints of the foot. The condition may commonly be easily recognized. The position assumed spontaneously by the part, is that in which there is least tension, the hand being slightly flexed and inclined to the ulnar side in the case of the wrist, and the foot being extended (" pointed toe") in the case of the ankle. The joint presents the usual evidences of inflammation, the swelling and heat being particu- larly marked, while the part, if not painful, is exquisitely sensitive to the touch. These symptoms may be developed in the course of from a few minutes to half an hour, though a patient with a sprained ankle may sometimes continue "to go about for several hours, not being indeed con- scious of the severity of his injury till he comes to remove his boot at night. The prognosis in the large majority of cases is favorable, though, in old persons, the joint may remain stiff and painful, for many weeks or even months after the subsidence of acute symptoms. The articulation sometimes becomes the sea^t of chronic rheumatism, while more rarely, if the patient be strumous, suppurative disorganization of the part may ensue. The treatment in the acute stage consists in keeping the joint at entire rest, and in making cold or warm applications, as most agreeable to the patient. I have often, by the use of warm spirituous fomenta- tions, such as the tincture of opium or tincture of arnica, succeeded in dispersing the swelling, and relieving the other symptoms of inflam- mation—stimulating them down, as it were—more quickly than by the use of evaporating lotions, as usually recommended. . In the later stages the part must be well supported with a soap plaster and bandage, or an elastic stocking, and subjected to methodical kneading and friction (massage), and the use of the cold douche. When a patient with sprained ankle is unable, from the nature of his avocations, to stay at home and keep the part at rest, it may advantageously be supported with a starched bandage, which will allow of a certain amount of exercise without injury to the joint. Should the surgeon have the opportunity of seeing the case at an early period, before the occurrence of inflammatoiy symptoms, it might be proper to completely surround the joint with long and broad adhesive strips, superadding a starch bandage—a mode of treatment which has occasionally succeeded in preventing the occurrence of inflam- mation and its troublesome sequelae; if this plan be adopted, however, the case should be very carefully watched, lest injurious constriction or even sloughing should result from the pressure employed. Wounds of Joints.—These injuries can usually be recognized with- out difficulty, either b}' the exposure of the articular cavity, orr if the 1 Under the name of sprain-fracture, Callender describes an injuiy consisting in the separation of a tendon from its point of insertion, with detachment of a thin shell of bone ; such a case should, of course, be treated as an ordinary fracture in the same locality. U 210 INJURIES OF JOINTS. wound be smaller, by the escape of synovia; if, however, these evidences be not present, it is an imperative rule of surgery that no exploration with the probe or otherwise should be instituted, lest the very compli- cation that is dreaded should be induced by these manoeuvres. The prognosis of a joint wound depends on the size and situation of the par- ticular articulation which is affected, the nature of the wound itself, and the constitutional condition of the patient. Wounds of the smaller joints, such as of the fingers and toes, are commonly recovered from without difficulty, although anchylosis of the articulation usually results. Small incised wounds of even large joints may terminate favorably under expectant treatment, while lacerated wounds of the same joints, espe- cially if complicated with dislocation or fracture, almost inevitably require excision or amputation. Again, in a strumous patient, a com- paratively slight wound may give rise to such disorganization of a joint as would not ensue in the case of a perfectly healthy person. Treatment.—In the case of a simple, uncomplicated wound of even so large a joint as the knee, the surgeon should make an attempt to save the°limb. If a portion of the instrument which has caused the injury remain in the wound (as often happens in cases of needle puncture), it should be carefully extracted, and the wound then hermetically sealed with gauze and collodion, or the antiseptic lac of Prof. Lister. The patient should be kept in bed, with the limb at complete rest, the joint being surrounded with ice-bags. The diet should be unirritating, and opium may be freely administered. Under this treatment the wound may heal, and a useful articulation be preserved. If, however, the course of events takes a less favorable turn, a£ is especially apt to happen with patients in adult life, the whole joint may become acutely inflamed, that condition being then developed which is known as traumatic ar- thritis. This differs from the ordinary forms of arthritis, which consti- tute the "white swellings" so often met with in practice, in that, in them, the disease usually originates in the cartilage <3r the bone itself, while in the traumatic form of the affection the synovial membrane is first in- flamed, and the other tissues of the joint involved secondarily. When traumatic arthritis occurs in a case of joint wound, the treatment above directed should be somewhat changed; the use of cold may be abandoned, and warm fomentations or cataplasms substituted, while a few leeches may be applied to the neighborhood of the joint, and calomel and opium exhibited internally. At the same time the strength of the patient must be sustained, by the administration of concentrated food, and even stimu- lants if necessary. Any abscesses which form around the joint should be opened as soon as they are detected, while, if suppuration occur within the joint itself, the question of excision or of amputation ma}' again arise. Free incisions into suppurating joints, as recommended by Mr. Gay, are often of the greatest service. To be effective, they should be free— mere punctures are worse than useless—and should be so situated as to allow of perfect drainage; it is not, however, necessary to slit up a joint from side to side, and it should not be forgotten that, as Mr. Holmes puts it, these incisions, "if they do no good, will certainly do harm." The object and the sole object of opening a suppurating joint is to secure free drainage, and this object can be better accomplished by an incision of moderate size judiciously placed, than by a larger one in another part of the joint. Drainage may be assisted, as suggested by Mr. Holmes, by the introduction of a Chassaignac's tube, a bent probe, or, which would be still better, a coil of fine wire, as recommended by Mr. Robert Ellis. Should this treatment prove successful, the inflammatory symp- EXCISION IN CASES OF JOINT WOUND. 211 toms will gradually subside, and the suppuration lessen in amount, the patient eventually recovering with a probably stiff, but otherwise useful limb; during convalescence the joint should be kept in such a position as will allow the limb to be of most use, should anchylosis occur. If, however, the patient's condition does not improve after opening the joint, the surgeon should not hesitate to resort at once to amputation, or, in some cases, excision; for, although the prognosis of operative interference, under such circumstances, is less favorable than in cases of chronic disease, still, as it offers the patient his only chance of life, it should be unhesitatingly resorted to. Amputation or Excision in Cases of Joint Wound. — If operative treatment be required, either as a primary procedure or in a subsequent stage, on account of the occurrence of suppuration within the articulation, the choice between amputation and excision will depend in a great degree upon the particular joint concerned. In the upper ex- tremity, amputation can be rarely required, except for special circum- stances connected with the constitutional condition of the patient, and excision, either primary or secondary, should be preferred, in cases which require any operation at all. In the lower extremity the case is some- what different; the hip-joint is so deeply seated that it is scarcely ever wounded except by gunshot injury, in which case, for reasons already given, primary excision is the mode of treatment to be adopted/' Wounds of the knee-joint are among the most serious injuries met with in civil practice; if complicated with fracture or dislocation, they should, I think, be considered as cases for amputation; although exceptional instances do undoubtedly occur in which recovery without operation follows, even under these unfavorable circumstances. Excision of the knee-joint, for traumatic causes, is not a very promising operation; still, in a young and healthy person, if the destruction of parts were comparatively slight, it might be at least a justifiable procedure. M. Spillman, who rejects knee-joint excision in military surgery, yet considers it a suitable opera- tion as applied to cases of injury met with in civil life. Eleven such cases which he has collected, excluding gunshot wounds, give six recov- eries, three deaths, and two consecutive amputations (Archives Gen. de Medecine, Juin, 1868, pp. 681-101). Five cases of total excision for compound fracture, collected by Penieres, give four deaths and but one recovery, while six operations for joint wound, without fracture, give but one death and five recoveries; as justly observed, however, by this writer, these cases might, perhaps, equally well have recovered without operation. When an attempt has been made to save the knee-joint, but without success, amputation should be unhesitatingly performed, as offer- ing the only remaining chance of preserving life. One point worthy of notice in connection with wounds of the knee, is the frequent occurrence of suppuration above the joint, abscesses being formed which dissect up the muscles of the thigh to a considerable extent, before giving evidence of their existence. It is this deep-seated destruction of the tissues of the thigh which constitutes one of the chief dangers of wounds of the knee-joint, and which renders any operation performed under these cir- cumstances very apt to terminate unfavorably. Wounds of the ankle are attended with less risk than those of either hip or knee, and recovery may often be obtained without operation, though in other cases excision or amputation may be required either primarily or secondarity. Spill- man has collected sixty-eight cases of complete or partial excision of the ankle for compound fracture or dislocation, the results having been ascer- 212 FRACTURES. tained in sixty-six. Fifty-one patients recovered with more or less useful limbs, two recovered after amputation, and thirteen died (two of these having been likewise previously amputated); the mortality of the opera- tion.is, therefore, about twenty per cent. (Archives Generates de Mede- cine, Fev. 1869, pp. 130-135). In the conservative treatment of these injuries it is of great importance to support the foot, so that the patient after recovery will be able to walk properly, and will not be left with an extremity anchylosed in the position of a pes equinus. I have already referred (p. 59) to the proposal to tie the main artery of a limb, as a means of preventing or curing traumatic arthritis; recovery t has indeed followed ligation under these circumstances, but no sufficient evidence has been adduced to show that the good result was in any de- gree due to the operation, which, besides being unphilosophical in con- ception, evidently adds an additional risk, without any compensating prospect of benefit. I have, besides, been assured by distinguished army surgeons, who saw the plan fairly tried during our late war, that it proved then as unsuccessful in practice as it is unscientific in theory. CHAPTER XI, FRACTURES. Fracture is the most common form of injury to which the bones are exposed, and, as such, becomes a subject of the deepest interest to every practising surgeon. Moreover, no injuries require more care and judgment in their treatment than fractures, and no cases contribute, more than these, to establishing the fame or the discredit of the sur- geon. A man who gets well with a crooked or shortened limb, is very apt, whether rightly or wrongly, to lay the blame of it upon his doctor, and though cases do undoubtedly occur in which the most skilful and attentive surgeon may fail in obtaining a satisfactory result, there can be no question that a great many bad cures of fracture are directly traceable to ignorance or neglect upon the part of the practitioner. Causes op Fracture. These may be divided into the exciting and the predisposing causes. Exciting Causes.—The exciting causes of fracture are external violence and muscular action. 1. External Violence may act directly or indirectly. Gunshot frac- tures are perhaps the best examples of fracture as the result of direct violence, while fracture of the clavicle from a fall on the shoulder, or of the radius from a fall on the hand, may be taken as illustrations of the injury as produced by indirect violence. Fracture by counter- stroke (the contre-coup of French writers) is a form of the fracture by indirect violence, in which the force is applied to one side or ex- tremity of the bone, or system of bones, which are so united and fixed that, by the natural elasticity of the parts, the force is transmitted, and produces its effect not at the point to which it was applied, but at a point CAUSES OF FRACTURE. 213 opposite. Familiar examples of fracture by counterstroke are those of fracture of the base of the skull, from force applied to the top of the head, of the frontal bone, from a fall upon the occiput, or of the sternum, from violence applied to the back. The subject of contre-coup, or coun- terstroke, has been involved in some confusion by the various meanings which different authors have given to the term; as used here, it is to be understood as denoting merely a variety of injury from indirect violence, the mechanism of which is explicable by simple and well-understood physical laws, depending entirely upon the structure and connections of the bones and other parts involved. 2. Fracture by Muscular Action is not of very unfrequent occurrence, though the cases in which fracture is produced by pure divulsion, or tearing asunder the fragments, are rarer than is commonly supposed. Indeed the only instances of the kind, with which I am acquainted, are those rare cases in which fracture of the sternum has occurred, during the acts of parturition, vomiting, etc. In the more commonly quoted instances of fractured olecranon, and fractured patella, the mechanism is somewhat different, the bones (as justly remarked by Dr. Packard) giv- ing way like over-bent levers, across the condyles respectively of the humerus and femur, though the fracturing force in these cases, as in those of fractured sternum, is muscular contraction. Predisposing Causes.—The predisposing causes of fracture may pertain to the bone itself, or to the general condition of the patient. Thus the situation of a bone influences its liability to fracture; the clavicle is much oftener broken than the scapula, and the lower than the upper jaw. Again, the function of a bone may predispose it to fracture; the bones of the lower extremity, which support the trunk, or those of the upper extremity, which are constantly engaged in the active employ- ments of life, are more liable to fracture than the vertebrae or sternum, the function of which is different. The following table, condensed from the statistics of Lonsdale, Norris, and Malgaigne, will exhibit the rela- tive frequency of fracture in different parts of the body, in the Middlesex Hospital, Pennsylvania Hospital, and Hotel Dieu:— Seat of Fracture. Lons-dale. Korris. Mal-gaigne. Seat of Fracture. Lons- Norris. 1 dale. Mal-gaigne. Skull............ Upper jaw and ma-Lower jaw... .[lar Ribs and costal car-Vertebra .. [tilages Pelvis, sacrum, &c. Scapula (or shoul- 6 years 48 13 1 33 2 357 8 7 273 18 10 yrs. 46 3 19 5 46 8 6 84 10 11 yrs. 53 13 3 27 1 263 11 9 225 12 Ulna............. Radius and ulna.. Thigh............ Tibia............ Tibia and fibula.. 6 years. 118 197 96 93 116 181 38 41 51 197 10 yrs. } j-252 9 133 16 295 11 yrs. 310 160 38 107 71 303 45 29 108 515 Among the predisposing causes which pertain to the general con- dition of the patient, age occupies a prominent place. There can be no question that the old are more apt to be the subjects of fracture than the young, partly on account of the greater brittleness of their bones, and partly from the general rigidity of ligaments and muscles, which attends advancing age, and which renders the entire frame less elastic and yielding, and therefore more liable to this form of injury. No age 214 FRACTURES. is, however, exempt from fracture, and not a few instances are on record in which this has occurred even during foetal life. The circumstance that old age predisposes to the occurrence of fracture, does not contravene the well-known fact that most of these injuries are met with in those in early adult life, for the simple reason that such persons are most engaged in active employments, and are, therefore, most exposed to all forms of injury resulting from external violence. Sex, as might be sup- posed, exercises an influence on the liability to fracture, men, from the nature of their occupations, being more apt to have broken bones than women; for a similar reason the right side of the body is more exposed to fracture than the left. Certain forms of cachexia, or certain diatheses, maj* be considered as predisposing causes of fracture. Rickets undoubt- edly exercises a powerful influence in this way, as do osteo-malacia, cancer, syphilis, scrofula, and gout. Some very remarkable cases are on record illustrating the fragility of bones under certain conditions: Gibson, Arnott, Tyrrell, Lonsdale, and H. Thomson have described such cases, but the most remarkable of all is that published in the Journal des Savants for 1690, and which appears to be the same as one quoted by Malgaigne from Saviart, in which an apparently healthy young woman of 30, during three months' confinement to bed, sus- tained, it is said, fractures of every bone in the body. Esquirol is said to have possessed a skeleton which exhibited traces of more than two hundred fractures. In many of these cases union readily took place, but in one mentioned by Stanley, and in that of H. Thomson (in which indeed the bones are described as separating rather than breaking), the fractures appear to have remained ununited. Varieties of Fracture. Fig. 104. Fractures may be Complete or Incomplete; these names sufficiently express their own meaning. The form of incomplete fracture usually met with in civil life is the partial or " green-stick" fracture, in which some of the bony fibres have given way, while the rest have yielded to the force, bending but not breaking. In military practice, in- complete fractures are occasionally produced by blows from sabres, but more often by gunshot wounds, the prin- cipal varieties being the fissured fracture, the grooving fracture, in which a piece is cut out from the side of a bone, and the button-hole or perforating fracture, in which a piece is fairly punched out from the centre of a bone. These terms (complete and incomplete) are principally used in reference to the long bones; in the case of flat bones, as of the skull, many of the fractures met with in civil life are incomplete. The most usual and the most important division of fractures is into simple and com- pound. A Simple Fracture, as the term is used in this book, is a fracture in which there are but two fragments, and which does not communicate ivith an open ivound. This definition, which seems to me to correspond with the mean- ing usually attached by surgeons to the term simple frac- PartiaTfracture. ture, is essentially the same as that given by Mr. Erichsen, VARIETIES OF FRACTURE. 215 but differs from the definitions given b}r Prof. Hamilton and Prof. Gross, the former author using the term as equivalent to Malgaigne's single fracture, without regard to its subcutaneous character, while the latter regards merely the absence of external wound, without reference to the number of fragments. The classification adopted by Mr. Hornidge, in Holmes' System of Surgery (which would make this form the " simple, single fracture"), is perhaps the most strictly correct, but is almost too complicated for common use. Compound Fractures are fractures which communicate with the external air through a wound: this wound is usually, though not neces- sarily, an external or cutaneous wound; a fracture of the jaw may be compound from a wound through the buccal mucous membrane. Comminuted Fractures are those in which there are more than two fragments, the lines of fracture, how- ever, intercommunicating with each other and occupying the same general position as regards the bone affected. A multiple fracture, on the other hand, is one in which the bone is the seat of two or more distinct fractures not necessarily connected with each other; thus the radius may be broken just below its head and again above the wrist, or the tibia through the malleolus and again just below its tuberosity. A double fracture is a multiple frac- ture in which the solutions of continuity are but two in number. Comminuted and multiple fractures mayor may not be compound, and a multiple fracture may be com- pound at one seat of lesion and not at the other. When the term comminuted fracture alone is used, it is under- stood that there is no communication with an external wound; if there be such communication, the injury be- comes a compound comminuted fracture. Comminuted fracture of the humerus. Fig. 106. Complicated Fractures are fractures which are ac- companied by some other serious injury of the same part. Thus a fracture may be complicated by dislocation of a neighboring joint, by rupture of an important artery, or by a severe flesh wound which does not communicate with the seat of fracture. Some authors speak of fractures being complicated (in this technical sense) by any of the various lesions to which the human frame is subject, but this, it seems to me, is incorrect; thus it would be wrong to de- scribe a fracture of the right thigh as complicated by a dislocation of the left shoulder, or a fracture of any of the extremities as complicated by a wound of the pleura or lung, though the latter le- sion, if produced by the sharp fragments of a broken rib, would be a technical complication of that injury, which would then be properly called a complicated fracture of the rib. Impacted one fragment other. Fractures are those in which is driven into and fixed in the Impacted fracture, through the trochanters. The upper fragment is wedged into the lower. 216 FRACTURES. Intra-periosteal Fracture is the term applied to a fracture unac- companied by laceration of the periosteum; it is a form of injuiy rarely met with except in certain flat bones, as those of the skull, and, indeed, the creation of this subdivision seems to me to be of very little practical utility. Direction of Fracture.—Fractures are also classified in accord- ance with the direction in which the separation of the bony fibres occurs; thus fractures are said to be transverse, oblique, or longitudinal. A Transverse Fracture is one in which the general line of separation is transverse or in a plane at right angles with the long axis of the bone. A perfectly transverse fracture in a long bone is very rarely met with, the line of separation being almost always more or less oblique; a variety of the transverse is the serrated fracture, in which the fragments present corresponding indentations which render it comparatively easy to maintain them in apposition. Transverse fractures usually result from direct violence or from muscular action. The Oblique Fracture is the form most commonly met with in the long bones. The plane of fracture may, of course, vary greatly in differ- ent cases; thus a fracture is said to be oblique from before backwards and from without inwards, etc. Oblique fractures are commonly caused by indirect violence. Longitudinal Fractures are those in which the line of separation runs in the general direction of the long axis of the bone. This form of frac- ture is comparatively rare in civil life, but is frequently met with as a result of gunshot injury, especially since the general introduction into warfare of the improved conoidal ball. Longitudinal fractures com- monly occur in the shafts of long bones, and usually do not extend beyond the epiphyseal lines, though occasionally they pass through the epiphyses into the neighboring joints. Several other divisions are made by French writers, according to the peculiar form of the fracture, but the above are sufficient for practical purposes. Separation of Epiphyses.—This is a form of injury which may fairly be classed among fractures, the symptoms and treatment of the two sets of cases being pretty much the same. Separation of an epi- physis may take place at either end of the humerus, the femur, or the tibia, and at the lower extremity of the radius; it is also frequently seen in the case of certain bony processes, as the acromion and olecranon; while in certain flat bones, as the sternum and os innominatum, similar injuries are met with, consisting in a separation of the osseous structure into its original constituent parts, in the lines of cartilaginous junction. Epiphyseal separation can of course only occur before complete ossifica- tion has taken place; hence, in the long bones it is not met with beyond the age of twenty or twenty-one, though in other situations, as in the acromion, it may occur at a much later period. The direction of an epiphyseal separation is transverse, and, from the proximity of the epiphyseal lines to the articulations, these injuries are liable to be con- founded with dislocations. The diagnosis in such cases can usually be made, by taking care, in the examination, to grasp the epiphvsis itself firmly with one hand, while the. other exercises the movements of flexion, rotation, etc., Avhen, if the case be one of separated epiphysis, the lesion can readily be recognized as being above or below the line of the joint, as the case ma}r be. SYMPTOMS OF FRACTURE. 217 Symptoms of Fracture. Deformity,—The most prominent, and one of the most character- istic symptoms of fracture is deformity or displacement. The Causes of Displacement, in cases of fracture, have been the subject of much dispute among systematic writers. Without entering into a minute discussion of this matter, I may say, in general terms, that the causes of displacement are fourfold, viz.: 1, the force that produces the fracture; 2, the action of surrounding muscles; 3, the weight of the limb below the seat of fracture; and 4, the natural elasticity and resiliency of the ligaments and other soft tissues above the seat of fracture. 1. Deformity from the influence of the fracturing force is seen in cases of depressed fracture of the skull, in cases of partial fracture of the clavicle with inward angular deformity, and in cases of impacted fracture generally. 2. Muscular action is the most common cause of displacement in cases of fracture. It is seen in the shortening which accompanies almost all fractures of the extremities, and in the rotatory displacement common in fractures of the femur, radius, etc. It is probably the sole cause of displacement in cases in which the fracture itself has been caused by mus- cular action, as in fractures of the patella or olecranon. Besides the ordinary contraction of the muscles around the seat of fracture, there is often a spasmodic condition induced by the irritation caused by the sharp fragments of the broken bone. 3. Displacement by the weight of the limb below the seat of fracture, is seen in the dropping of the arm and shoulder, in cases of fractured acromion or fractured clavicle. It assists the action of the rotator mus- cles, in producing eversion of the foot, in fractures of the lower extremity. 4. Finally, the natural elasticity of the soft tissues above the seat of fracture, is seen as a cause of deformity in the projection of the inner fragment of a fractured clavicle, when, as pointed out by Anger, the weight of the arm being taken off by the fracture, the inner end of the clavicle is jerked upwards, by the normal resiliency of its ligamentous and other attachments. Direction of Displacement.—The displacement in cases of fracture may take place in various directions; thus, there maybe angular, trans- verse, longitudinal, or rotatory displacement. 1. Angular displacement is usually due in the first place to the action of the fracturing force, but is kept up or may be originally produced by muscular action. Thus, in fracture of the thigh there is often an angular displacement outwards and forwards, due to the fact that the most powerful of the femoral muscles are those on the back and inner side of the limb. This is the form of displacement met with in partial or "green-stick" fractures, and it may also accompany oblique or commi- nuted fractures, or those in which there is impaction. 2. Transverse displacement is comparatively rare; it occurs princi- pally in cases of serrated fracture of the long bones, in which the separa- tion has not been sufficient to allow overlapping from muscular contrac- tion. It is also met with in fractures connected with joints, as in splitting fractures of the cond3des of the humerus or femur. 3. Longitudinal displacement is displacement in the direction of the long axis of the bone at the point of fracture. It may consist in shorten- ing, or in lengthening. Shortening occurs principally in oblique fractures of the long bones, and is due to muscular action, often assisted by the 218 FRACTURES. nature of the fracture, which allows one fragment to slide upon the other as upon an inclined plane. When the shortening is so great that the upper end of the distal fragment is drawn above the lower end of the proximal fragment, there is said to be overlapping, and the more promi- nent fragment is said to ride the other. The overlapping often amounts, in fracture of the thigh, to several inches. Another form of shortening is due to impaction; this is often seen in fracture of the cervix femoris, the shortening being principally in the direction of the axis of the neck of the bone, not of its shaft; hence the deformity in such a case is com- paratively slight. The form of longitudinal displacement which con- sists in lengthening, is chiefly seen in cases of fractured patella, fractured olecranon, fractured calcaneum, etc., in which the fragments are often widely separated by muscular action; it is, however, as pointed out by Malgaigne, occasionally met with in fractures of the articular extremi- ties of the long bones, as of the fibula, when it is a secondary condition dependent on antecedent rotatory displacement. 4. Rotatory displacement consists in one of the fragments being twisted upon its own axis; this form of displacement may be due to muscular action, or to the weight of the limb below the seat of fracture. This dis- placement is constantly seen in fracture of the upper part of the femur, when the lower fragment is rotated outwards by the powerful external rotator muscles of the thigh; in fracture of the bones of the leg, by the action of the same muscles, the upper fragments, moving with the femur, are subjected to rotatory displacement. So in fracture of the radius, particularly if above the insertion of the pronator radii teres, the upper fragment is usually rotated outwards by the biceps and supinator brevis. Displacement in cases of fracture may be confused with deformuy from other causes; thus a periosteal node or an exostosis may closely simu- late angular displacement; shortening may result from old joint disease or from contracted tendons; the position which a joint assumes when the seat of sprain, may be mistaken for rotatory displacement; while the transverse, or, indeed, any of the varieties of displacement may be due to dislocation and not to fracture. Hence, the surgeon, in making his diagnosis, must not rely upon the appearances presented to the eye, or even upon mere tactual examination. The limb involved should be carefully and repeatedly measured between known fixed points, and compared with the corresponding unaffected limb; and in cases of doubt, not only the injured limb, but the bone itself should be accurately measured and compared with its fellow of the opposite side. Mobility is often a striking and easily recognized symptom of frac- ture: the part which gives support to the limb is broken, and the limb can be bent in any direction. In fractures, however, of the leg or forearm, when but one of the two bones is broken, the other acts°as a splint, and hinders the development of this symptom; again, in serrated, and especially in impacted fractures, there will often be no undue mobility; or the swelling of the soft parts may be so great as to render the mobility of a fracture, especially if near a joint, difficult of recogni- tion. On the other hand, dislocation, which is usually characterized by immobility of the affected joint, may, if there be much destruction of the articular ligaments, be accompanied by positive increase of mobility, and thus simulate fracture. But in the continuity of a bone, at a distance from its articular extremities, mobility, when present, is a sign of the greatest value, and may, indeed, be considered as almost pathognomonic. SYMPTOMS OF FRACTURE. 219 Crepitus is another symptom of great importance, and when existing in connection with undue mobility, may be looked upon as establishing the presence of fracture. Crepitus or crepitation is the grating sensa- tion produced by rubbing together the rough ends of the fragments. It is felt as well as heard, and is usually recognized without difficulty: it must not be mistaken for the grating produced by moving diseased joints, nor for the crackling due to effusion in the tendinous sheaths, nor yet for the crepitation of traumatic emphysema, each of which conditions may, under certain circumstances, closely simulate the true crepitus of fracture. The diagnosis might, perhaps, be aided in such cases, as suggested by Lisfranc, by the use of the stethoscope. The non-existence of crepitus is no evidence that a bone is not broken, and its absence may be due to several causes: thus, the fragments may overlap to such a degree that their rough ends are not in contact—a condition often met with in fracture of the thigh, when it is necessary for an assistant to make extension before the fragments can be brought together and crepitus produced; or the fragments may be widely separated—as in cases of fractured patella; or a portion of muscular tissue may be caught between the fragments, and prevent crepitus. In partial fracture, there is no crepitus; nor in impacted fracture, so long as the irnpaction continues. Pain and Tenderness are symptoms of fracture, but may be equally due to so many other causes, that they cannot be considered as diag- nostic. In some cases, however, persistent, localized tenderness is a sign of some value, especially in cases of partial or impacted fracture, in which the more characteristic symptoms are absent. Loss of Function used to be considered an important symptom of fracture. Yelpeau, however, showed that a fractured clavicle interfered with raising the arm to the head, merely by the pain caused by the act; and Gouget, a French army surgeon, has shown the same thing, as regards the power of walking, after fracture of the patella (Rec. de Mem. de Med. de Chir. et de Phar. Mil., Mai, 1865, p. 394). I have myself known a man with fracture of both bones of the leg, to walk about the ward, when under the influence of mania-a-potu, using his fracture-box as a boot, and apparently not feeling any inconvenience from his injury. Muscular Spasm is a not unfrequent accompaniment of fracture, though, of course, in no degree a diagnostic symptom: it is produced by a reflex condition, due to the irritation produced by the sharp ex- tremities of the fragments. Numbness is occasionally met with in cases of fracture, and is pro- duced by simultaneous injury, or subsequent compression of neighboring nerves. Extravasation and Ecchymosis, to a greater or less extent, occur in almost every case of fracture: the degree of ecchymosis is often much greater after a few days, than when the injury is first received, and may then (especially if accompanied by much vesication, as it is apt to be if the soft parts have beep much bruised) be mistaken by a hasty observer for incipient gangrene. When extravasation proceeds from a ruptured artery, giving rise to a traumatic aneurism, it constitutes a very serious complication of fracture. 220 FRACTURES. Diagnosis of Fracture. The diagnosis of fracture can usually be made without much difficulty by attending to the symptoms above enumerated, the first three of which, when coexisting, may indeed be considered as pathognomonic. In cases of partial and of impacted fracture, the surgeon has not the evidence furnished by crepitus and mobility, and must rely upon the other signs of fracture, especially deformity and localized tenderness. Again, in cases where but one of several bones is broken, as in the hand or foot, the diagnosis is more obscure, especially if there be much swelling of the soft parts. In such a case, the surgeon carefully explores the surface, by making firm but gentle pressure upon each part in succession, and is thus enabled to detect any abnormal prominence, and often to elicit crepitus, which could not otherwise be obtained. If the metacarpus or metatarsus be involved, each bone should be successively grasped by its extremities, and so manipulated as to render evident any fracture which may be present. As it is of great importance in any case of sus- pected fracture that the surgeon should arrive at a correct diagnosis, his examination should always be made deliberately and systematically. The deformitj', mobility, impairment of function, pain, etc., should be successively noted, before proceeding to the manual examination which is to determine the existence or non-existence of crepitus. In this final part of the investigation, preliminary extension being made by an assistant, if necessary, the surgeon grasps the limb above and below the suspected seat of fracture firmly—so that he controls the bone as well as the flesh, and gently moves his hands in various directions, so that if there be a fracture, the ends of the fragments must rub against each other. It is scarcely necessary to say that in this examination, all rough and needless manipulation is to be positively interdicted. If true bony crepitus be once elicited, it is sufficient, in connection with the other symptoms, to establish the diagnosis; and nothing can be more repre- hensible than for a surgeon to persist, in spite of the pain thereby caused, in endeavoring again and again to renew this evidence, thus appearing more anxious to make a clinical demonstration for himself or for the bystanders, than to relieve the sufferings of his patient. The examination of a case of suspected fracture should be made as soon as possible after the time of reception of the injury, as the diag- nosis is then more easy than if oedema and inflammatory swelling have already occurred. If, however, the surgeon do not see the case in an early stage, it is often judicious to defer any minute examination, treat- ing the case as one of fracture until the swelling has subsided, when, if there be really no bone broken, at least no harm will have been done by the delay. Or-if for any reason it were important to ascertain the nature of the case at once, the plan recommended by Rizet, a French army surgeon, might be tried. This plan consists in endeavoring to dis- perse the swelling by systematic friction and kneading (massage), in the course of which proceeding, the fracture, if there be one, will become evi- dent. Under certain circumstances, the use of an anaesthetic would be justifiable, in order to facilitate the diagnosis (see page 13). In any case of doubt it is safe to presume that the worst has occurred, and treat the case as one of fracture. It is remarkable what severe injuries of bone may exist, and yet, for a time at least, escape attention; Mr. Erichsen gives a remarkable case of compound comminuted fracture of the humerus, which, though carefully examined by himself and others, PROCESS OF UNION IN FRACTURED BONES. 221 was not detected until the eighth day, and I can myself recall a case in the Pennsylvania Hospital, in which the swelling of the part prevented the recognition of anything further than that the patieut had a fracture of both tibia and fibula, and yet in which (death taking place soon after from mania-a-potu) an autopsy showed that the bones were broken into at least a dozen fragments. Process of Union in Fractured Bones. In order to understand the process of repair after fractures, it will be necessary to pause for a few moments to consider the natural process of growth and maintenance of bone in its normal condition. This subject has been recently most fully and carefully studied by Oilier, of Lyons, to whose elaborate and admirable Treatise on the Regeneration of Bones I would respectfully refer the reader for a detailed exposition of the whole subject of bone pathology. Bone grows in length by the development of bone cells from the epiphyseal cartilages, or cartilages of conjunction, and in thickness by the development of bone cells from the inner or osteo-gene- tic layer of the periosteum: while this peripheral thickening is going on, there is a simultaneous conversion of the innermost layers of bone into medulla or marrow, and hence the medullary cavity enlarges as the bone grows. Turning now to consider the effects of any traumatic irritation upon the constituents of bone, we find the various nutritive and forma- tive changes which were described as parts of the inflammatory process (see Chap I.), taking place in the periosteum, the bone tissue proper, and the medulla. Direct irritation of either periosteum or medulla is apt to result in giving rise to what was described as the second formative change of inflammation, the formation of pus, or suppuration: indirect irritation, however, whether propagated from the bone or from the external soft parts, gives rise (usually) only to the earlier changes, viz., temporan' hypertrophy, and the formation of lymph. In the case of the periosteum the effect of propagated traumatic irritation is to cause a hyperplasia of the deep or osteo-genetic la3?er, manifested by swelling, and ultimately resulting in an increased production of new bone: in the marrow the irritation, if not excessive, results in induration and a local retrograde metamorphosis into bone. Finally the bone tissue itself responds to the stimulus, and becomes medullized (assuming the character of granula- tions), proliferation of its cells takes place, and hypertrophy, temporary or permanent, results, with (if the irritation continue) the various changes which will be hereafter considered under the head of osteitis. These are not mere theoretical views, but have been adopted by Oilier, after numerous carefully conducted and often repeated experiments upon the lower animals, as well as after extended clinical observation.1 Taking now the simplest case of fracture—an intra-periosteal fracture, so called—the process of repair can be seen at a glance. The traumatic irritation propagated from the broken bone causes swelling of the peri- osteum, active proliferation, and formation of a sheath of new bone 1 It is but right to say that a different explanation is given by Billroth; according to this distinguished surgeon and pathologist, the periosteum possesses no peculiar osteo-genetic power, and the formation of callus is due not to proliferation of pre- viously existing cells, but to an accumulation of wandering cells, which, following Cohnheim, he looks upon as white blood corpuscles escaped from the vessels. The same difference of opinion, in fact, prevails with regard to the pathology of inflamma- tion and repair in the osseous tissues, that has already been noted with regard to those processes in the soft structures of the body. 222 FRACTURES. around the seat of fracture; this is the "ensheathing" or " ring callus" of surgical writers. At the same time the medulla feels the effect of the irritation, becomes hardened and partially ossified ; this constitutes the "interior" or "pin callus." Lastly, the osseous tissue itself undergoes cell proliferation, and union of the fragments takes place, mutatis mutan- dis, precisely by the same process that we have already studied in con- sidering wounds of the soft tissues. The new material which is thus developed between the fragments themselves, constitutes what Dupuy- tren called the intermediate, permanent, or. definitive callus, in contra- distinction to the ensheathing and interior forms of callus, which are temporary or provisional. This explanation is applicable to the process of repair as seen in every variety of fracture. The new formations from the periosteum and medulla gradually disappear, the ensheathing callus is partly absorbed and partly incorporated in the bone, in the process of its normal main- tenance, while the ossified medulla, or interior callus, undergoes rarefac- tion and medullization, so that in time the continuity of the marrow cavity is again restored, and the whole bone resumes its pristine appear- ance. In the case of fracture unaccompanied by displacement, the peri- osteal and medullary new formations may be so small in amount and so temporary in duration, as to escape observation; this is seen in certain serrated, impacted, and partial fractures, and is often spoken of as union by intermediate callus alone. On the other hand, the fragments them- selves sometimes fail to unite, the sole bond of union being the provi- sional (though in these cases not temporary) callus, resulting from the action of the periosteum or medulla. In cases in which there is great dis- placement, especially in neglected fractures of the thigh, very large and thick bands of callus are often seen, stretching across and uniting the fragments which are themselves widely separated. The time occupied by the process of repair, varies of course according to the size of the frac- tured bone and other extraneous circumstances. For the first few days, no apparent change occurs in the neighborhood of the fracture, nature being apparently engaged in repairing the injury of the soft parts, caus- ing the absorption of effused blood, etc. The formation of the provi- sional callus usually begins during the second week, and by the end of the third or fourth week this new structure has commonly attained suffi- cient bulk and strength to prevent displacement by any moderate degree of force. The definitive union of the fragments is not completed until a later period—sometimes many months subsequently. In certain situa- tions, or under certain circumstances which will be considered hereafter, bony union does not take place, and the fragments are connected by fibrous tissue only. In cases of compound fracture, the process of union, though the same, is much slower in its progress, being delayed by the occurrence of granulation, of suppuration, and often of necrosis, and presenting similar differences to those which are observed in the healing of open, as compared with that of subcutaneous wounds. Cartilage is occasionally met with in callus; it is, however, but a temporary con- stituent, due to excess of irritation. Separated epiphyses unite as frac- tured bones : the part usually remains permanently thickened, while from the injury to the cartilage of conjunction, the growth of the bone in length is permanently interfered with. For further information on the interesting subject of the repair of bones after fracture, I would respect- fully refer the reader to the writings of Dupuytren, Malgaigne, Stanley, and Paget, but especially to the work of Oilier, already referred to. TREATMENT OF FRACTURES. 223 Treatment of Fractures. The general indications to be met, in the treatment of all fractures, may be said to be—1, to reduce or set the fracture as soon as possible; 2, to prevent a recurrence of displacement; and 3, to see to the well doing of the part affected, and to look after the constitutional condition of the patient. I shall first consider the general principles which should guide the surgeon in the treatment of simple fractures, then the modifi- cations of treatment required by the principal complications of simple fracture, and finally the treatment of compound fractures. Treatment of Simple Fractures.—Fractures are often met with at a distance from home, and in localities where no surgical appliances are at hand, and where no treatment can be satisfactorily carried out. Under such circumstances, it becomes necessary for the surgeon to at- tend, in the first place, to the transportation of his patient. If the frac- ture be in the upper extremity, it may be sufficient to support the in- jured limb in a broad sling made from handkerchiefs, when the patient can ride or even walk a short distance without much inconvenience; if the fracture be in the lower extremity, it will be necessary for the patient to be carried upon a sofa, or litter extemporized from boards, a window- shutter, etc. If a mattress cannot be obtained, the patient's head and the broken limb may be supported on any old cloths that can be procured, or upon straw. Temporary splints may sometimes be formed from the bark of trees, or made by laying together three or four thicknesses of folded straw or rushes. The limb should be laid in as easy a position as possible, and the litter borne deliberately, but with a firm step; it is usually recommended that the bearers should be instructed to step off with alternate feet, as it is said that thus less vibration is communicated to the litter. Before the patient is removed from the litter, the surgeon should see that a suitable bed has been prepared. Various fracture-beds have been invented by surgeons, amongst the most ingenious being those of Daniels, Burges, Coates, and Hewson, but, for practical purposes, I know of nothing better than a simple perforated hard mattress, with a pad accurately fitting the perforation, and a pan which slides in a frame- work beneath a corresponding opening in the bedstead; the latter should be provided with strong wooden or metallic slats, so as to furnish an even surface and secure firmness and rigidity to the whole arrangement. The lower sheet must, of course, be also perforated, and should be se- cured to the mattress so as not to form ridges under the patient's bod}'. If a fracture-bed cannot be procured, an ordinary bedstead with a hard mattress may be used, in which case a bed-pan must be employed to receive the fecal evacuations. These preliminary matters having been attended to, and the patient being in bed (if the fracture be in the lower extremity), the surgeon removes the clothing as gently as possible, and exposes the injured part and the corresponding part of the opposite side. He then, by a care- ful and methodical examination, proceeds to satisfy himself as to the nature and extent of the injury, and then, replacing the limb in an eas}' position, prepares his splints and bandages before attempting to reduce the fracture. 1. Reduction or Setting the Fracture consists in replacing the frag- ments by manipulation as nearly as possible in their normal position, as regards each other. I say advisedly, " as nearly as possible," for I 221 FRACTURES. believe with Prof. Hamilton, that it is only in exceptional cases that the displacement of fracture can be entirely overcome. Reduction should be effected as soon as possible, for the reason that it is much easier to the surgeon, and much less painful to the patient, if done before the development of inflammation; if, however, the patient is not seen until a later period, or if displacement should, from any cause, have recurred, the surgeon need not hesitate at any stage of the case to effect as perfect reduction as he can, for the slight additional irritation thus produced' will be of much less consequence than the evils which would result from continued displacement. Reduction should be effected by the hands alone; no mechanical contrivance should be used to give increased force, lest serious mischief to the already lace- rated tissues should be produced. In the immense majority of cases, little or no force will be required, it being sufficient to place the limb in such a position as to relax the displacing muscles, when the bones will fall into position of themselves. Even in fracture of the femur, how- ever, in which extension is commonly necessary to effect reduction, it is a good rule that no more force should be used than can be applied with the hands alone. In cases in which one or both fragments are embedded in the muscular tissue, or in which, from any other cause, there is great muscular resistance, it may be justifiable to employ anaesthesia as an aid to reduction. 2. To Prevent the Recurrence of Displacement, the surgeon makes use of various forms of apparatus, splints, bandages, etc. It is often veiy difficult to maintain reduction during the first few days, on account of the spasmodic action of the muscles constantly reproducing the de- formity; but the tendency to spasm gradually passes off, so that by constant attention and careful dressing during the early stage of the treatment, it is almost always possible to obtain such accurate apposi- tion of the fragments, as will secure a well-shaped and useful limb, though probably not one absolutely free from deformity. The different forms of bandage used by surgeons, and their modes of application, were considered in the chapter on Minor Surgery; the splints and special apparatus employed, will be described in discussing fractures of the several bones. Suffice it to say here, that the surgeon should aim to use as simple apparatus as possible; plain and light splints of wood, pasteboard, wires, or thin metal, such as can be made by any carpenter or blacksmith, are, I think, in every way preferable to the elaborate and complicated appliances which have been, from time to time, recommended for the treatment of fractures. Straight and angular splints, made of smooth half-inch boards, for the upper extremity, straight splints and plain fracture-boxes with soft pillows for the lower extremity, a roll of cotton wadding or of tow for padding splints, or bags filled with bran or sand for the same purpose, a few pieces of binders' board, a half dozen or a dozen roller bandages, a few yards of adhesive plaster, and two or three bricks for use in making ''weight extension," constitute an armamentarium sufficient for the treatment of almost all cases of frac- ture. The general principles to be observed in the use of splints and other apparatus may be stated as follows:__ (1.) They are to be used as means of retention only, not of reduction or extension; these are effected by the surgeon's hands, and splints and bandages are merely to prevent the recurrence of displacement. (2.) All splints, etc., should be firmly and evenly padded, so as not to exert injurious pressure on the bony prominences with which they come TREATMENT OF SIMPLE FRACTURES. 225 in contact, while at the same time the padding must not be so bulky as to render the splints clumsy or unmanageable. (3.) Circular compression is to be carefully avoided, as swelling is inevitable after a fracture, and the risk of gangrene from this cause is by no means only theoretical. Hence, as a rule, in the early stages of fracture, no bandage should be applied beneath the splints. (4.) In treating fractures of the shaft of a bone, the nearest joints above and below should, if practicable, be fixed by the splints used; if the fracture involve an articulation, the shafts of the bones which form the joint should themselves be so fixed. (5.) When a fracture is properly " put up," unless the patient suffer so much pain as to render it probable that displacement has recurred, or that the splints are pressing unevenly, the dressing should not be disturbed more than absolutely necessary. It is a good rule to leave the fingers or toes exposed, so that the surgeon can by them judge of the condition of the circulation in the injured limb; and if they appear unduly congested or swollen, the dressings should be at once removed, and reapplied with additional precautions against gangrene. If a case do well, every other day is quite often enough to renew the bandages during the first fortnight, the interval between the dressings being gradu- ally lengthened after that time to half a week, and finall}', to a week. At the same time, while in no class of cases is meddlesome surgery to be more reprobated than in this, fractures should be invariably looked upon as cases requiring careful and continual watching, and a patient with a broken bone should receive from his surgeon at least daily visits, until after the subsidence of all inflammatory symptoms. 3. The third indication for treatment (see p. 223) brings up the con- sideration of the various accidents which may arise during the manage- ment of a case of fracture. Muscular spasm and extravasation are such constant accompaniments of fracture, as to entitle them to be considered as symptoms, under which head they have been referred to. Spasm is best controlled by the free use of opium; moderate compression with a firm bandage is often recommended, but is a somewhat hazardous re- medy, and should be used with great caution. Tenotomy has been also proposed for this purpose ; but I can scarcely conceive of a case in which its use would be justifiable. Extravasation, if moderate, may be disre- garded ; if there be much contusion and vesication, the limb should be simply laid on a pillow, protected by oil-cloth, while evaporating lotions are applied until the subsidence of inflammation; if large vesicles or bullae form, they should be opened with the point of a lancet. If the extravasation proceed from the rupture of a large artery, the case will require special treatment, which will be considered under the head of complications. Gangrene is the most serious accident which can be met with in the treatment of a simple fracture, and may be due either to arterial ob- struction at a point above the seat of fracture, to venous obstruction due to swelling of the part or to tight bandaging, or to a combina- tion of these causes. With regard to tight bandaging, it is to be remembered that a bandage may seem sufficiently loose when applied, and yet in a few hours may become the cause of great constriction from subsequent swelling of the limb; hence the importance of not applying a bandage beneath the splints; it is, as remarked by Mr. Erichsen, almost invariably to a neglect of this rule that the occurrence of gangrene from the pressure of a bandage is due. Especially is this true in the case of the forearm, in fracture of which part this accident most often occurs. 15 226 FRACTURES. It should not be forgotten, however, that this accident may be partly or entirely due to arterial obstruction, which is of course an unavoidable occurrence; hence we should not be too hasty in accusing a fellow-prac- titioner of mal-practice on account of such an accident, for it may be really due, at least in some measure, to causes entirely beyond control. The treatment of grangrene occurring under such circumstances must vary according to its nature and extent; if it be due to constriction, and the surgeon fortunately discover it in time, he must instantly remove the bandages, when possibly the patient may escape with superficial Fig. 107. Gangrene from tight bandaging. sloughing. If complete gangrene have occurred, amputation of course becomes necessary; if the disease show a disposition to self-limitation, the surgeon may await the formation of the lines of demarcation and separation, but if the gangrene be of the rapidly spreading traumatic variety (p. 148), immediate removal of the limb must be practised at a point above the furthest limits of the disease. In the former case a favorable result may be anticipated, but under l!he latter circumstances the patient is apt to sink after the operation, as happened in a case in which some years since I amputated at the shoulder-joint, for spreading gangrene following a badly treated fracture of the forearm. The other accidents which occur during the treatment of fractures, cannot be considered as peculiar to these injuries. Thus there may be excessive inflammation, followed by abscess or sloughing, surgical fever, traumatic delirium, tetanus, erysipelas, or pyaemia. In old persons the confinement to bed required in the ordinary treatment of fractures may produce pulmonary or cerebral congestion; hence the advantage in such cases of using the starched bandage or other immovable apparatus, which may enable the patient to get about as soon as possible. In renewing the dressings of a fracture, the limb should be firmly and carefully held by an assistant, so as to prevent any recurrence of dis- placement while the splints are off; it is well at each dressing to gently rub the affected limb with soap liniment or dilute alcohol (carefully drying the part afterwards), so as to keep the skin in a healthy state. The patient's general condition should be attended to, and any dis- order of the bowels or chest remedied by appropriate measures. The use of the catheter is very often required for a few days, when the patient is confined to bed, especially if the fracture be situated in the pelvis or femur. Passive Motion is effected by the surgeon flexing and extending the joints of the injured limb, while firmly holding the parts above and be- low. There is a difference of opinion as to the time at which passive motion (which is designed to prevent anchylosis) should be begun; my TREATMENT OF COMPLICATED FRACTURES. 227 own conviction is very clear, that it should not be practised until firm union has occurred between the fragments—usually, therefore, not be- fore the third or fourth week after the accident, and that it should even then be used with moderation and with gentleness. The patient may, indeed, often be safely left to regain mobility of the joints, by the ordinary plrysiological exercise of the limb, assisted by methodical friction, and the use of the cold douche. In the case of the upper ex- tremhry, the patient may, after recovery, be advantageously directed to swing a flat-iron or put up a dumb-bell with the affected member, several times a day, continuing the exercise on each occasion until slight fatigue is experienced. Treatment of Complicated Fractures.—Fractures may be com- plicated by various conditions which will require special modifications of the general course of treatment above described. Thus the extravasation, although proceeding from vessels of moderate size, may produce so much swelling as to give rise to great congestion or even strangulation of the tissues, and consequent gangrene, demanding amputation; or the contu- sion and subsequent inflammation may be so great as to cause suppura- tion and sloughing, resulting in the conversion of the case from one of simple, into one of compound fracture. Rupture of the Main Artery of a limb is a very serious complication of fracture. This accident is principally met with in connection with frac- ture about the knee-joint, and the injured vessel may be either the pos- terior tibial or the popliteal. In either case, a rapidly increasing, ob- scurely pulsating tumor—a diffuse traumatic aneurism in fact—forms in the ham; and, unless promptly treated, will inevitably cause gangrene. If the posterior tibial be the wounded artery, at least partial warmth will be restored to the leg and foot, and pulsation will return in the an- terior tibial: under these favorable circumstances, an effort should be made to save the limb by resorting to compression or ligation of the superficial femoral, in Scarpa's space. The reason for not treating the case as one of ordinary wounded artery is, that by so doing, even if the opening in the vessel could be found, which would be doubtful, the injury would be converted into a compound fracture of the worst kind, which would almost inevitably require amputation; while there would be a chance, though not a very brilliant one, that, by the use of the proximal ligature, the arterial wound might heal, and allow the preservation of the limb. If, however, the temperature of the leg and foot continue to sink, and no pulsation can be detected in the anterior tibial, gangrene appearing imminent, it becomes almost certain that the popliteal artery is ruptured ; and, under such circumstances, amputation should be at once performed. So, also, if after an attempt to save the limb gangrene should occur, am- putation would be necessarjr. In any case of doubt, I think the safety of the patient would be consulted rather by removing the limb, while he was yet in good general condition, and when the operation could be done immediately above the knee, than by running the risk of being com- pelled to amputate at a higher point, with the patient under the depress- ing influence of gangrene. Rupture, or other Serious Injury of an Important Nerve, as the mus- culo-spiral or median, is a very troublesome and annoying complication of fracture, causing loss of power or permanent impairment of the nutri- tion of the limb, as in a number of cases collected by Callender. This accident may not be apparent at the time of reception of the injury, and I have even known a surgeon to treat a broken arm until complete union 228 FRACTURES. of the fracture had occurred, not discovering the existence of paralysis until the splints were finally removed, when the limb dropped helplessly by the patient's side. The treatment of such a case is very unsatis- factory ; it should be conducted on the principles laid down in the last chapter, in discussing injuries of the nerves in general. A very Severe Flesh Wound, even if not communicating with the seat of fracture and thus rendering it compound, may seriously complicate the progress of the case, and may occasionally necessitate amputation. Unless, however, the injury to the soft tissues were, in such a case, in itself sufficient to condemn the limb, a fair trial should always be given to conservative treatment before resorting to amputation. The Implication of a Joint in the line of fracture, will very often give rise to a certain amount of stiffness if not to absolute anchylosis, after recovery; or, in a strumous constitution, may cause disorganization of the articulation, and thus eventually render amputation imperative. In every case of fracture involving a joint, the treatment should be con- ducted with great caution, and the prognosis should be extremely guarded. Dislocation of an Adjoining Articulation is a not unfrequent complica- tion of fracture. In such a contingency the fracture should be tempo- rarily put up with wooden splints and firm bandages, so that the limb may be used as a lever in effecting reduction of the dislocation, the patient being of course etherized. The fracture is then to be treated in the ordinary manner. If the dislocation be not recognized until a later period of the case, the surgeon must wait until firm union of the fracture has occurred, and then, applying splints, make an effort to reduce the dislocation, a feat which, under these circumstances, may be very difficult to accomplish. A fracture in a limb which is the seat of an old Unreduced Dislocation, or of a Previously Anchylosed Joint, presents no peculiar difficulties of treatment, though it may require a modification in the form of the splints used, to adapt them to the existing deformity of the part. Fracture of the bone in a Stump, or into the site of a Previously Ex- cised Joint, is occasionally met with, but requires no special treatment beyond the necessary modification of apparatus. Chorea, affecting a limb which is the seat of fracture, is a very serious complication: in a case of simple fracture of the humerus complicated with chorea, reported by Dr. Wm. Hunt, of this city, it was found impos- sible to keep the parts at rest, and the patient died exhausted on the tenth day. A fracture occurring in a Previously Paralyzed Limb, commonly unites without particular difficulty. There is, of course, no risk of recurring displacement from muscular action, but special care must be taken to avoid undue pressure, which might readily induce sloughing. Treatment of Compound Fractures.—The first question to be determined with regard to any case of compound fracture, is whether or not amputation is to be performed; if the operation is to be done at all, it should be done as soon as possible, for the reasons already given • in Chapter Y. If amputation have not been done before the setting in of the intermediate or inflammatory stage, it must be, if possible, further postponed until suppuration is freely established. Amputation for Compound Fracture.—No universal rules can be laid down, as to what cases of compound fracture should be submitted to primary amputation, but each individual case must be treated on its own merits, according to the judgment of the surgeon. It may, how- TREATMENT OF COMPOUND FRACTURES. 229 ever, be said that the circumstances which usually call for amputation in these cases are the following :— 1. Extensive and severe laceration of the muscular and other soft tissues.—A compound fracture, in which the wound is made by the frac- turing force, is a more serious injury than one in which the wound is made by the fragments perforating the skin, for the reason that in the latter case the soft tissues are comparatively little injured, while in the former they are apt to be greatly torn and bruised, or perhaps completely pulpefied. Hence compound fractures from railway and machinery acci- dents, especially in the lower extremity, are almost invariably cases for amputation ; in the upper extremity it is often possible to save the limb, even in these unfavorable circumstances, and if the age and general con- dition of the patient should justify the attempt, it should certainly be made. It is in such cases that irrigation is found to be of special service in moderating the consecutive inflammation. 2. A compound fracture accompanied with a wound of a large artery will often require amputation. If the bleeding vessel can be readily found and tied in the wound, or can be controlled by position, pressure, etc., this should be done, when, if other circumstances are favorable, an attempt may be made to save the limb. If, however, the wounded vessel cannot easily be secured, and if the part injured be the lower extremity, immediate amputation should be unhesitatingly resorted to. In the upper extremity such extreme measures may not be required, and if the bleeding vessel can neither be controlled by pressure, etc., nor secured in the wound, a ligature may be applied to the brachial artery, which has been several times successfully tied under such circumstances. 3. Great comminution of the bones themselves may be a cause for am- putation in cases of compound fracture. In the upper extremity much may be done in the way of conservatism, by removing splinters, and then placing the bones in such a position as to favor union. In the lower extremit}', if the comminution be so extensive that removal of the pri- mary and secondary sequestra will leave a gap in the continuity of the bone, the resulting limb, even if it could be preserved, would scarcely have sufficient firmness to be useful, and hence in such cases primary amputation is to be recommended. An exception should, perhaps, be made in cases of compound fracture in the upper third of the thigh, in which position primary amputation is so fatal an operation, that the surgeon is loath to resort to it under any circumstances; but, indeed, these injuries are very apt to terminate in death under any mode of treatment. 4. Compound fractures into large joints often require amputation. In the case of the shoulder or elbow, provided the extent of bone lesion, or of laceration of the soft tissues, is not too great, excision should be practised in preference to removal of the limb. The hip-joint is so deeply seated that it can scarcely be involved in a compound fracture, unless from gunshot wound, or from some crushing injury which would necessarily prove fatal from visceral complication; if the accident should occur, however, primary excision would, I think, be the correct mode of treatment. Compound fractures of the wrist, ankle, and knee joints are J usually cases for amputation. Especially should this rule be considered imperative as regards the knee-joint; much as I admire the operation of excision, and strenuously as I would advocate the practice of conserva- tive surgery, I cannot but believe that in the immense majority of in- stances the best interests of the patient will be promoted by primary amputation in cases of compound fracture of the knee-joint. 230 FRACTURES. 5. A compound fracture, which would of itself require amputation, may be complicated by the existence of a simple fracture in the same limb, but at a higher point. In such a case, should the amputation be done at the seat of the upper fracture, or below ? In my own experience, such cases, when an attempt has been made to save the limb, have inva- riably terminated fatally; hence, I should be disposed (unless the upper fracture were situated high up in the thigh) to recommend primary am- putation, at or above the seat of highest lesion. Still, if it were certain that the soft parts between the two fractures were healthy, and quite free from injury, it might be right to remove only the part that was irretrievably hurt, and to make an attempt to save the rest of the limb; as it happens, however, these cases are usually such as result from acci- • dent by railway or other vehicles, or by machinery, and are apt to be attended with much greater destruction of soft parts than is at first apparent; so that, in most instances, amputation at the highest point of injury will be found the safest mode of treatment. The complication of compound fracture with dislocation at a higher point of the same limb, is of less consequence. In such a case the broken bones should be temporarily put up, and the dislocation reduced, the compound fracture being afterwards treated on its own merits. Compound epiphyseal separation is sometimes met with in young per- sons, and may be mistaken for compound fracture involving an articu- lation, from which lesion it can, however, always be distinguished by careful examination. If, as sometimes happens, the diaphysis project through the wound, reduction is very difficult, and can usualby be accom- plished only by resecting the projecting portion, an operation which may be best performed with Butcher's or a chain saw. The after-treat- ment does not differ from that of ordinary compound fracture; the resulting limb, though shortened, is not materially impaired in utility, even in the case of the lower extremity. Treatment of Compound Fractures which do not require Amputa- tion.—Many ingenious forms of special apparatus have been invented for the treatment of compound fractures, but I am not aware that they present any advantages over the ordinary splints and boxes habitually used in the management of simple fractures. The only special precau- tion to be observed is, to so arrange the splints and bandages that free drainage may be secured from the wound, and that the latter may be readily accessible without removing the entire apparatus. The points to be particularly attended to in the treatment of these injuries are: 1. Reduction of the fracture. 2. Extraction of splinters. 3. Closure of the wound; and 4. Management of the consecutive inflam- mation. 1. Reduction is to be effected, as in the case of simple fracture, by re- laxing the neighboring muscles, and by gentle manipulation. If a frag- ment project through the skin, the difficulty of reduction is much in- creased, and in such cases it may be necessary to enlarge the external wound, or even to resect the projecting end of bone. This measure should, however, be resorted to with extreme hesitation, especially in the lower extremity, for the loss of any considerable portion of the con- tinuity of a long bone will be apt to result in the formation of a false joint, requiring subsequent amputation. This, indeed, has been the invariable result in cases in which I have seen this operation performed. 2. In the management of splinters or sequestra, the rules which were given in the chapter on Gunshot Wounds, founded on Dupuytren's divi- sion of splinters into primary, secondary, and tertiary, are to be observed. TREATMENT OF COMPOUND FRACTURES. 231 Those fragments which are loose or but slightly connected are to be removed, while those which are more firmly attached are to be pushed into place, that they may give solidity to the callus, and assist in the repair of the injury. In case of doubt, it is better to err on the side of allowing fragments to remain, as, if they afterwards become necrosed, they will be spontaneously loosened, when they can usually be removed without much difficulty, though in some cases a dead splinter may be- come surrounded by callus, requiring division of the latter before the sequestrum be extracted. 3. If the external wound be small, and unaccompanied with much contusion, an attempt should be made to close it, and thus convert the case into one of simple fracture. I have occasionally succeeded in doing this; and the effort should always be made when the nature of the case will permit it. For this purpose the wound is to be washed and freed from blood, and then hermetically sealed with gauze and collodion, styptic colloid, or Paresi's antiseptic preparation (page 146); or, in the absence of these agents, simply with a piece of lint dipped in blood, as recom- mended by Sir Astley Cooper. If, however, the wound be a large one, or if it be accompanied with much contusion and laceration, it will be useless to attempt its closure, and it should then be dressed lightly, and in such a way as to allow of free drainage. Even if an attempt have been made to close the wound, the parts should be frequently examined, and if it appear that pus is accumulating underneath the dressing, the latter should be immediately removed, and free vent given to the accu- mulated discharges. 4. The management of the inevitable consecutive inflammation which attends compound fractures, is to be conducted in accordance with the principles enunciated and the rules laid down in the chapters on the Treatment of Inflammation, and on Wounds in General. Ice, water- dressing, irrigation, laudanum fomentations, poultices, astringent washes, antiseptic applications, etc., may each and all be appropriately used in different cases and under different circumstances. The splints employed should be protected by oiled silk from being soiled by the discharges; and while the fracture should not be unnecessarily disturbed, the utmost care must be taken to keep the parts clean, and to preserve the neigh- boring integument in a healthy condition. In compound fractures of the lower extremity, the bran dressing, introduced by Dr. J. Rhea Bar- ton, of this city, will be found most serviceable. It affords equal pres- sure and support to the injured member, restrains hemorrhage, absorbs discharges, and can be daily renewed, as far as necessary, without material disturbance of the limb. Its mode of application will be de- scribed in the next chapter. The patient's general condition must also receive attention. The action of the bowels must be regulated, and traumatic fever moderated by the administration of suitable reme- dies. When suppuration is fairly established, tonics, especially iron, quinia, and cod-liver oil, may be freely exhibited. The diet should be nutritious, but unirritating; and in the later stages, or perhaps from the first, free stimulation may be required. The connection which has now been so often traced as to make it appear causal, between prolonged suppuration and the peculiar form of visceral degeneration known as albuminous or amyloid, clearly indicates the paramount importance, in these cases, of maintaining the patient's strength and supporting his system in every possible manner. The time required for the cure of a compound fracture may be estimated at from two to three times as long as would be needed in the case of a simple fracture of the same part. 232 FRACTURES. Secondary amputation may be required in the treatment of com- pound fractures, on account of traumatic gangrene, sloughing follow- ing erysipelas, osteo-myelitis, extensive necrosis, general exhaustion of the patient, hectic, etc. The proper period for amputation in cases of traumatic gangrene has already been pointed out in preceding chapters. In the case of the other complications which have been men- tioned, the surgeon must choose his time as best he can, operating at some period when there is a momentary subsidence of constitutional disturbance, and while not hastily condemning a limb without fair trial of conservative measures, yet not delaying interference till the patient has sunk so low that interference will be of no avail. The only general rule that can be given with regard to these cases, is, to avoid, if possi- ble, operating during the intermediate stage, which usually ranges from the second to the tenth or twelfth day. After suppuration has been fairly established, the case becomes somewhat assimilated to one of chronic disease, and amputation can then be performed with compara- tively fair prospects of success. Treatment of Badly United Fractures.—From various causes, over some of which the surgeon may have no control, a fracture may unite with so much deformity as to disfigure the limb, if not to render it useless. If the deformity be in a longitudinal direction, depending on overlapping of the fragments, the case is, I believe, hopeless, for the surrounding muscles will have probabty become permanently contracted and shortened, and attempts at extension after union has once occurred will prove fruitless. Transverse deformity will be gradually lessened by the processes of nature, superfluous callus being absorbed, and pro- jecting bony prominences rounded off. Angular deformity, if very slight, may be left to nature, in the hope that it will be gradually removed by the physiological action of the muscles. If at all marked, however, it will require treatment, and this, if the bony union be comparatively soft, can usually be satisfactorily carried out by careful bandaging and the judicious use of pads and compresses—or the surgeon may by gentle but firm pressure bend the newly-formed callus, so as to restore the limb to its proper shape. If the union of the fracture be further advanced, more force may be required, and the surgeon may break the bone over again, with a view to resetting it in a better position. A remarkable case has recently been reported by Mr. Switzer, an English army surgeon, in which a large amount of deformed callus disappeared under inunction with compound iodine ointment, and it would certainly be proper to try the sorbefacient effects of this remedy before resorting to the severer measures which will next be described. When the callus is so firm as to resist the application of such an amount of force as the surgeon deems justifiable, he may adopt measures to weaken the bond of union, by operative interference. Perhaps the best plan in such a case is that suggested by Brainard, of Chicago, which consists in sub- cutaneously drilling through the uniting medium in various directions, and then rupturing the remainder; or, as done by Wrarren, of Boston, a wedge-shaped piece might be removed from the apex of the bony angle, the rest of the bond of union being broken through as in the former case; or the deformed callus might be entirely exsected—an operation, however, which, in addition to its inherent risks, would expose the patient to the chance of recovering with a false joint; or, finally, in an aggravated case, it might be necessary to resort to amputation. Fdt further information on this subject, the reader is respectfully referred UNUNITED FRACTURE AND FALSE JOINT. 233 to Dr. G. W. Morris's well-known paper, in the Amer. Journal of Med. Sciences, for October, 1842, pp. 305-316. Reduction of Deformity in Partial, and in Impacted Fractures.—In connection with the subject of Badly United Fractures, I may refer to the question which often arises as to whether or no reduction should be attempted in cases of partial and of partially impacted fractures. The answer to this question may be said to depend upon the position of the fractured bone; thus, while it would be manifestly improper to attempt reduction of an impacted fracture of the neck of the femur, it would, I think, be right to reduce a partial fracture of the clavicle or of the forearm, even at the risk of converting the case into one of com- plete fracture. In the forearm (and in the clavicle, if the angular pro- jection be outwards), the deformity would be so great as to be very objectionable, while inward angular displacement of the clavicle might endanger the integrity of the important underlying structures by irrita- tion from bony spiculae. Tardy or Delayed Union of Bones is occasionally met with, and is, probabby, more often dependent on constitutional than on local causes. Sometimes it appears to result from mere debility and depres- sion, without the existence of any positive cachexia; under such circum- stances it may be sufficient to get the patient out of bed, with his limb supported in a starched bandage, letting him recover his health by means of out-door exercise. In some cases the process of union may be assisted by the use of tonics, especially cod-liver oil and the phosphates (which, however, have not been found as practically useful as was an- ticipated), and by giving an extra allowance of ale or porter. If a syphilitic taint be suspected, iodide of potassium or mercury niay be cautiously administered. Ununited Fracture and False Joint. Occasionally a broken bone does not unite at all, or unites only through the medium of fibrous or ligamentous bands, or, having been united, becomes again separated by the absorption and softening of the callus. In some bones, indeed, as in the patella, bony union almost never occurs, but in such cases the want of union cannot be considered abnormal. The terms ununited fracture and false joint are applied only to fractures in those situations in which bony union is habitually met with, as in the various long bones, or the lower jaw. The proportion of cases in which non-union occurs is estimated by Hamilton at 1 in 500; it is, there- fore, a rare accident. Dr. Norris, of this city, whose monograph on this subject (Am. Journ. of Med. Sciences, Jan. 1842, pp. 13-67) is the best that has yet been published, describes four distinct forms under which non-union of frac- ture occurs. The first is that which has already been referred to under the name of delayed union; here callus is formed, but does not un- dergo complete ossification, and, hence, the union is imperfect. "In the second class of cases, there is entire want of union of any sort between the fragments, the ends of which seem to be diminished in size, and are extremely movable beneath the integuments. The limb in these cases is found greatly shrunken, and hangs perfectly useless." In the third and most usual form, the ends of bone are rounded off and tapering, and "are connected together by strong ligamentous or fibro- ligamentous bands," passing between the fractured extremities; there 234 FRACTURES. may be but one band, or several; "in either case the newly-formed sub- stance is firmly adherent to the bones, and, if of any length, is in a high degree pliable." In the fourth variety, to which the name of pseud- arthrosis or false joint is properly given, " a dense capsule without opening of any sort, containing a fluid similar to synovia, and resembling closely the complete capsular ligaments, is found. In these cases the points of the bony fragments corresponding to each other are rounded, smooth, and polished, in some instances are eburnated, and in others are covered with points or even thin plates of cartilage, and a membrane closely resembling the synovial of the natural articulations. It is in this kind of cases that the member affected may still be of some utility to the patient, the fragments being so firmly held together as to be dis- placed only upon the application of considerable force." The diagnosis of ununited fracture is usually sufficiently easy: I have, however, known great relaxation of the ligaments of the wrist-joint to be mistaken for ununited fracture of the extremity of the ulna. Causes of Non-union after Fracture.—These may be either constitutional or local. Among the former may be enumerated general impairment of health, and various cachectic conditions and diatheses, ' such as scurvy, phthisis, rickets, syphilis, or cancer. With regard to the influence of cancer in preventing union after fractures, Dr. Norris says that when the accident depends upon the presence of a cancerous tumor at the seat of fracture, union will not occur, but when it depends on mere brittleness, resulting from what Mr. Curling has called eccentric atrophy, the bones unite readily enough. So with regard to syphilis and rickets; though cases are recorded in which these appear to have acted as causes of non-union, other cases are frequently met with in which the disease is well marked, and yet union readily occurs. Pregnancy is often regarded as a cause of non-union in fractures, but it is probably thus effective in those cases only in which the pregnant state is accompanied by great debility, as from sympathetic vomiting. The same remark applies to the supposed efficiency of lactation as a cause of ununited fracture. Age does not appear to exert any particular influence, fractures in the very young and the very old often uniting quite as well as in those of middle life, and more than one-third of the whole number of cases of ununited fracture occurring in those between twenty and thirty. Among the more prominent local causes, may be mentioned deficient vascular or nervous supply, mobility or want of proper apposition of the fragments, the intervention between the fragments of a shred of muscle or other soft tissue, or of a foreign body, necrosis, or other disease of the end of the fragments themselves, injudicious treatment (especially tight band- aging and prolonged use of cooling applications), and too early use of the fractured limb. The frequency with which ununited fracture occurs in different parts, is shown in the following table taken from Dr. Norris's paper. Locality. Thigh.......... Leg............ Arm........... Forearm........ Jaw............ Total ... Number of cases. Cured. No benefit. Died. Result unknown. 48 31 9 6 2 33 32 1 48 31 14 3 19 17 1 1 2 2 150 113 25 10 2 TREATMENT OF UNUNITED FRACTURE, ETC. 235 Ununited fracture is also occasionally met with in the clavicle, sca- pula, ribs, and spine. Treatment.—The treatment of ununited fracture, and of false joint, consists in removing, as far as possible by constitutional, hygienic, and local measures, aii}r cause which ma}' seem to hinder the process of union between the broken bones, and in endeavoring to excite in the periosteum, in the medulla, and in the fragments themselves, such activity as will induce those changes which we have seen to be necessary in the natural process of repair after fracture. For this purpose, those remedies should be employed which were spoken of in treating of delayed union, the fragments being accurately adjusted, and rendered perfectly immov- able by the use of suitable splints and bandages. Firm and accurately fitting splints of metal, leather, or pasteboard may be employed, or the starch or dextrine bandage, or (in the case of the lower extremity) the ingenious and elegant contrivances of Prof. Smith, of this city, or of Dr. Hudson, of Xew York. In order to excite renewed activity in the periosteum and other bone-producing tissues, various plans, such as blistering, cauterizing, or galvanizing the skin, have been employed, and when the beneficial effect of transmitted periosteal and medullary irrita- tion is remembered, it can readily be understood that these methods should occasionally have proved successful. Another plan which has sometimes succeeded, consists in rubbing together the ends of the frag- ments themselves. In the event of these simple remedies failing, severer measures may be employed: of these the most important are the estab- lishment of a seton between the fragments, as recommended by Dr. Physick, or on either side of the ununited fracture, as suggested by Oppenheim; the introduction of stimulating injections, as practised by Dr. Hulse; acupuncture, as suggested by Malgaigne; the introduction of ivory pegs (Dieffenbach); electro-puncture (Lente); subcutaneous scari- fication (Miller); drilling the fragments themselves (Detmold and Brainard); scraping or cauterizing the fragments ; holding the fragments together by means of sutures or pins (Severinus, Rogers, and Gaillard); resection (White, Roux, Jordan, and Bigelow), and finally amputation. Of all these, the most promising methods are, I think, those of Physick, Brainard, Gaillard, and Bigelow. Before resorting to any of them, the suggestion of Oilier should be adopted, to rejuvenate, as it were, the peri- osteum by the milder forms of irritation, that it may afterwards more readily respond to the severer operation. Physick introduced a piece of silk or tape, by means of a long seton needle, directly between the frag- ments, and allowed the foreign body to remain four or five months. Norris has, however, shown that the seton is equally efficient and more safe when removed at an earlier period, and surgeons now seldom allow it to remain longer than a fortnight; it is rarely used in the case of the thigh, where other means are more successful. Brainard's plan consists in drilling the fragments subcutaneously with a metallic perforator (Fig. 108). His manner of using the instrument, as quoted by Hamilton, is as follows: " In case of an oblique fracture, or one with overlapping, the skin is perforated with the instrument at such a point as to enable it to be carried through the ends of the fragments, to wound their surfaces, and to transfix whatever tissue may be placed between them. After having transfixed them in one direction, it is withdrawn from the bone, but not from the skin, its direction changed, and another perforation made, and this operation is repeated as often as may be desired." Prof. 236 SPECIAL FRACTURES. Gaillard's method consists in pinning together the fragments by means of a gimlet-like instrument, provided with a movable silver sheath, a Fig. 108. Brainard's perforator, reduced one-half. handle, and a brass nut (Fig. 109): the sheath is introduced through an incision, and held against the bone, while the shaft is passed through and made to transfix both fragments; the nut is then screwed down firmly on the sheath, the whole instrument being allowed to remain in Fig. 109. Gaillard's instrument for ununited fracture. situ till union is obtained. This plan affords more secure apposition than merely wiring together the fragments, as practised by Rogers, Flaubert, N. R. Smith, and others. The operation employed by Prof. Bigelow, of Boston, is almost identical with that independently sug- gested by Oilier, of Lyons, and is probably the very best method of treating ununited fracture: it consists in making a subperiosteal resec- tion of the ends of the fragments, the freshened extremities being then held together by a wire suture. Dr. Bigelow has thus treated eleven cases with but one failure, and that from disease of the bone, which subsequently required amputation. Whatever method be employed, the after-treatment must be carefully conducted by the use of proper splints, and by the administration of tonics and good food. In some cases, when the inconvenience resulting from the ununited fracture is not very great, it might be advisable to decline any operation, and employ the apparatus of Prof. Smith, already referred to, or some similar contrivance. CHAPTER XII. SPECIAL FRACTUKES. I have gone so fully, in the last chapter, into the consideration of the causes and symptoms of fractures in general, and of the principles by which the surgeon should be guided in undertaking their treatment, that it will not be necessary to repeat what has been said, with regard to each FRACTURES OF THE FACE. 237 several bone; hence, in the present chapter, I purpose merely to point out the peculiar symptoms and diagnostic marks of the special fractures, and to indicate very briefly the most convenient and satisfactory modes of treatment, referring the reader, for more detailed information upon this subject, to the excellent treatises of Hamilton, Malgaigne, Cooper, Smith, of Dublin, Lonsdale, etc.; and to the chapter on Fractures in Dr. Wales' valuable work on " Mechanical Therapeutics," which contains a very good account of the different forms of apparatus devised for the treatment of broken bones. Fractures of the skull, and of the vertebrae, are principally interesting on account of their involving respectively the brain and spinal cord; hence their consideration will be postponed till we come to speak of injuries of those parts of the body. Fractures op the Face. Any of the facial bones may be broken by direct violence, and espe- cially by gunshot wound; the nature of the injury is usually recognized with facility, and the treatment should be particularly directed to the lesion of the soft tissues. Nasal Bones.—These are not unfrequently broken, and the injury may escape detection from the rapid swelling of the soft parts. The treatment consists in removing the displacement (if there be any), by inserting a broad director or a pair of polypus forceps into the nostrils, and moulding the bones into their proper places; the parts may then be supported by means of a compress on either side, and a few strips of adhesive plaster. If the septum be broken, it should be restored to its proper place in the same way, the shape of the nose being preserved by plugging the nostrils, if necessary. Occasionally, the whole nose is split off, as it were, from the face, hanging by the alae in front of the mouth. In such a case, in which the injury was produced by a blow from an iron pan, I kept the nose in place by numerous sutures, the patient making a good recover}'. Sometimes the whole nose is driven inwards, fracturing the ethmoid bone, and involving the brain. Under such circumstances, the nose should be gently drawn forwards with forceps, and the case treated as one of fracture at the base of the skull. Profuse hemorrhage may require plugging of the nares. Fracture of the Lachrymal Bone may cause obstruction of the nasal duct, and consequent epiphora ; or emphysema of the subcutaneous tissue may follow whenever the patient blows his nose. Fracture of the Malar Bone is to be treated by keeping the parts in place with compresses, adhesive strips, and bandages. Fracture of the Zygoma, if comminuted, may interfere with mas- tication, by the impaction of splinters in the temporal muscle; in such a case, the surgeon should cut down and remove the offending fragments. Upper Maxilla.—Fractures of the upper jaw are sometimes attended with such profuse hemorrhage as to require plugging the antrum, or even ligation of the external carotid. If the malar bone be thrust in upon the antrum, it should be drawn out with a tire-fond or screw elevator (Fig. 74), aided by pressure from within the mouth. If the upper jaw be broken through the alveolus, the teeth may be held together by means 238 SPECIAL FRACTURES. of wire. The vascular supply is so free in this part, that necrosis rarely follows, even in cases of gunshot injury; the fetid discharge is, however, a source not only of annoyance, but of constitutional depression, and hence free use should be made in such cases of detergent and disinfectant washes. Sometimes all the bones of the face are crushed and separated from their attachments by explosions, violent blows, or falls. Such cases are attended with great shock, and usually prove fatal from hemorrhage or cerebral complication. Lower Maxilla.—The lower jaw is more frequently broken than any other bone in the face. The fracture, which is usually caused by direct violence, may be in any part of the bone, the most usual seats being, however, near the symphysis, and about the position of the mental foramen. The lower jaw is often broken in two or more places at once, and its fractures are frequently rendered compound by laceration of the mucous membrane. Fractures near the symphysis are more or less transverse, while those further back are almost invariably oblique from before backwards, allowing considerable displacement, which is evidenced by shortening of the alveolar border, and depression of the chin. In fractures near the angle of the bone, the dental nerve is occasionally involved, an accident which causes temporary paralysis, or more rarely convulsions. The displacement, mobility, and crepitus, which accom- pany fracture of the jaw, render its diagnosis usually easy: in cases of fracture below the condyle, there is, besides, embarrassment in the motions of the jaw, and pain, felt especially on opening or shutting the mouth. Fractures of the lower jaw commonly unite without much difficulty, and with little deformity. Treatment.—For the treatment of an ordinary case of broken jaw, nothing is required except a compress to support the chin, and a roller bandage. Velpeau, indeed, during the last years of his life, is said to have abandoned all forms of apparatus, in the treatment of these injuries, believing that sufficient rest was insured to the fragments by the inevitable occurrence of pain upon any attempt at motion made by the patient. I am in the habit of treating these fractures, in the manner recommended by Dr. J. Rhea Barton, of this city, with the superaddition of a few occipito-frontal turns of the roller, as in Gibson's bandage. The following descrip- tion of Barton's bandage is taken from Sargent's minor surgery:—"Composition: A roller five yards long, and two inches wide; suitable compresses. Application : Place the initial extremity of the roller upon the occiput, just below its protuberance, and conduct the cylinder obliquely over the centre of the left parietal bone, to the top of the head; thence descend across the right temple and the zygomatic arch, and pass beneath the chin," which should be supported by a compress, "to the side of the face; mount over the left zygoma and temple to the summit of the cranium, and rejoin the starting-point at the occiput, by traversing obliquely the right parietal bone; next, wind around the base of the lower jaw on the left side to the chin, and thence return to the occiput along the right side of the maxilla;" to these three turns, I add a fourth, around the head just Fig. 110. Barton's bandage for fractured jaw. FRACTURES OF THE TRUNK. 239 above the ears, making an occipitofrontal turn, which being pinned at its intersection with the others, serves to prevent their slipping. The same course is to be continued until the roller is exhausted, and additional security may be furnished by sealing the bandage (as it were) with a few strips of adhesive plaster. Gibson's bandage consists of a compress beneath the chin, with turns of a roller passing from that part to the top of the head, from the occiput to the forehead, and from the nape of the neck to above the mental protuberance, the whole being held in place by a short strip passing from the forehead, backwards to the nape along the median line of the head. Many surgeons prefer to treat fractures of the jaw with an external splint, moulded from pasteboard or gutta-percha, and held in place by a simple sling of four tails, two of which are tied on the top of the head and two behind the neck (Fig. 15), or with an ingenious apparatus composed of a leathern sling, with strong linen webbing straps, devised for the treatment of these cases by Prof. Hamilton; wiring together the teeth on either side of the fracture is often recommended, but I confess to have seen very little advantage from the practice: a better plan is the application of clasps of ivory, silver, steel, or other material, as practised by Lonsdale, Mutter, N. R. Smith, Nicole, Wales, Bullock, and others, or of interdental splints of gutta-percha or vulcanized India-rubber, as ingeniously applied by Dr. Gunning, of New York, and Dr. Beans, of Atlanta, Ga. Whatever mode of treatment be adopted, care must be taken not to produce uneven or undue pressure. Neglect of this precaution will cause great irritation, and probabty the formation of abscess, a very troublesome and painful complication of fractured jaw, and one that may give rise to necrosis and to consequent non-union, which accident is, in this position, I believe, more apt to result from tight bandaging than from the bandage being too loose. Gunshot fracture of the lower jaw is sometimes attended with so much splintering as to require partial resection of the bone. The period required for the cure of a simple fracture of the jaw is usually from three to six weeks. Fracture of the Hyoid Bone is a very rare accident. Hamilton has collected ten cases, of which three were caused by hanging, three by grasping the throat between the thumb and fingers, three by direct blows or falls, and one by muscular action. The accident is attended with great pain, sometimes with hemorrhage, and with difficulty in open- ing the mouth, in swallowing, and in speaking. The diagnosis can be made by observing the mobility of the fragments, and the inward angu- lar displacement, with or without crepitus. The treatment consists in reducing the deformity, by pressure from within the mouth, and in keeping the parts at rest by use of a pasteboard or leather collar, with the enforcement of quiet, and the hj^podermic administration of opium. Of thirteen cases collected by Dr. Gibb, two proved fatal. Fractures or the Trunk. Ribs,—The ribs are more frequently broken than any of the other bones of the trunk: these injuries may be produced by direct violence, as from the kick of a horse, or by indirect violence, the front and back of the chest being pressed together, and the ribs giving way like an over- bent bow, at the weakest part. The ribs are occasionally broken by muscular action (as in parturition), or, according to Malgaigne, even by 240 SPECIAL FRACTURES. the impulse of the heart. The middle ribs, from the fourth to the tenth, are those most exposed to fracture, and the usual seats of injury are near the junction of the costal cartilages, and in the neighborhood of the angles. The direction of the fracture is commonly transverse or slightly oblique; occasionally a rib is comminuted, or broken in more than one place. These fractures are rarely compound, except as the result of gunshot wounds. The displacement in cases of fractured rib is usually slight; if the result of a direct blow, there will probably be some inward angular deformity, while if from indirect violence, the projection will be outwards; if a number of ribs on the same side be broken, there may be a slight tendency to overlapping. The diagnostic signs are deformity, mobility, and crepitus, which is sometimes readily perceived, but at other times can only be elicited by careful and prolonged manipulation, by compressing the chest from before backwards, or by auscultation. There are, besides, pain and localized tenderness, with a sharp stitch, if the pleura be wounded, and, possibly, haemoptysis, pneumothorax, or emphysema, if the lung be involved. The pain is much increased by movements of the chest wall, and the breathing is therefore shallow, and to a great extent diaphragmatic. The prognosis is favorable; except in cases complicated with thoracic or other severe injury, it is very rare for death to follow fracture of the ribs. Union commonly takes place in from three to five weeks, with very little deformity, anil by means of a well-marked en- sheathing callus. False-joint is occasionally met with in this situation, while, on the other hand, the production of new bone is sometimes exces- sive, causing coalescence between adjacent ribs. Treatment.—In the treatment of fractured ribs, the surgeon may dis- regard any existing deformity, which will usually spontaneously disap- pear by the expansion of the chest in the respiratory movements; even if it should not, it would be preferable to allow the displacement to remain, rather than to attempt its removal, as has been proposed, by the use of sharp hooks or screw elevators. The chief indication in any case of fractured rib, is to put the affected part in a state of complete rest, and this may be best done by surrounding the side of the chest which is involved, with numerous overlapping broad strips of adhesive plaster, each reaching a little beyond the median line, both behind and before. This mode of treatment, which appears to have originated with Dr. Hannay, of England, is, according to my experience, much superior to any other which has been proposed. The strips, which should be about two inches wide, are laid on in circular layers, beginning from below, each strip overlapping its predecessor b}' about one-third of its width. As the dressing becomes loosened, other layers of strips are to be tightly applied immediately over the first, so that the chest is kept constantly fixed by a stiff and firm splint of adhesive plaster. The patient will usually be most at ease in a sitting posture for the first day or two. Thoracic complications must be met by appropriate treat- ment, and in any case opium may be freely administered. The dressing may be removed at the end of three weeks, when union is commonly sufficiently firm to enable the surgeon to discontinue his attendance. If, in any case of injury of the chest, it is uncertain whether a rib be broken or not, the dressing above described should be applied, as it will afford great comfort, even in cases of contusion without fracture. The emphysema which sometimes accompanies fracture of the ribs requires no special treatment, usually disappearing spontaneously in the course of a few days or weeks. Rupture or laceration of an intercostal FRACTURE OF THE STERNUM. 241 artery, which proved fatal in a case recorded by Amesbury, could scarcely be recognized unless the fracture were compound. Under such circumstances an effort should be made to secure the bleeding ves- sel, for which purpose, if necessary, a portion of the adjacent rib might be excised, as was done by Dr. Cuyler, U. S. A., during our late war. In cases of gunshot fracture, all spiculae should be carefully removed, and the after-treatment conducted with reference to the condition of the tho- racic viscera, on the principles which will be laid down in the chapter on Injuries of the Chest. The Costal Cartilages are occasionally broken, either at their junction with the ribs or through their middle. The causes are the same as in the case of fractured ribs; but, as the violence required is greater, there is more apt to be serious visceral complication. The symptoms are the same as those of fractured ribs, except that crepitus is rarely percepti- ble. The direction of the fracture is transverse, the anterior fragment usually projecting in front of the posterior. Union takes place b}^ the production of bone, not of cartilage; non-union has been observed in one case by Hamilton. The treatment consists in the application of adhesive strips, as for fractured ribs. Sternum.—True fracture of the sternum is a very rare accident. Diastasis of the first from the second bone is more often met with, and is a less serious affair. These injuries may result from direct violence, from counterstroke (the force being applied to the back), or from muscu- lar action, as in parturition, or in the act of vomiting. The line of sepa- ration is usually transverse, though it may be bevelled as regards the thickness of the bone. Malgaigne, Kramer, and Meyer have each observed longitudinal fractures of the sternum. The most usual seat of injury is at the junction of the manubrium and gladiolus, and in this situation the lesion is, as already observed, commonly a diastasis, or, according to Maisonneuve, of Paris, and Dr. "Brinton, of this city (who have repeatedly observed a true joint in this position), a dislocation. It is a matter of some importance, as regards the prognosis, to be able to say in any individual case whether the lesion be a true fracture or a diastasis, for in the latter case, the posterior ligament being intact, the patient usually escapes visceral complication. In true fracture, the lung or even the heart may be torn, and, even if these dangers be avoided, there is considerable risk of the subsequent formation of abscess in the medi- astinal space. The following may be looked upon as evidences of true fracture, viz.: the presence of crepitus, the injury being below the junc- tion of the first and second bones, or the fact of the upper fragment projecting in front of the lower. In diastasis the lower rises in front of the upper fragment. Direct violence exerted upon the manubrium has never been known to produce true fracture, while when exerted upon the gladiolus it almost never produces diastasis. In cases of injury from indirect violence, if the marks of fracture above given be not pre- sent, the diagnosis must be made by noting the presence or absence of haemoptysis, emphysema, etc. The ensiform cartilage is rarely the seat of fracture, though one well- marked case has been observed by Hamilton. In making the diagnosis of fractured sternum, the possibility of a con- genital deformity being mistaken for the result of violence, must not be overlooked. The prognosis of diastasis, or of uncomplicated fracture, is favorable; union usually takes place in from three to four weeks. The 16 242 ' SPECIAL FRACTURES. treatment consists in keeping the parts at rest, by the application of a broad compress, held in position with adhesive strips or bandages. If there be much displacement, attempts at reduction may be made, In- straightening the spine and drawing the shoulders backwards. Opium, will usually be required, and any thoracic complications must be met by suitable remedies. Mediastinal abscesses should be opened at the side of the sternum, when pointing occurs ; they have been evacuated by Gibson and others by the use of the trephine, but the results of the operation do not warrant its repetition. Pelvis.—Fractures of the pelvis are chiefly interesting on account of the liability to implication of the adjacent viscera. One of the Ossa Innominata, may be broken, the injury being sometimes limited to a separation of the crista ilii, or of one of the spinous processes, and at other times passing through the rami of the pubes or ischium, or in the neigh- borhood of the sacro-iliac symphysis. The ilium, pubes, and ischium may separate in their lines of conjunction, the acetabulum being thus split into three portions ; or diastasis may occur at the pubic or sacro- iliac symphyses. Fractures of the pubes and ischium assume a some- what oblique direction, while those about the sacro-iliac junction corre- spond pretty generally to the line of the symphysis. The diagnosis of fractured pelvis can usually be made without much difficulty. There is great pain, aggravated by motion, and especially by any attempt to walk or stand; there is abnormal mobility; and crepitus can be elicited In; grasping the ilia in either hand and moving them in opposite direc- tions. The displacement in fractures of the pubes and ischium is often considerable, and can usually be readily detected. These injuries are commonly caused by great violence of a crushing nature, such as the fall of a bank of earth. In one case, which was under my care, the crest of the ilium was knocked off by a sharp blow resulting from the fall of a stove-pipe. The pubes has sometimes been fractured as the result of muscular contraction, as in a remarkable case recorded by M. Leten- neur, while diastasis of the pubic, and occasionally of the sacro-iliac symphysis may occur in the process of parturition. Fracture of the Acetabulum is an accident that is often spoken of as complicating dislo- cation of the hip. I believe, however, with Prof. Bigelow, that this fracture is much rarer than is generally supposed, and that its existence should never be assumed unless crepitus can be detected at the seat of supposed lesion, while even in such a case the injury (as pointed out by Birkett) may really consist in a luxation, complicated with frac- ture of the head of the femur. Fracture of the acetabulum may con- sist merely in a separation of its posterior lip, or in a destruction of its floor, attended sometimes with impaction of the head of the femur in the pelvic cavity. The latter form of injury is commonly attended with such severe visceral lesions as to prove fatal. Separation of the lip of the acetabulum is marked by the signs of dislocation, the displace- ment being readily reduced with crepitus, but as readily reproduced when extension is discontinued. The great danger in cases of fracture of the pelvis is from rupture or laceration of the bladder or urethra. Hence the surgeon's first step should be to pass a catheter, with a view of ascertaining the condition of those organs: if they are found to have been injured, prompt treat- ment must be employed, according to the principles which will be laid down in speaking of Injuries of the Pelvic Viscera. FRACTURES OF THE UPPER EXTREMITY. 243 The treatment of fractured pelvis consists in the first place in restor- ing the displaced fragments to their proper position, if this can be done without violence: in the case of a woman, reduction may be assisted by introducing one or more fingers into the vagina. The entire pelvis should be surrounded by a padded belt, or firm and broad roller, so as to keep the parts at perfect rest, while the hip-joint of the affected side is fixed by means of a pasteboard splint or a sand-bag, as in cases of fractured thigh. The patient should lie on his back, on a hard mattress, with the knees slightly flexed, and supported by pillows. Compound fractures of the pelvis are usually fatal accidents, though I have seen recovery after perforating gunshot fracture of the ilium. In the treat- ment of such a case, all splinters should be carefully removed, and means adopted to secure free drainage through the external wound. Sacrum and Coccyx.—Fractures of these parts usually result from direct violence, the fracture 'being transverse, and the lower fragment pressed inwards upon the rectum. Richerand gives one case of longi- tudinal fracture of the sacrum. These injuries are rarely met with except in connection with other severe pelvic lesions, and are then apt to prove fatal; the treatment would consist in endeavoring to effect reduction by pressure from within the rectum, and in the application of a padded belt. Bernard, a French surgeon, plugged the rectum with a lithotomy tube, in order to maintain reduction, but I should prefer, with Hamilton, to dispense with such an instrument, and rely upon keeping the parts at rest and administering opium. Fracture of the coccyx sometimes results in the development of a very painful neuralgic condi- tion of the part, constituting a form of what the late Sir J. Y. Simpson called coccydynia; the treatment recommended by that gentleman con- sisted in subcutaneous division of the ligamentous attachments of the part, or, if that failed, in excision of the bone itself. Fractures of the Upper Extremity. Clavicle.—The clavicle is peculiarly liable to fracture, not only from its exposed position, but from the fact of its being the sole bond of osseous connection between the trunk and the upper extremity. It may be broken by direct violence in any part of its length, but is much oftener fractured by indirect violence (such as a fall or blow on the shoulder), and then usually gives way near the outer end of its middle third, where the bone is weakest. Partial fracture from indirect vio- lence is usually situated towards the inner end of the middle third, and is characterized by slight angular projection. Partial fracture from direct violence is commonl}' situated more externally, and is marked by angular depression. Muscular action is an occasional cause of frac- tured clavicle, the immediate mechanism of the accident in some cases possibly being, as suggested by Dr. Packard, the bending of the clavicle over the first rib, which acts as a fulcrum. Fractures from direct vio- lence are commonly transverse, and may occasionally be comminuted; fractures from indirect violence are almost invariably oblique, the beveb ling being from before backwards, and from without inwards. Fracture of the sternal end of the clavicle, within the fibres of the costo-clavicular ligament, is usually attended with but little displacement, though, ac- cording to R. W. Smith, the outer fragment is in these cases displaced forwards, or forwards and slightly downwards; similarly there is little 244 SPECIAL FRACTURES. displacement in fracture of the outer third, within the limits of the coraco-clavicular ligament, but if the fracture be outside of the trapezoid branch of that ligament, the displacement, according to the same sur- geon, is quite marked. Fractures of the middle of the clavicle, especially Fig.111. Attachments of outer end of clavicle; showing branches of coraco-clavicular ligament. such as are produced by indirect violence, are accompanied with great and very constant displacement. This consists in a tilting upwards of the inner fragment, and a dropping of the outer fragment, which is also rocked inwards and somewhat backwards, by the action of the powerful muscles attached to the scapula, particularly the rhomboidei, trapezius, levator anguli scapulae, pectoralis minor, and some fibres of the serratus magnus. The diagnosis of fractured clavicle can usually be made without dif- ficulty : if the middle of the bone be involved, the displacement is in itself sufficiently characteristic, while crepitus can readily be elicited in any position of the fracture, on account of the subcutaneous character of the bone in its whole length. In cases of partial or partially im- pacted fracture from direct violence, an accident of not unfrequent occurrence among quite young children, persistent tenderness over the point of injury will be found a valuable diagnostic sign. The attitude of the patient, in cases of complete fracture^is peculiar, and often sig- nificant of the nature of the injury; the head is bent towards the affected FRACTURE OF THE CLAVICLE. 245 side, so as to relax the muscles, Fig. 112. while the elbow and forearm are supported in the opposite hand, so as to diminish the dragging sensa- tion produced by the weight of the' limb. The prognosis, as regards the life of the patient and the util- ity of the limb, is very favorable; I believe, however, that a perfect cure—that is, without deformity— is very rarely obtained, at least in oblique fractures of the middle of the bone. Comminuted fracture of the clavicle is sometimes a se- rious injury, from concomitant lace- ration of the subclavian vein or plexus of nerves. Compound frac- ture of this bone is rare, except as the result of gunshot injury, when it is apt to prove fatal from tho- racic complications; I had, bow- ever, under my care, some years ago, a case of multiple fracture of the clavicle from direct violence, Which became Secondarily Com- Complete obUque fracture of clavicle near its pound by the occurrence of sup- middle. puration ; slight necrosis followed, but the patient eventually made a good recovery. Fracture of both cla- vicles is an accident of rare occurrence, but presents no peculiarities, except that of course it requires some modification of the apparatus used in treatment. Treatment of Fractured Clavicle__The treatment of fractured clavicle may be conducted by position alone, or by position aided by various forms of apparatus. The deformity, as we have seen, depends (1) on the tilting up of the inner fragment, by the resiliency of its ligamentous attachments and the action of the sterno-cleido-mastoid muscle; (2) on the falling of the shoulder with the outer fragment, due to the weight of the arm; but (3) chiefly on the rocking inwards and backwards of the outer fragment, by the action of the powerful muscles attached to the scapula. Hence the indications for treatment are, (1) to relax the sterno-cleido-mastoid muscle, (2) to prevent the weight of the arm from dragging down the outer fragment, and (3) by fixing the scapula, to carry the attached external fragment outwards and forwards, and thus restore the shape of what has been not inaptly called the "shoulder girdle." These indications may all be met by position alone. For this purpose the patient should lie flat on his back on a firm, hard mattress, with the head slightly elevated, and the arm flexed and carried across the chest, so that the hand rests on the sound shoulder—the position commonly known as the "Velpeau position," from its having been employed by that dis- tinguished surgeon in the treatment of these and other injuries (see Fig. 114). The elevation of the head (by means of a single pillow, which must not touch the shoulders) relaxes the sterno-cleido-mastoid muscle, and thus obviates the tendency to upward tilting of the inner fragment; the position of the arm across the chest makes the weight of the limb act, if at all, in an upward direction, and thus effectually prevents any downward i 246 SPECIAL FRACTURES. displacement; while the weight of the chest, together with the firm and even counter-pressure of the mattress, serve to fix the scapula, and thus prevent that rocking of the bone around the chest, which causes the inward and backward displacement of the outer fragment. By this simple mode of treatment the deformity can, at least in the immense majority of cases, be completely reduced, and could the patient be trusted to remain quiet for a sufficient length of time (three to four weeks), nothing further would be required. In practice, however, very few patients can help shifting their posture in sleep, if not while awake, and hence retentive apparatus is usually necessaiy. If the patient can remain in bed, the scapula may be fixed by a broad and long wedge-shaped pad, applied as a/compress on the lower blade of the bone, and held in place by several broad strips of adhesive plaster, while the arm is fastened in the "Velpeau position" by a few strips of the same material. If the patient cannot remain in bed, the same appliances may be used, with the addition of a compress upon the projecting end of the inner frag- ment, and a broad roller bandage used as what is known as the "third roller of Desault,"1 with additional cirpular turns to fix the arm in the required position. The same indications may be met by using Fox's apparatus (to be presently described), or any of its modifications, taking care to apply the pad—not as an axillary fulcrum, but simply as a scapular compress. The posterior figure-of-8 bandage, recommended by some authors, is defective in that its force is exerted on the acromial part of the scapula only, and not on the entire bone; the same objection applies to most of the back splints devised for these cases, though a back splint, broad enough to fix both scapulae, might be made a useful adjuvant to the compresses already described. The apparatus most frequently used in this neighborhood is that introduced by Dr. George Fox, of this city, and is thus described b}' Sargent: "The apparatus consists of a firmly stuffed pad of a wedge shape, and about half as long as the humerus, having a band attached to each extremity of its upper or thickest margin; a sling to suspend the elbow and fore- arm, made of strong muslin, with a cord attached to the humeral ex- tremity, and another to each end of the carpal portion; and a ring made of muslin stuffed with cotton to encircle the sound shoulder, and serve as means of acting upon and securing the sling." The application of this apparatus can be seen at a glance from the accompanying illustration (Fig. 113). Fox's apparatus has undoubtedly produced a great many excellent cures; it has done so, however, I believe, by fixing the scapula more or less perfectly, and not by affording leverage to the humerus as it was originally intended to do. Indeed, the wedge-shaped pad, if used as a fulcrum, produces so much pain that few patients can endure it for any length of time; so that in practice surgeons generally apply it far back—where it acts merely as a scapular compress—or else reduce its thickness to such a degree that its action as a fulcrum is entirely de- 1 The application of the third roller of Desault is thus described by Wales: Place the initial extremity of the roller "under the axilla of the sound side, then conduct the cylinder over the broken clavicle, upon which a compress must be placed, down the posterior surface of the arm under the elbow, and over the fore- arm to the point of departure; thence across the back obliquely over the injured shoulder, down the front of the arm and under the elbow, to pass obliquely across the chest to the axilla of the sound side." These turns are repeated until the roller is exhausted, thus forming two triangles, one in front and the other behind the chest; the firmness of the bandage may be much increased by making additional circular turns as recommended in the text. FRACTURE OF THE SCAPULA. 247 Fox's apparatus for fractured clavicle. feated. Fox's apparatus has been ingeniously modified by Dr. Levis, Prof. Hamilton, and others, and any of these forms of the sling and pad dressing may be used with good results, provided they are accurately adjusted and carefully watched by the surgeon.1 Union of a fractured Fig. 113. clavicle usually occurs within three weeks, but the dressings should be retained, as a matter of safety, at least a couple of weeks longer. Scapula.—The scapula may be broken through its body, through its neck, through the glenoid cavity, or through the acromion or coracoid processes. Fracture of the Body of the Scapula is a rare accident, and is usually due to direct violencp, though it is said in one case (Hej^- len's) to have been produced by muscular action. If the spine of the scapula be involved, the line of fracture can commonly be detected with facility by palpation, and in other cases crepitus can generally be elicited by pressing firmly on the scapula with one hand, while the other moves the shoulder in various directions. The treatment consists in attempting to reduce the de- formity, if there be any, by manipulation, and in then fixing the arm to the side by circular turns of a roller bandage or by adhesive strips, the forearm and elbow being supported in a suitable sling. If the lower angle have been separated from the rest of the bone, it may be secured, as advised by Boyer, by the additional application of a firm compress. Fracture of the Neck of the Scapula (in the anatomist's sense of the term) is an accident the possibility of which has never been established by dissection, and which, if it have ever occurred, except when compli- cated with comminution of the glenoid cavity, must certainly be very rare. The term "fracture of the neck of the scapula," as used by Sir Astle3>- Cooper, however, means fracture through the supra-scapular notch, and in this position the lesion has unquestionably been met with, though very rarely. The amount of displacement depends on the degree of integrity of the various ligaments of the part, especially the coraco- clavicular and coraco-acromial. If these be ruptured, the glenoid cavity and head of the humerus fall into the axilla (where the latter may be some- times felt), causing a depression beneath the acromion as in dislocations of the shoulder, though not so deep; crepitus is elicited by laying one hand on the shoulder so as to touch the coracoid process, and with the other hand moving the arm in various directions; the deformity can readily be reduced, but instantly recurs when support is removed, and the coracoid process can be felt moving with the humerus, instead of with the acromion. The treatment consists in fixing the scapula by placing a thin pad or folded towel in the axilla, fastening the arm to the 1 See a full and able discussion of the principles of treatment of fractured clavicle, and the comparative merits of different forms of apparatus, by Dr. Edward Harts- horne, of this city, in the 2d volume of the Pennsylvania Hospital Reports, pp. 108-142. 248 SPECIAL FRACTURES. side by circular turns of a roller or adhesive strips, and supporting the forearm and elbow in a sling. The same dressing would be applicable in a case of comminution of the glenoid cavity. Fracture of the Acromion is probably a rarer accident than epiphyseal separation of that process. When the line of fracture is through or behind the acromio-clavicular articulation, the shoulder drops forwards, inwards, and downwards, as in cases of fractured clavicle: if, however, the fracture be in front of the acromio-clavicular articula- tion, there will be little or no displacement, and the diagnosis must be made by the detection of mobilit}' and crepitus. Union occurs with- out much deformity, though rarely, according to Cooper, except by fibrous tissue. The treatment consists in fixing the arm and scapula by an axillary pad and band- age, and in supporting the elbow with a sling. This, as well as fracture of the body or neck of the scapula, may be also efficiently treated with the bandage known as Yelpeau's, the application of which can be seen from the accompanying illustration. Fracture of the Coracoid Process occasionally though rarely occurs, as the result of direct violence. There is seldom any displacement, and no treatment is required, beyond the use of a sling, with perhaps a few turns of a roller around the arm and shoulder. Two or more of these various forms of scapular fracture may coexist in the same case, or any one of them may be complicated by fracture or dislocation of the humerus or clavicle; for the treatment of such inju- ries no general rules can be laid down, but each case must be managed with reference to its own peculiar exigencies. The ingenuity of the sur- geon will often be much taxed in endeavoring to meet the different indi- cations presented, and he will often be disappointed by the persistence of deformity, which, however, fortunately seldom proves much of an impediment to the usefulness of the arm. The time required for treat- ment, in cases of fractured scapula, is usually from three to four weeks. Fractures of the Humerus.—Fractures of the humerus are divided by Hamilton into eleven classes, of which four are fractures of the upper extremity (head, neck, and tubercles), one of the shaft, and six of the lower extremity. 1. Fractures of the Upper Extremity of the Humerus.— (1.) The fracture may pass through the Head and Anatomical Neck of the Velpeau's bandage. FRACTURES OF THE HUMERUS. 249 bone, being chiefly intra-capsular, and ma}' or may not be impacted, according to circumstances. If the fracture be entirely intra-capsular, bony union cannot well occur, and the detached head of the humerus is apt to become carious or necrosed, requiring an operation for its re- moval. Fracture of the anatomical neck is attended with but little deformity, nor does it much interfere with the motions of the part. There may be slight shortening, and crepitus can usually be elicited by pressing the head of the bone into its socket and making rotation; the shoulder is the seat of severe pain. This injury results from direct vio- lence, and is principally met with in old persons. (2.) Fracture through the Tubercles of the humerus differs from the preceding variety merely in being completely extra-capsular. Bony union takes place in these cases, but the motion of the joint is apt to be im- paired by the irregular masses of callus which are formed. Crepitus may be detected by grasping the tubercles with one hand, and rotating the arm with the other; there is rarely much displacement, though if the fracture be impacted, there may be slight shortening. The signs of this injuiy are very obscure, and in many cases the diagnosis cannot be posi- tively made during life. (3.) Longitudinal Fracture of the Head and Neck, or Splitting off of the Greater Tubercle, produces a marked increase in the antero-posterior diameter of the upper end of the humerus, and while there is some depression under the acromion, a smooth, bony prominence can be felt under the coracoid process; crepitus can be usually elicited by pressing together the tubercles and rotating the arm, while the mobility of the limb is unimpaired. Union takes place by bone, or by fibrous tissue, according to the amount of separation between the fragments. (4.) Fracture of the Surgical Neck of the humerus, under which head may be included separation of the upper epipliysis, is the most frequent form of injuiy met with in this region. The surgical neck is that part of the humerus which extends from the line of epiphyseal junction to the place of inser- tion of the latissimus dorsi and pectoralis major muscles. Fracture of this part usu- ally results from direct violence, and is often accompanied with great contusion and swell- ing of the soft parts. Separation of the epiphysis is an accident of early life, but true fracture, though met with in chil- dren, is more frequent among adults. Cre- pitus can be readily elicited, unless either impaction or overlapping have occurred ; in the latter case the diagnosis can be easily made from the deformity, which is charac- teristic, and which consists in the upper end of the lower fragment being drawn upwards, inwards, and forwards, while the upper frag- ment is rotated outwards. Reduction is often difficult and sometimes impossible in these cases, in spite of which, union commonly occurs without material im- pairment of the usefulness of the limb. Treatment of Fractures of the Upper Extremity of the Humerus.— Compound fractures of these parts, especially if resulting from gunshot injury, usually require either excision or amputation. The treatment Fig. 115. Fracture of the surgical neck of the humerus. 250 SPECIAL FRACTURES. Dressing for fracture of the surgical neck of the humerus. of simple fractures of the upper end of the humerus may be conducted satisfactorily in the following way. A roller should be in the first place applied smoothly and evenly to the injured arm, from the tips of the fingers to, but not above, the seat of fracture. This bandage should be applied while the*elbow is in a flexed position. A thin pad, compress, or folded towel is then to be placed in the axilla, so as to fill up the hollow of that part and afford a firm basis of support to the humerus. This pad may be held in place by a bandage or by adhesive strips. The arm is then to be brought to the side, with the elbow a little forwards, so as to obviate the anterior angu- lar projection, and sufficient extension made to reduce the fracture The arm is to be securely fastened to the chest with circular turns of a roller or adhesive strips, and the forearm secured across the chest, somewhat as in the " Velpeau position," or merely supported by a sling, as may be found most convenient. After a few days, when swelling has subsided, a moulded pasteboard or gutta- percha cap may be applied to the shoulder and upper half of the humerus, and will give additional security and firmness to the dressing. This simple mode of treatment, which is very similar to that recommended by Fergusson (Fig. 116), will, I think, be found quite as efficient and a great deal less annoy- ing to the patient than the angular splint, short splints, and axillary pad often used for the purpose. Erichsen uses a pad, a leather shoulder cap, and a sling, while Hamilton employs a simple outside splint of gutta- percha without any pad. Welch's shoulder splint may be also used in the treatment of these injuries. 2. Fracture of the Shaft of the Humerus is an accident of fre- quent occurrence, and may result from either direct or indirect violence. The seat of the fracture is more often below than above the middle of the bone, and its line usually somewhat oblique, from above downwards and outwards. The displacement consists in the drawing upwards and inwards of the lower fragment, with some eversion of the upper frag- ment, and an anterior angular projection, due to the weight of the fore- arm. The diagnosis is easy, the increased mobility and crepitus render- ing the nature of the injury almost unmistakable". The treatment con- sists in the application of a bandage up to, but not above, the seat of fracture (until after the subsidence of swelling), and the use of an inter- nal angular splint, with an outside splint moulded from pasteboard or gutta-percha. If the anterior angular deformity give any trouble, the internal may be replaced by an anterior angular splint, or a short anterior splint may be used with the moulded pasteboard splint, while the forearm is laid across the chest, and fixed by a broad bandage, or merely supported by a short sling around the wrist. Various plans of making permanent extension have been proposed, but are all of ques- tionable utility, sufficient extension being afforded by the weight of the elbow, which for this purpose should be unsupported, or at= least not pressed upwards. If the internal angular splint be used, care should FRACTURES OF THE HUMERUS. 251 Fracture at the base of the condyles. be taken that it do not press on the axillary vein; the angle of the splint may be varied at different dressings, so as to avoid stiffness of the elbow. 3. Fractures of the Lower Extremity of the Humerus.— (1.) Of these the first to be considered is the Fracture at the Base of the Condyles not implicating the joint, under which head may be properly included separation of the lower epiphysis of the hu- Fig. 117. merus. This form of frac- ture usually results from indirect violence exerted upon the extremity of the elbow, and its line is gene- rally oblique, upwards and backwards. This injury is frequently confused with dislocation of the elbow backwards, but the diag- nosis can be made by ob- serving that in fracture there is increased mobility, crepitus, shortening of the humerus, but no change in the relative position of the olecranon and condyles, and that the deformit}', while easily reduced, instantly recurs on the removal of extension. In dislocation, on the other hand, there is immobility, no crepitus, no shortening, but an obvious projection of the olecranon behind the line of the condyles, and the displacement when reduced does not return. (2.) Fracture at the Base of the Condyles, complicated by a Splitting Fracture between them, is a somewhat rare accident; it is marked by the same symptoms as the preceding variety, with the addition of increased breadth of the lower end of the humerus, and of crepitus between the con- dyles, developed by pressing them together. Besides the above varieties there may be sepa- rate fractures of (3) the Inner Condyle (trochlea), (4) the Inner Epicondyle (epitrochlea), (5) the Outer Condyle, and possibly (6) the Outer Epi- condyle, though I am not aware that the existence of this lesion has ever been demonstrated by dis- section. The diagnosis of these varieties of fracture can usually be made by the detection of mobility and crepitus, elicited by grasping the arm firmly with one hand, and moving either condyle successively in various directions, or by pressing and rubbing the condyles together. There is commonly not much displacement, except in the case of fracture of the inner epicondyle, when the separated fragment is often displaced downwards in the direction of the hand. These injuries generally result from direct violence, and after recovery the elbow is often left stiff, if not absolutely anchylosed. Treatment of Fractures of the Lower Extremity of the Humerus.— Any of these fractures may be conveniently and efficiently treated by Fig. 118. Fracture at the base of, and between the condyles. 252 SPECIAL FRACTURES. Physick's elbow splints. means of a simple internal rectangular splint (Fig. 119), the forearm being in a semi-prone position with the thumb pointing upwards, or by means of an anterior angular splint, the .forearm being supine. The splints should be well padded, and no bandage should be applied beneath the splint, until after the subsidence of inflammatory swelling. Indeed, the soft parts are often so much involved in these cases, that the use of evaporating lotions may be required for a few days, the limb being bandaged to the splint above and below, while the joint itself is left exposed. Several forms of apparatus have been de- Fig. 119. vised for the treatment of these injuries, among the most ingeni- ous of which may be specially mentioned the splints of Sir A. Cooper, Hamilton, Bond, Welch, and Mayo. I am not aware, how- ever, that the}r present any ad- vantages over the simple form of dressing above recommended; whatever plan be adopted, great care must be taken to avoid undue or uneven pressure, which might produce excoriation or even gan- grene. Great difficulty is some- times experienced in maintaining reduction, from the action of the pow'erful muscles at the back of the arm ; by careful bandaging, how- ever, and the judicious use of compresses, this difficulty can usually be overcome. As already mentioned, if the elbow-joint be involved in the fracture, there will always be great risk of anchylosis ; hence, it may be proper to resort to passive motion at a comparatively early period in these cases, as soon sometimes as the end of the third or fourth week ; or the patient may be directed to swing a flat-iron, as recommended in the last chapter. Compound fracture of the elbow-joint is a very serious injuiy, and usually requires excision or amputation. The time required for the treatment of a fractured humerus is com- monly from five to eight weeks, according to the age of the patient, and other modifying circumstances. Fracture of the Olecranon is usually produced by direct violence, such as a fall on the point of the elbow. It may also be caused by indi- rect violence—a fall on the hand, etc.; or even by muscular action, through the powerful contraction of the triceps extensor muscle. In the latter case, the mechanism of the injury probably consists in the ole- cranon process being broken as an overbent lever, across the condyles of the humerus, which act as a fulcrum. The symptoms of the accident are sufficiently obvious. If the ligamentous expansion of the triceps be extensively ruptured, the detached process will be drawn a considerable distance up the arm, giving rise to marked displacement. In the ma- jority of instances, however (at least according to my own experience), there is little or no separation, and the diagnosis must then be made by noting the existence of abnormal mobility and of crepitus. Crepitus can commonly be elicited simply by seizing the olecranon and rubbing it laterally against the extremity of the shaft of the ulna, or, if there be any displacement, by grasping the forearm just below the elbow, so that the forefinger rests upon the point of the olecranon, which it draws down in contact with the shaft, when crepitus may be brought out by FRACTURES OF THE FOREARM. 253 flexing and extending the forearm with the other hand. Union occa- sionally takes place by bony deposit, but is more often ligamentous merely. The utility of the arm may, however, be preserved even with considerable retraction of the upper fragment. The treatment consists in fixing the olecranon in apposition with the shaft (which may be con- veniently effected by means of a compress and adhesive strips), and keeping the joint at rest in an extended position for four or five weeks, or until union has occurred. Surgeons are divided as to the compara- tive advantages of complete or of partial extension, many agreeing with Sir Astley Cooper, and Prof. Hamilton, in recommending the former, while the majority of French surgeons, Mr. Erichsen, and others, prefer the latter. I am myself in the habit of using a simple obtuse-angled splint, well padded, and applied to the inside of the arm, and to the pal- mar surface of the forearm, which is kept in a semi-prone position. Figure-of-8 turns around the elbow assist in fixing the olecranon. This position—one of slight flexion—is less irksome to the patient, and is at least as effective in obviating deformity as that of complete extension, which sometimes causes an angular depression at the seat of fracture. In cases of compound fracture of the olecranon, or of any compound fracture about the elbow-joint, in which an attempt is made to preserve the limb, the arm should be flexed to an angle of from 100° to 120°, which will be found the most useful position should anchylosis ensue. Fracture of the Coronoid Process of the Ulna has been sup- posed to be a frequent complication of backward dislocation of the elbow-joint. Hamilton, however, has been unable to collect more than nine cases in which this lesion has been diagnosticated during life (and in none of them was the diagnosis confirmed by dissection), while none of the four specimeus to which he refers, gives satisfactory evidence as to the existence of fracture. Hence, even if the possibility of the acci- dent be admitted, it must be considered very rare. The cause of such an injury would probably be indirect violence, and its diagnosis would have to be established principally by exclusion. The treatment would consist in fixing the elbow on a rectangular splint, and in practising passive motion after three or four weeks. Fractures of the Forearm.—Both bones of the forearm are fre- quently broken through their shafts, either by direct, or more frequently by indirect violence, while by direct violence either the radius or the ulna may be fractured separately. If only one bone be broken, the other acts as a splint, and prevents the occurrence of much displace- ment, in spite of the obliquity of the fracture; but if both bones have given way, there is marked shortening, which, with the mobility and crepitus, render the nature of the case evident. The treatment consists in reducing the deformity by extension and manipulation, and in fixing the limb so that the line of the bones is preserved, and the interosseous space not encroached upon, while the motions of pronation and supi- nation are preserved. For this purpose the supine position, advised by Lonsdale, is preferable to that of semi-pronation ordinarily recom- mended. The reason is that in any fracture of the radius, particularly in one above the insertion of the pronator radii teres, the upper frag- ment is supinated by the action of the supinator brevis and biceps muscles, and therefore, unless the lower fragment be also supinated by the surgeon, union with rotatory deformity will almost inevitably ensue. Two straight splints are required, which should be just wide 254 SPECIAL FRACTURES. enough to prevent the encircling bandage from pressing the bones together, and thus diminishing the interosseous space. The palmar splint should reach from the bend of the elbow to beyond the fingers; the dorsal from just below the olecranon to just above the styloid process of the ulna. They should be well and evenly padded, the object being not to thrust the bones apart as by a wedge, but to fix them in the posi- tion which they have assumed under the surgeon's manipulations. No bandage should be used underneath the splints, and the dressing should be renewed at least every other day during the first fortnight. For fracture of both bones, the splints should be retained for from five to seven weeks, but for fracture of the shaft of either bone alone, four weeks will usually suffice. A perfect cure of a fracture of both bones of the forearm is perhaps rarely obtained; but I believe that the surgeon will secure better results by this mode of treatment than by any other. Fracture of the Neck of the Radius is rarely met with except when complicated with other lesions. The diagnostic signs are slight anterior displacement, with localized pain, mobility, and crepitus. The treatment consists in the application of a well-padded internal rectangu- lar splint, the separated fragment being kept in place by means of a firm compress. Fracture of the Lower Extremity of the Radius is an acci- dent of very frequent occurrence. Its nature and pathology have been made the subject of special study by Colles, R. W. Smith, Erichsen, Goyrand, Yoillemier, Nelaton, and J. R. Barton, of this city. There are two varieties of this form of fracture, known generally as Colles's, and as Barton's fracture. Colles's fracture, which is by far the most com- mon, is a transverse or slightly oblique fracture, situated at from a quarter of an inch to an inch and a half above the articular extremity of the radius. Barton's fracture is a very oblique fracture, extending from the articulation upwards and backwards, separating and displac- ing the whole or a portion of the posterior margin of the articulating surface. It is a very rare accident, constituting probably not more than one or two per cent, of the whole number of fractures in this locality. The cause of these injuries is almost invariably a fall upon the palm of the hand, and the displacement is very constant, the lower fragment being drawn somewhat upwards and backwards, while the upper frag- ment projects downwards and forwards; the hand at the same time in- clines somewhat to the radial side, though if, as sometimes happens, Fig. 120. Fracture of the radius near its lower end. there be also a fracture of the styloid process of the ulna, this symptom ma}r not be present. The so-called " silver fork" deformity, which usually characterizes this injuiy, is well seen in the accompanying illustration (Fig. 120). The diagnosis of this fracture is generally easy. Besides FRACTURE OF LOWER EXTREMITY OF RADIUS. 255 the peculiar displacement, there is pain, greatly increased by motion and especially by attempts to rotate the wrist, while crepitus can be readily elicited by drawing down the hand and rubbing together the fragments. In some rare cases the fracture is completely impacted, when crepitus will be absent, and reduction very difficult, if not impos- sible. The treatment consists in effecting reduction by means of exten- sion and manipulation, and in fixing the limb by the use of splints and compresses. Two compresses are required, one over the dorsal projec- tion (lower fragment), and one over the palmar prominence (upper frag- ment). Two straight splints may be applied over these compresses (as recommended by Dr. Barton), or the pistol-shaped splint (Fig. 121) of Ne'laton may be adjusted to either the dorsal or the palmar surface, Fig. 121. Nelaton's splint for fracture of the radius. or, which I prefer, the well-known splint of. Dr. Bond (Fig. 122) may be used, or one of the ingenious modifications of Drs. Hays, Hamilton, and others. To any of these a short dorsal splint may be sometimes advan- tageously added. Bond's splint consists of a piece of wood, of the shape Fig. 122. Bond's splint. indicated in the figure, with a carved block to support the hand and fin- gers, and side strips of leather or pasteboard. It is prepared for use by placing in it a layer of cotton wadding or folded lint, and adjusting upon this the palmar compress in such a position that when the splint is applied, it will press accurately upon the lower end of the upper fragment. The splint is laid on the fractured limb, so that the hand folds lightly over the block (which should fit the hollow of the palm), and the dorsal compress is then adjusted to the lower fragment so as to maintain the reduction which has hitherto been kept up by the surgeon's hands. The dressing is completed by the application of a roller bandage, 256 SPECIAL FRACTURES. firmly, but not tightly* for fear of gangrene. The semi-prone position is that usually recommended for the treatment of this injuiy, but I myself prefer the position of supination, recommended by Lonsdale, which I have already advised for fractures of both bones of the forearm. When Colles's fracture is complicated with Fracture of the Styloid Process of the Ulna, the case should be treated with two straight splints, as an ordinary fracture of the forearm, with the addition of compresses to combat the " silver-fork" deformity, if required. Five to seven weeks are usually necessary for the treatment of these cases. Fractures of the Hand.—Fracture of the carpus or metacarpus should be treated on a broad palmar splint, which is so padded as to fill up the hollow of the hand, and afford firm support to the injured mem- ber ; fractures of the phalanges require, in addition, a small pasteboard splint, applied immediately to the injured finger. The use of apparatus may be dispensed with after two or three weeks. In the treatment of all fractures of the upper extremity, the limb should (unless fastened to the chest) be supported in a sling, which may, within reasonable limits, be lengthened or shortened according to the patient's preference or fancj'. Fractures of the Lower Extremity. Femur.—Fractures of the thigh-bone may be divided into—1, those of its upper extremity; 2, those of its shaft; and 3, those of its condyles. 1. Fractures of the Upper Extremity of the Femur are usually classified as fractures (1) of the neck within the capsule, (2) of the neck without the capsule, (3) of the neck, partly intra- and partly extra-capsular, (4) through the trochanter major and base of the neck, and (5) of the epiphysis of the trochanter major. The terms intra- and extra-capsular have, however, as justly remarked by Prof. Bigelow, not much practical significance, for the reason that the attachment of the capsule varies in different individuals, so that, apart from the diffi- culty of diagnosis during life, it is often impossible, in looking at a specimen which shows bony union, to say whether the fracture was originally inside or outside of the capsular ligament. Hence, this dis- tinguished surgeon divides these injuries merely into the impacted and the non-impacted varieties of fracture. The old classification, however, is at least unobjectionable, and may properly be retained, as being more familiar than any other. (1.) Intra-capsular Fracture of the Neck of the Thigh-bone is an accident of frequent occurrence, being met with principally in those of advanced life, and in women oftener than in men. It is predisposed to, by the ordinary senile change in the structure and shape of the cervix fern oris, which is, in old age, often less obliquely attached to the shaft than in earlier life. This form of fracture results, usually, from indirect violence of an apparently trivial nature, such as slipping from a curb- stone, tripping over a loose piece of carpet, or even turning in bed. The symptoms are alteration in the shape of the hip, pain, crepitus, inability to stand or walk, shortening, and eversion of the foot. Alteration in the shape of the hip is evidenced by flattening of the trochanter, which may also be observed to rotate in an arc of abnormally small radius, the reason being that its centre of motion is changed from the acetabulum to the seat of fracture. FRACTURES OF UPPER EXTREMITY OF FEMUR. 257 Pain is markedly increased by any motion of, or pressure on the joint, and is sometimes so intense as to render the use of anaesthesia neces- saiy, as an aid to diagnosis. Crepitus may sometimes be detected by simply rotating the limb, but is usually not elicited until, by means of extension, the separated frag- ments are brought into contact. Inability to stand or walk is usually present from the first, though instances are not wanting in which patients have walked a short distance after the accident before falling, probably from the fracture being at first incomplete, or par- tially impacted. The attitude of the limb, as shown in the accompanying illustration (Fig. 123), is often characteristic, and sometimes almost diagnostic. The shortening, in these cases, is commonly not ver}' marked at first—probably not exceed- ing half an inch to an inch; it subsequently, and often suddenly, increases, by the giving way of ligamentous attachments, by rupture or stretching of the capsule, or by unlocking of fragments, and not unfrequently amounts, un- der these circumstances, to two inches or even more. Eversion of the limb almost always accom- panies these cases, and is probably due to a combination of causes, some mechanical—as the weight of the foot, and others physiologi- cal—as the action of the external rotator mus- cles upon the lower fragment. In a few cases inversion has been observed, and is attributed by Mr. Erichsen to paralysis of the external rotator muscles from concomitant injury. In cases of impacted fracture, these symptoms are all much less' marked, and the eversion may be so slight that, as justly remarked by Bigelow, it may be "best indicated by a comparison of the extent to which the two limbs can be inverted." The diagnosis between intra- and extra-capsular fracture will be con- sidered when we come to speak of the latter form of injuiy. The prognosis of unimpacted intra-capsular fracture must always be guarded. Bony union very rarely takes place in these cases, chiefly on account of the deficient vascular supply to the pelvic fragment, and the difficulty, often amounting to impossibility, of keeping the fragments in apposition. Many surgeons, indeed, have doubted whether bony union ever occurs under these circumstances, and those specimens which have been produced as instances of osseous union are all open to the objection that the line of fracture may have been at least partly extra- capsular. In cases of impacted intra-capsular fracture, however, bony union may undoubtedly occur. As these injuries are commonly met with in those of advanced age, the shock and general constitutional disturbance are often considerable; old persons, too, bear confinement badly, and in such these injuries not unfrequently prove fatal, through the occurrence of congestion or inflam- mation of internal organs, the formation of bed-sores, etc. Under more favorable circumstances the patient inaj7 recover, union taking place, if 17 Intra-capsular fracture of th neck of the thigh-bone. 258 SPECIA.L FRACTURES. at all, by means of fibrous bands, and the limb remaining permanently shortened and lame. 2. Extra-capsular Fracture of the Cervix Femoris is a less common injury than the intra-capsular variety. It is like the latter, usually, though less exclusively, met with in advanced life, and is generally pro- duced by direct, though occasionally by indirect violence, such as a fall on the feet or knees. The line of fracture commonly corresponds with the anterior and posterior inter-trochanteric lines, and the inner almost invariably pene- trates the outer fragment, in such a way as to split and comminute it into several portions. Either trochanter may be completely detached, and the fracture mav involve the summit of the shaft itself. Occasionally the fracture is completely impacted. The symptoms are much the same as those of the intra-capsular form of injury, the chief differences being that the trochanter moves in an arc of still shorter radius, that the pain is acuter and more superficial, and that the crepitus is more distinct, the fragments being sometimes felt loose under the skin; the shortening (unless in cases of impaction) is greater at first, but does not undergo much subsequent change, while eversion is not so invariably present. As this form of fracture usually results from direct violence, it is com- monly attended with great contusion and swelling of the soft parts. The differential diagnosis between intra- and extra-capsular fracture may in many cases be made by attention to the above-mentioned pecu- liarities, taken in connection with the history of the case, the age of the patient, etc. In cases of impacted fracture the diagnosis is much more difficult, and in such cases the surgeon must be very cautious in his examination, lest he inadvertently remove the impaction, and thus seriously complicate the condition of the patient: for in any fracture about the neck of the femur, impaction is a most desirable circumstance, limiting the amount of shortening, and favoring the occurrence of bony union. Severe contusion of the hip may cause temporary eversion and immobility, and thus simulate fracture; if the joint be also the seat of rheumatoid arthritis, there will be superadded shortening and false crepitus. The diagnosis, under such circumstances, must be made by careful inquiry into the history of the case and the previous condition of the patient. The prognosis of extra-capsular fracture, unless the patient die from shock or general constitutional disturbance, or from some concomitant injury, is usually favorable. Bony union readily occurs in these cases, the amount of callus, on account of the comminution of the fracture, being very large, forming stalactitic projections or osteophytes, which are most abundant along the posterior inter-trochanteric line. 3. The neck of the thigh-bone may be broken Partly Within and Partly Without the capsule; the symptoms would, of course, be essentially those of the previously described varieties, and the chances of bony union proportional to the degree in which the fracture was extra capsular. 4. Fracture through the Trochanter Major and Base of the Neck.—The line of fracture in this injury, which is sufficiently described by its name, separates the femur into two segments, the upper of which em- braces the head, neck, and trochanter major. The signs of the injury are crepitus, eversion, and shortening of about three-fourths of an inch; bony union readily occurs. 5. Fracture of the Epiphysis of the Trochanter Major must be an FRACTURES OF UPPER EXTREMITY OF FEMUR. 259 extremely rare accident, there being, according to Hamilton, but one authentic case on record. The diagnosis, I should suppose, could only be made during life by observing displacement of the epiphysis, without the ordinary signs of fractured femur. Treatment of Fractures of the Upper Extremity of the Femur__I have no hesitation in expressing my preference for the treatment of these injuries by means of the straight position with moderate extension, when- ever that mode of treatment is applicable. In cases of impacted frac- ture, extension is (for reasons already indicated) undesirable, and such cases may be treated by position alone, the joint being fixed by means of the long splint, in any of its varieties, or simply supported by means of heavy sand-bags placed on either side of the injured member. If the fracture be unimpacted, the same treatment should be employed, with the addition of moderate extension. For this purpose, Liston's splint (Fig. 124), or that of Desault, as modified by Physick and others, may Fig. 124. Liston's long splint. be conveniently used; or the surgeon may employ Hagedorn's apparatus, as modified by Gibson, or the less cumbrous contrivances of Gross, Hartshorne, or Horner. The simplest mode of treatment, however, and that which I much prefer, is the old-fashioned weight extension, first popularized in this country by Prof. Gurdon Buck, of New York, with the addition of sand-bags to either side of the limb. Weight extension is thus applied: A strip of adhesive plaster (cut lengthwise and well stretched) is prepared, 2% to 3 inches wide, and 3^ to 4 feet long. On Fig. 125. Adhesive-plaster stirrup for making extension in cases of fracture of the lower extremity, etc. the middle of this is placed a block of wood, of the same width as the adhesive strip, but four inches long, and half an inch thick; over this, again, is placed another adhesive strip of the same width, and l£ to 2 feet in length; the block which is sometimes called the stirrup is thus 260 SPECIAL FRACTURES. secured in the centre of a long band, of which the upper twelve inches at either end are adhesive. This band is then applied to the leg on which extension is to be practised, so that it adheres on either side from just below the knee to just above the malleolus, the stirrup remaining as a loop about four inches below the sole of the foot (Fig. 125). The apparatus is fixed by two or three broad strips passed circularly around the limb, which is finally surrounded with an ordinary spiral bandage. The malleoli should be protected by a layer of cotton, to prevent ex- coriation. It is well to allow a short time to elapse before applying the extending force, so that the strips may become firmly adherent. To the stirrup is fixed a cord, which plays over a pulley fixed at the foot of the bed, and which carries the extending weight, which, for fractures of the neck of the femur, need not usually exceed ten or twelve pounds. Counter-extension may be made by means of a perineal band fastened to the head of the bed, or, which is usually sufficient, simply by elevating the foot of the bed, thus utilizing the weight of the body itself as the counter-extending force. The sand-bags are merely long bags, like the "junks" used with Physick's splint, except that they are filled with clean sand instead of bran: the outer should reach from the axilla to the sole of the foot, and the inner from the perineum to the internal malleolus. While I have recommended this mode of treatment for every case to which it is applicable, it is but right to say that there are certain cases, especially of intra-capsular fracture in old persons, in which no apparatus can be borne, and in which even confinement to bed is fraught with danger- ous consequences; under such circumstances, the injured limb should be simply laid across pillows, as recommended by Sir Astley Cooper, until the pain and inflammation which attend the injury have subsided, the patient being then allowed to get up in a chair or on crutches; bony union, under such circumstances, cannot be hoped for, and the general rather than the local condition of the patient should be the object of attention. In some of these cases, a moulded leather' or pasteboard splint, or a starched bandage, may be used with advantage. 2. Fracture of the Shaft of the Femur.—This injury may be met with at any age, and in any part of the bone; it is most frequent, however, in the middle third. The accident commonly results from direct violence, and the direction of the fracture is almost invariably oblique. The fracture is marked by mobility, shortening, eversion, and crepitus, which are so manifest that the nature of the injury can scarcely be mistaken. "With regard to the prognosis of fracture through the shaft of the femur, I have no hesitation in saying that I have never seen a perfect cure, either in my own practice or in that of others; by this, I mean that I have never seen a cure without shortening. Without entering upon a discussion as to the possibility of such a result (for a full and candid consideration of which question I would respectfully refer the reader to Prof. Hamilton's excellent treatise), I will merely say that I have never seen less shortening than a quarter of an inch, after fracture of the thigh, even in children; and that I consider a shorten- ing of from half an inch to an inch, a satisfactory result in adults. The treatment of fractures of the shaft of the thigh is most conveniently conducted with the weight extension apparatus already described, sub- stituting, however, for the sand-bags, long splints (either padded or provided with bran junks), which have the effect of fixing both the hip FRACTURE OF THE SHAFT OF THE FEMUR. 261 and the knee joints, a very important consideration in the management of these injuries (Fig. 126). The chest and pelvis should both be secured to the external splint by broad and firm bands, while the splints themselves should be kept in position by similar bands, passing at intervals across the affected limb. In fractures of the upper part of the shaft there is fre- quently seen an anterior angular projection, which is generally attributed, Fig. 126. Weight extension with long splints for treatment of fractured thigh ; counter-extension made by raising foot of bed. and is probably usually due, to the tilting forwards of the lower end of the upper fragment; though that it is occasionally due to the projection of the lower fragment is shown by several specimens described by Mr. Butcher. Whatever be the cause of the projection, it will usually require the Fig. 127. N. R. Smith's anterior splint, applied for a fracture of the thigh. application of a third, anterior splint, which should reach from the groin to above the knee, and should be well padded to prevent excoriation. After several weeks, when union is pretty well advanced, short moulded pasteboard splints may be applied immediately around the seat of fracture, 262 SPECIAL FRACTURES. the long splints and weight extension being continued as before. This is the mode of treatment which I am in the habit of employing in cases of fractured thigh, and I have found it to be as efficient as it is simple. Excellent cures may, however, doubtless be obtained by the use of other means, such as the various forms of apparatus already mentioned (page 259), or the wire " anterior splint," of Prof. N. It. Smith, of Maryland (Fig. 127). Compound Fractures of the Thigh may be conveniently treated with the weight extension apparatus, with the bracketed long splint (Fig. 128), with a simple long fracture-box (particularly useful when the Fig. 128. Compound fracture of shaft of thigh-bone ; treatment by bracketed long splint. bran dressing is to be employed), or, in some rare cases, with the old- fashioned double-inclined plane, which was so popular at the end of the last and the beginning of this century.1 3. Fracture of the Condyles of the Femur.—Either condyle may be broken off separately, or there may be a splitting fracture be- tween them, complicated with a more or less transverse fracture through their base. The symptoms are mobility, crepitus—elicited by rub- bing the condyles together, and, if the fracture extend through their base, shortening; there is also an increase in the breadth of the limb around the condyles, which persists after recovery. These accidents usually result from direct violence, and are often followed by secondary inflammation of the knee-joint, which may run on to suppurative dis- organization, endangering either the limb or life of the patient. The treatment consists in placing the limb at rest in a straight or almost straight position, in a long fracture-box with a firm but soft pillow, and in making moderate extension, if there be much shortening; recovery will usually be attended with more or less anchylosis. Separation of the Lower Epiphysis of the Femur would require the same treatment as fracture of the condyles. Compound Fracture of the Femur, Involving the Knee-joint, should, almost invariably, be considered a case for ampu- tation. The time required for the treatment of a fractured thigh may be said to be from eight to ten weeks; even if union appear firm before that time, the patient should not be allowed to bear any weight on the limb, for fear of consecutive shortening, which I have known to occur after appa- rently complete recovery. • I will merely mention, without in any degree commending, the plan proposed by Dr. Hennequin, in an essay which received the Barbier prize, that " in frac- tures of the thigh the limb should be placed in a horizontal plane, in moderate ab- duction and outward rotation, with the leg flexed at a right angle, and the trunk elevated ;" a position which would require the patient to sit on the side of the bed, with his leg hanging over the edge (.Archives Generates de Medecine, Dec. 1868, pp. 657-662). * FRACTURE OF THE PATELLA. 263 Fig. 129. Fracture of patella; fragments sepa- rated by flexing the knee. Patella.—Fractures of the patella are usually met with in male adults, and are commonly produced by muscular action, the patella being broken as an over-bent lever across the condyles of the femur ; under such cir- cumstances, the line of fracture is trans- verse, and the upper fragment may be drawn some distance upwards by the powerful muscles of the thigh. The patella is occa- sionally broken by direct violence, when the fracture may be comminuted or longitudi- nal. The diagnosis is easily made: in trans- verse fracture there is always some displace- ment, which is increased by flexing the knee; while in comminuted or longitudinal frac- tures, the nature of the case is rendered evident by the mobility and crepitus, which, under such circumstances, are very distinct. Inability to walk or stand, which is often spoken of as a sign of frac- tured patella, is, as remarked by Gouget, more apparent than real, the patient being able, though not willing, to walk, on account of the pain which attends the effort. The prognosis is favorable; though bony union is rarely obtained, especially in the case of transverse fracture, the utility of the limb is not materially impaired, and instances are on record in which patients, after recovery, have engaged in duties requiring great activity and strength of limb, although with a separation of several inches between the fragments of the patella. The treatment consists in placing the limb in a straight position, with the leg somewhat elevated, so as to relax the fibres of the quadriceps femoris muscle.1 The upper fragment of the patella, being drawn downwards, is held in place by means of a firm compress, which is secured by strips of adhesive plaster, fastened to a broad posterior splint, provided for the purpose with notches or cross-pieces. The whole limb and splint are then surrounded with a roller, which, by figure-of-8 turns around the knee, gives addi- tional security and firmness to the part. The limb should be raised, simply by pillows, or by an inclined plane, the relaxation of the quadri- ceps femoris muscle being further assisted, as recommended by Hamil- ton, by elevating the patient's trunk. Care must be taken, as with all fractures of the lower extremity, to keep the foot strictly at right angles with the leg, so as to avoid the "pointed-toe" deformity which is other- wise apt to ensue. This simple mode of treatment, which is essentially the same as that recommended by Hamilton (Fig. 130), is quite as efficient as the more complicated plans devised by Lonsdale, Amesbury, Cooper, and others. Malgaigne's hooks, while doubtless efficient, and probably less dangerous than is usually supposed, are at least unnecessary, and, from their formidable appearance, undesirable. A better mode of treat- ment, which has lately been revived by Gibson of Missouri, Eve of Tennessee, and Blackman of Ohio, consists in holding the fragments in apposition by means of an iron ring. Dr. Blackman thus twice suc- ceeded in obtaining bony union. Many authors advise that no dressing should be employed until the swelling which follows the accident has 1 According to Hutchinson, this precaution is unnecessary; the separation of the fragments is due, in his opinion, not to the action of the quadriceps femoris, which he believes to be entirely passive, but to fluid pressure from within the joint. (See an able paper in Med.-CMr. Trans., vol. lii. pp. 327-340.) 264 SPECIAL FRACTURES. subsided; but this delay exposes the patient to the risk . permanent shortening of the rectus femoris, and I, therefore, think it better to apply the apparatus at once, though, of course, not too tightly, watching it carefully, and being prepared to loosen it, should the exigencies of Fig. 130. Hamilton's mode of dressing a fractured patella. the case so require. After recover}', a pasteboard or leather cap should be worn around the joint for some time, until the ligamentous bands which unite the fragments have attained the necessary degree of firmness, to resist any ordinary force to which they may be subjected. The duration of treatment, in cases of fractured patella, should be about six weeks, the joint being still longer protected with a suitable cap, as already directed. In any case in which confinement would be very inconvenient, a starched bandage might be used after the first week or two, the patient being then allowed to go about. Compound Fracture of the Patella, involving, as it usually does, the knee-joint, is commonly considered a case for amputation. The elabo- rate statistics of Mr. Poland show, however, that this extreme measure is in reality seldom called for; thus, of 68 cases treated without opera- tion, 56 recovered and only 12 died (17.65 per cent.), while of 7 in which amputation was performed, 5 recovered and 2 died (28.57 per cent.), and of 10 treated by excision, only 4 recovered and 6 died (60 per cent.). Of the whole 85 cases, therefore, 65 recovered and 20 died. Suppuration of the joint occurred in 43 of those cases which terminated favorably, and in all of those which proved fatal.1 Fractures of the Bones of the Leg.—Either the tibia or fibula, or both, may be broken, the cause of these injuries being usually direct, though occasionally indirect violence, and the line of fracture generally oblique, except in the upper part of the tibia, where it is commonly transverse. If only one bone be broken, there will not be much displace- ment, the other acting as a splint, except in fractures just above the ankle, when the foot inclines to the injured side. Fracture of both bones, in the middle or lower third, is often attended with considerable displacement, the line of fracture being oblique (from above downwards, forwards, and inwards), and the lower being drawn up behind the upper fragments by the powerful muscles of the calf. The existence of 1 Med.-Chir. Trans., vol. liii. p. 49. FRACTURES OF THE BONES OF THE LEG. 265 this displacement, together with undue mobility and crepitus, render the diagnosis easy; and even when one bone only is broken, the nature of the case can be readily ascertained by careful examination. Separation of the Upper Epiphysis of the Tibia is a very rare accident, there being, indeed, so far as I know, but three instances of it on record; one is mentioned by Mad. Lachappelle, the case being that of a new-born infant, and the injuiy having been produced during delivery; the second is figured in the last edition of Holmes's System of Surgery, from a speci- men in the museum of St. George's Hospital; and the third occurred in my own practice, in a boy eleven years old, who was caught between the bumpers of railway cars; the laceration of the soft parts was so great as to require amputation, and the nature of the accident was thus ascertained by dissection; the specimen from which the accompa- nying illustrations are taken, is now in the museum of the Episcopal Hospital. Dr. Yoss, of New York, has recorded a case of separation of the lower epiphysis, in which, in spite of the occurrence of necrosis, recovery with a useful limb was ultimately obtained. Fig. 131. Fig. 132. Separation of upper epiphysis of tibia. (From a specimen in the museum of the Episcopal Hospital.) Treatment.—For the treatment of the great majority of fractures of the leg, whether one or both bones be involved, I know of no apparatus which presents so many advantages as the old-fashioned fracture-box with movable sides (Fig. 133), containing a soft but firm pillow; the fracture having been reduced, the limb is gently laid in the box, the sole of the foot being adjusted to the foot-board, with the heel well brought down, and raised on a pad of cotton or tow placed beneath the tendo Achillis. The foot is then secured by a turn of bandage, and the sides of the box brought up so as to make firm and equable pressure upon 266 SPECIAL FRACTURES. Fig. 133. the fractured limb. Care must be taken to keep the foot at a right angle with the leg, to prevent eversion of the knee by frequent adjustment,1 to pre- vent excoriation of the heel by the use of the pad under the tendo Achillis, and of the malleoli by pads above and below those prominences, and to coun- teract any tendency to lateral displace- ment by the use of suitable compresses. Fracture-box, with movable sides. By strict attention to these points, I do not hesitate to say that in the im- mense majority of cases, as good a cure can be obtained with the simple fracture-box, as with any of the complicated contrivances which the ingenuity of surgeons has suggested. In fact, the chief difficulty with the fracture-box is that it is so simple, that surgeons are apt to think that nothing is required beyond placing the limb in it, and there letting it stay for the requisite number of weeks; and it is, I believe, to the neglect of the surgeon, rather than to'any fault of the apparatus, that are to be attributed the bad results, on which many modern writers, in objecting to the use of the fracture-box, lay such stress. If in cases of very oblique fracture it be desired to make extension, this can readily be done bj' means of the ordinary adhesive-plaster stirrup, pulley, and weight, the extending bands (which, of course, must not be attached above the seat of fracture) being brought through slits in the foot-board of the fracture-box. Certain cases of oblique fracture2 may be best treated in the flexed position, and a very good apparatus for this purpose is the anterior splint of Prof. N. R. Smith, of Mary- land (Fig. 127). The comfort of the patient may often be promoted by suspending the fractured limb from a yoke attached to the sides of the bedstead, for which purpose either the ordinary fracture-box, or Salter's swing cradle (Fig. 134), or the "anterior splint," may be conveniently employed. After three or four weeks, when union is pretty well advanced, the limb may be advantageously surrounded with moulded and well-padded pasteboard splints, being then replaced in the fracture-box. The treat- ment of a broken leg usually occupies from six to eight weeks. It is in cases of compound fracture of the leg, that the bran dressing, ■""""■^ introduced by Dr. J. Rhea Barton, of this city, is particularly useful. It is thus applied: inside of an ordinary fracture-box, of suitable size, is placed a sheet of oil-cloth, or India-rubber cloth, and on this a layer of fine and clean bran about two inches deep; the fracture being reduced, the limb is laid in the box, with a pad of cotton beneath the tendo Achillis and around either malleolus, and a layer of the same material around the limb just below the knee; the sides of the box are then brought up and secured, and more bran is dusted and packed around and over the leg till the box is filled, the fractured limb being thus 1 A convenient practical rule is to see at each visit that the ball of the great toe, the inner malleolus, and the inner condyle of the femur are all in the same vertical plane. 2 For the treatment of these oblique fractures, Malgaigne recommends an appa- ratus, provided with a sharp screw to hold the fragments in place; while Laugier, and more recently Mr. Bloxam, recommend division of the tendo Achillis. I have no personal experience with either of these modes of treatment, which, however, I cannot but think unnecessarily severe. FRACTURES ABOUT THE ANKLE. 267 firmly and evenly supported on all sides. The same precautions as to position are to be observed as in the management of a simple fracture, the daily dressing consisting in letting down one or both sides of the box, and, without disturbing the limb, removing the soiled bran with a Fig. 134. Salter's cradle. spatula, and replacing it with fresh material. The great advantages of the bran dressing are its simplicity and cleanliness, the bran readily absorbing all discharges as they are formed, and affording a sure pro- tection against flies; in recent cases, the uniform pressure of the bran has been, moreover, found very efficient in checking hemorrhage. Fracture of the Head of the Tibia into the knee-joint is apt to be complicated with injury of the popliteal vessels (see page 227). For its treatment, a fracture-box, long enough to fix the joint, is em- ployed, such as was recommended for fracture of the condyles of the femur. This injury is often followed by anchylosis. Fractures about the Ankle are, perhaps, more troublesome than any other fractures of the leg. The fibula alone may be broken, usually giving way about three inches above the joint, or the tip of the inner malleolus may be torn off as well (Pott's fracture), or the inner malleolus may be longitudinally splintered into the ankle-joint (an accident com- monly followed by anchylosis), or, finally the inner malleolus alone may be broken, the fibula escaping. Any of these forms of injury may be safely and conveniently treated with the frac- ture-box, the deformity being obviated by fre- Fig. 135. quent and careful adjustment and the judicious use of compresses. I have never had occasion to use Dupuytren's splint for fractured fibula, though I doubt not that when carefully applied it is an efficient apparatus. In the manage- ment of fractures of the leg, or in fact of any part of the lower extremity, the injured limb wire rack for fracture of the leg. should be protected from the weight of the bed- clothes by means of a suitable framework of bamboo, wood, or wire, as shown in Fig. 135. 268 SPECIAL FRACTURES. In cases of fractured leg occurring in very young children, or in adults suffering from mania a potu, when no restraint can be borne, it is a good plan to surround the broken limb with a soft pillow, which is held in place by means of firm bandages ; the part can then be tossed about without risk of further injury. Fractures of the Bones of the Foot.—The only tarsal bones, the fractures of which require special notice, are the calcaneum and astragalus. The Calcaneum may be broken by direct violence, or by muscular action; the line of fracture may assume any direction, and, when the injuiy results from direct violence, the fracture may be comminuted or impacted. If the tuberosity of the bone only be separated, the frag- ment may be drawn upwards for a considerable distance by the action of the gastrocnemius muscle, whereas, if the fracture be through the body of the bone, there can be little or no displacement, the fragments being held in place by the lateral ligaments. The treatment, if there be no displacement, consists merely in placing the limb in a fracture- box or on a pillow, and combating inflammation by evaporating lotions, etc., applying subsequently splints or a starched bandage. When the posterior fragment is* drawn upwards, the foot should be kept in an ex- tended position, so as to relax the gastrocnemius, by means of a well- padded anterior splint, or the apparatus already recommended for rup- ture of the tendo Achillis (Fig. 103). The Astragalus is almost invariably broken by the patient falling from a height, alighting on his feet. Simple fracture of this bone is rarely attended with displacement; in fact there are, so far as I know, but two cases of the kind on record, one reported by Dr. Norris, and one by myself.1 In the former, the displacement was downwards and forwards; in the latter, downwards, outwards, and backwards. The treatment consists in reduction (if practicable), the limb being then placed in a fracture-box, and subsequently dressed with pasteboard splints or a starched bandage. If reduction were impracticable, in a case of simple fracture, I should be disposed to temporize, reserving excision (which is usually recommended under such circumstances), as a secondary operation, to be employed should sloughing or necrosis ensue: in Dr. Norris's case, the displaced fragment was excised by Bar- ton, but amputation was subsequently required, and the patient ulti- mately died, a year and a half after the occurrence of the accident. In a Compound Fracture of the astragalus, if reduction were imprac- ticable, I should advise complete excision, which Rognetta (whose paper on this subject is classical) considers preferable to excision of the dis- placed fragment only. When, however, such an injury is attended with much comminution, or is complicated with fracture of the malleoli or other tarsal bones, amputation will often be required as a primary operation. Fractures of the Metatarsal Bones or Toes are usually pro- duced by direct violence, and, if attended with much laceration, com- monly require amputation. In cases of simple fracture, it would be sufficient, after effecting reduction, to apply a plantar splint, and to place the limb in a fracture-box, the dressing being changed, after a time, for pasteboard splints or a starched bandage. 1 Amer. Journal of Med. Sciences, April, 1862, pp. 335-340. # DISLOCATIONS. 269 CHAPTEE XIII. DISLOCATIONS. A dislocation or luxation is a displacement, as regards their relative position, of the bones which enter into the formation of a joint. Dislo- cations are variously classified; thus they are said to be traumatic, pathological or spontaneous, and congenital. Traumatic dislocations are such as result from the sudden application of force; pathological or spontaneous luxations are such as occur from an alteration in a joint as the-result of disease (as in the dislocation of the femur in hip-disease), or simply from a paralyzed condition of the muscles around the joint, without any evidence of disease of the articulation itself; while congeni- tal dislocations are, as the name implies, such as 'exist at the moment of birth, being usually due to original malformation of the parts con- cerned. When the term dislocation or luxation is used alone, it is generally understood to mean one of the traumatic, or, as Hamilton calls it, accidental variety. When dislocation occurs in the form of joint designated by anatomists as "amphiarthrosis" or "mixed articu- lation," it is sometimes called diastasis, as in the separations between the first and second bones of the sternum, between the vertebras, or at the pubic or sacro-iliac symphysis. Dislocations are further classified as complete or partial; as simple, compound, or complicated; as recent or old; and as primitive or conse- cutive. In a complete dislocation, the bones which enter into the formation of the joint are entirely separated from each other; in a partial or incom- plete luxation (also called a subluxation), the articulating surfaces re- main in contact, through a portion of their extent. The terms simple, compound, and complicated bear the same relative meanings as when applied to fractures. Compound luxations may be made so directly by the luxating force, or may become so through rupture of the over- stretched soft parts which surround the dislocated joint. Among the most serious complications of a luxation may be mentioned fracture of either of the articulating surfaces of the injured joint, and rupture of the main artery of the limb, as of the popliteal in backward dislocation of the knee. A recent dislocation is one in which time has not been afforded for the production of inflammatory changes in the articulating surfaces and surrounding tissues, or at least not to such a degree as seriously to impede reduction; an old dislocation being, of course, one in which sufficient time has elapsed to permit such changes to occur. A primitive luxation is one in which the displaced bone remains in the position into which it was first thrown by the luxating force. A consecu- tive dislocation is one in which the displaced bone has secondarily changed its position, either under a continuance of the influence of the luxating force, or as the result of subsequent muscular contraction, or of the surgeon's manipulations in an attempt to effect reduction. 270 DISLOCATIONS. Causes of Dislocation.—Age and sex are Predisposing Causes of dislocation, only so far as they influence the exposure of the individual to external violence; thus these accidents are rare in infancy and in old age, being usually met with in those in active adult life, and much more frequently in men than in women. More important predisposing causes are the anatomical relations of the joint, and the condition of the neigh- boring muscles and ligaments; thus the ball-and-socket joints are more liable to luxation than the ginglymoid, while persons of vigorous, mus- cular frame are less exposed to these injuries than those whose tissues are relaxed and feeble. The following table, compiled from Malgaigne's statistics, shows the relative frequency with which various parts are dis- located :— Cases. Cases. Cases Jaw . . . 7 Femur. . . . 40 Vertebrae . . 4 Radius . . . . 7 Patella . . . 2 Pelvis . . . . 1 Wrist . . . . . 16 Knee . . . . 9 Clavicle . . . 42 Thumb . . . . 20 Ankle . . . . 31 Humerus . . 370 Fingers . . . . 7 Metatarsus . . 2 Atrophy and paralysis of a limb predispose it to dislocation, as do likewise stretching and relaxation of ligaments from articular effusion, or from previous dislocation, ulceration, etc. The Exciting Causes of dislocation are external violence, direct or in- direct, and muscular action. The latter is the more usual agent in the production of pathological dislocations, when it acts slowly and gradu- ally ; traumatic luxations are also, however, traceable to the effect of muscular action, especially when the joint has been previously weakened by any of the causes above mentioned; thus cases are recorded by Cooper, Haynes, Bigelow, and others, in which patients possessed the power of producing dislocation by a voluntary effort, and I have myself seen such a case in the person of an epileptic woman, who was in the habit of dislocating her hip in the public streets, as a means of exciting sympathy. Symptoms and Diagnosis of Dislocation.—The usual signs of dislocation are: (1) a change in the shape of the joint and in the rela- tive position of the articulating surfaces, the extremity of the displaced bone being often felt in an abnormal position; (2) an alteration in the length of the limb, either shortening or elongation; and (3) unnatural immobility of the affected joint. The first is the only symptom which can be considered essential, for in partial luxations (as of the elbow) there may be neither lengthening nor shortening, and if the articular ligaments be extensively lacerated, there may be a positive increase in- stead of diminution of mobility. From a fracture in the neighborhood of a joint, a dislocation may usually be distinguished, by observing the immobility (when that is present), the absence of crepitus, and the fact that the displacement when removed by reduction does not return. True crepitus does not exist in a case of pure dislocation; there is, however, a rasping or crackling sound, due to effusion or inflammatory changes in the articular structures, which is commonly developed in the course of two or three days, and which may readily be mistaken for the crepitus of a fracture in which the process of repair has already begun. Again, while displacement does not always recur in cases of fracture, it may recur in a case of dislocation, if there be much laceration of the liga- mentous tissues, or if the articular surfaces themselves have undergone ARTICULAR CHANGES PRODUCED BY DISLOCATION. 271 structural change from inflammatory action; thus in old luxations of the hip it is often easier to effect than to maintain reduction. Hence no one of these symptoms can be considered as in itself pathognomonic, and it is found in practice that the most experienced surgeon is occa- sionally liable to err in the diagnosis between luxation and articular fracture. Dislocation, like fracture, is commonly accompanied by pain, swelling, and ecchymosis; wide-spread extravasation may occur from rupture of vessels, and paralysis (temporary or permanent), or neuralgia, from compression or laceration of neighboring nerves. Articular Changes produced by Dislocation.—The immediate effects of a dislocation consist of a rupture more or less extensive of the capsular ligament, with or without laceration of the other ligaments of the joint, and of neighboring tendons, muscles, vessels, and nerves ; in cases of dislocation from muscular action, however, the capsular liga- ment may be merely stretched, without rupture. If the luxation be promptly reduced, the lacerated structures are gradually restored to their normal condition, though the joint is often left permanently weak- ened, and paralysis or neuralgia may continue for an indefinite period. If reduction be not effected, the articular surfaces themselves undergo changes. In a ball-and-socket joint, the old cavity becomes filled up, and its margins absorbed and flattened, while a new socket is commonly formed around the head of the dislocated bone, which changes its shape, and becomes gradually accommodated to its new position; if, however, the head of the bone rests upon muscle, instead of a new socket being formed, the soft tissues undergo condensation, forming a cup-shaped cavity of fibrous structure, which becomes attached by its margins to the dis- placed bone, and is lubricated by a synovia-like fluid. In the hinge- joints similar changes occur, the osseous prominences being rounded off, and the displaced bones gradually accommodating themselves more or less perfect^ to their new positions. These changes, which occur with comparative rapidity in childhood, take place very slowly in adult life, often occupying several years in their completion. At the same time, the surrounding muscles and tendons become shortened and atrophied, and abnormal adhesions often form between the displaced bones and neigh- boring nervous and vascular trunks—a circumstance which has several times been the cause of fatal hemorrhage in attempts to reduce old dis- locations. Prognosis.—In some cases, beyond a temporary stiffness and weak- ness of the part, a dislocation appears to entail no unpleasant conse- quences ; but in the majority of instances, a limb which has been the seat of luxation will not be completely restored for months or even years, or occasionally during the whole lifetime of the patient. An unreduced dislocation of course causes permanent disability, and yet it is surprising to what an extent the displaced parts accommodate themselves to their new positions, the utility of a limb after dislocation being often much greater than would be thought probable in view of its evident deformity; so that it is sometimes a question, in cases of old dislocation, whether reduction would be desirable, if even it could be accomplished. Treatment.—The indications for treatment in any case of disloca- tion may be said to be to effect reduction, to put the joint in such a con- dition that the natural process of repair may take place without undue 272 DISLOCATIONS. inflammation, and to encourage the restoration of the functions of the part. Reduction.—This should be effected in every case, at the earliest pos- sible moment. While I have advised that in certain cases of suspected fracture, minute examination should be delayed until after the subsidence of swelling, the case meanwhile being treated as one of fracture, in a case of suspected dislocation no such temporizing course would be justi- fiable, for the reason that while reduction in a recent case is usually quite easy, a very short delay will render it difficult, and in some cases almost impossible. Hence, if the nature of the case be not perfectly clear, the surgeon should not hesitate to employ anaesthesia as an aid to diagnosis, more particularly as the use of the anaesthetic will greatly facilitate reduction, should the existence of a dislocation be determined. The principal obstacles to reduction, in any case of luxation, are mus- cular resistance, and the anatomical relations of the joint. There are three distinct elements to be considered in estimating the influence of the muscles in hindering reduction; these are, (1) the passive force which the muscles possess in common with the other soft structures of the body, and which is brought out by the stretching of their tissues across the displaced bony prominences; (2) the active force, whereby the patient voluntarily though unconsciously resists the surgeon's efforts at reduction; and (3) a state of reflex tonic contraction into which the muscles are thrown as the result of the traumatic irritation, produced by the injury itself; this, which is the most important form in which muscular resist- ance is manifested, is more and more fully developed as the luxation remains longer unreduced. It often happens that if a patient is seen immediately upon the occurrence of a dislocation, the muscular relaxa- tion due to the general state of shock which accompanies the accident is so great, that the displacement can be reduced with the greatest facility, and,.indeed, is often so reduced by the bystanders or by the patient himself. The knowledge of this fact led surgeons, before the discovery of anaesthetics, to prepare patients for the reduction of luxa- tions by the use of the warm bath, the administration of tartar emetic, and even general bleeding. To obviate the unconscious though volun- tary resistance of the patient, the older surgeons laid stress upon the importance of surprising the muscles, as it were, by diverting the patient's mind, by asking a sudden question, or making an unexpected remark, at the moment of attempting reduction. The tonic, reflex contraction of the muscles may be overcome, to a certain extent, by the use of opium, especially by the hypodermic method, or, as was done by Physick, by inducing intoxication; but a more efficient and trustworthy plan than any of these, and the only one which is habitually resorted to at the present day, is the administration of ether or chloroform, so as to pro- duce anaesthesia and complete muscular relaxation. Anaesthetics are indeed invaluable in the treatment of dislocations, occurring in vigorous adults; but in cases met with in children, or in adults of feeble and relaxed muscular frame, reduction should be attempted, and may often be conveniently effected, without anaesthesia. Muscular resistance having been overcome, all that the surgeon has to contend with, in a case of recent dislocation, is the hindrance to reduc- tion presented by the anatomical structure of the joint, the shape and altered relations of the articular surfaces themselves, and the condition of the capsular and other ligaments which in a state of health keep the bones in apposition. Hence the paramount importance of an accu- rate knowledge of anatomy, in undertaking the treatment of these cases; TREATMENT. 273 Fie. 136. as Prof. Hamilton well observes, in a very large majority of instances force and perseverance will finally succeed, by whomsoever they may be employed, but they succeed at the expense of great suffering, and perhaps permanent injury to the patient. It is the mark of the skilful surgeon not to employ blind force, but to adapt his manipulations to the exigen- cies of the case, gently eluding the resistance to his efforts, and making the ligaments, muscles, and bones themselves act as efficient mechanical powers under his intelligent guidance. In the immense majority of cases, at least of recent dislocation, re- duction can be effected without the use of greater force than can be applied simply through the hands of the surgeon and his assistants. The processes by which reduction is effected, are three in number, viz.: manipulation, extension and counter-extension, and direct pressure. 1. Manipulation—This term is used in a technical sense to describe certain movements by which the surgeon aims to effect reduction by utilizing the structural elements of the joint itself. 2. Extension and Counter-extension.—Here the proximal articular surface is fixed by the knee or heel of the operator, by the hands of an assistant, or by means of a folded sheet, padded belt, etc., while the extending force is applied directly by the surgeon's hands, through the medium of bandages or towels, secured with the " clove-hitch knot" (Fig. 136), or bjr still more powerful means, such as the compound pulleys (Fig. 154), Fahnestock's and Gilbert's rope windlass (Fig. 152), Bloxam's tourniquet (Fig. 153), or Jarvis's adjuster. Continuous Elastic Extension, by means of India-rubber bands, has been utilized by Dr. H. Gr. Davis, of Xew York, in the treatment of old disloca- tions, and by this means Dr. Davis claims to have reduced a dislocation of the hip of four- teen years' standing. 3. Direct Pressure.—By this alone, or in combination with the other methods, it ia often possible to simply push the displaced bone into its normal position. When extending bands are used, great care should be taken to prevent their excoriating the soft parts ; for this purpose they should be smoothly and evenly applied, and should be wet—a wet bandage being less apt to slip, and producing less friction, than one that is dry. These bands may be applied directly over the displaced bone, or to the furthest extremity of the affected limb; thus, in luxations of the humerus, they may be fixed above the elbow, or around the wrist. I have already indicated my preference for simple and gentle means of effecting reduction in cases of dislocation, and may add that, in my own practice, I have never had occasion to resort, in recent cases, to anything beyond manipulation, with manual extension and pressure; and though I should be loath Wsay that more powerful means should never be employed in cases of recent luxation, I cannot help thinking that the pulleys, and even extending lacs, are less often required in the treatment of these injuries than is commonly supposed. 18 Clove-hitch. 274 DISLOCATIONS. After-treatment.—This consists in placing the joint at complete rest, by the use of suitable bandages and splints, as in cases of fracture; if there be much inflammation, it maybe necessary to leave the part exposed, for the application of evaporating lotions or other topical remedies. Opium may be used to relieve pain, and the general condition of the patient should be attended to, laxatives, diaphoretics, etc., being admin- istered, if necessaiy. To encourage the restoration of function, passive motion should be employed as soon as the inflammatory symptoms have subsided, usually in the course of the second or third week. Loss of tone in the muscles should be combated by the use of friction, electricity, and the cold douche, and by the cautious administration of strychnia. Compound Dislocation is always a very grave accident; if the wound be small and clean cut, with but little concomitant injury, an attempt may be made to save the part, by effecting reduction, and then treating the case simply as one of wounded joint; but if there be much laceration, and especially if there be a fracture of either or both articular extremities, excision or amputation should be performed, according to the particular joint affected, and the extent of lesion present. As far as any general rule can be given for such cases, it may be said that excision should be practised in the upper extremity and at the hip, and amputation at the knee and ankle. Complicated Luxations.—The complication of dislocation with fracture has already been considered in Chapter XL A graver compli- cation is rupture of the main artery of the limb. This has occurred in connection with dislocations of the shoulder and of the knee; in the former situation, ligation of the subclavian artery (after reduction) would be indicated, and in the latter (as a general rule), amputation. The consequence of non-interference would be the formation of a dif- fused traumatic aneurism, which would prove fatal either by hemorrhage, or by the supervention of gangrene. Extensive extravasation from the rupture of smaller vessels may, however, occur, and may usually be successfully treated by the enforcement of rest and the use of evapo- rating lotions. Paralysis from compression or rupture of nerve trunks is occasionally met with as a complication of luxation, and is to be treated by the use of friction, electricity, etc. Old Dislocations.—The reduction of old dislocations is attended with more difficulty, and likewise with more risk, than the reduction of recent dislocations. The increased difficulty is due to the permanent contraction and structural changes which occur in the muscles, to the abnormal adhesions which form between the displaced bone and the parts with which it is in contact, and to the changes which have already been described as taking place in the articular surfaces themselves. The increased dangers which attend efforts at reduction in these cases are dependent on the same morbid changes: among the accidents which have occurred under these circumstances, may be enumerated laceration of the skin and subcutaneous tissues, rupture of muscles in the neigh- borhood of the dislocated joint, deep-seated inflammation and suppura- tion around the joint, rupture of arteries, veins, or nerves, fracture of the displaced bone or of neighboring bones, and finally avulsion of the entire limb, as happened in a remarkable case reported by Guerin. Hence, while greater force is required in the treatment of these cases than in that of recent luxations, the employment of such force is always PATHOLOGICAL AND CONGENITAL DISLOCATIONS. 275 attended with considerable risk. Even manipulation without extension is not free from danger—for the displaced bone may, in its new position, have acquired adhesions to the main artery or vein, rupture of which, in the act of reduction, would probably cause serious, if not fatal, hemorrhage. It is impossible to fix any definite period beyond which reduction should not be attempted in cases of old dislocation. Dr. Nathan Smith reduced a luxation of the shoulder nearly a year after the accident, and luxations of the hip have been reduced by Dr. Blackman, and by Dr. Smyth, of New Orleans, at periods respectively of six and nine months after the reception of the injury. Even if the attempt at reduction fail, the surgeon's manipulations, if practised with caution and gentleness, may be of service in increasing the mobility of the limb, and thus adding to its usefulness in its abnormal position. Hence, in a case of disloca- tion, even of several months' standing, provided the effort were warranted by the general condition of the patient, I should recommend an attempt at reduction, undertaken, of course, with the extremest caution and delicacy. The patient should be thoroughly relaxed by anaesthesia, and gentle manipulation and moderate extension then employed, so as to stretch or slowly sever any morbid adhesions, and allow the displaced bone to be gradually brought into its proper position; or the elastic extension recommended by Dr. Davis, might be resorted to, and would certainly be worthy of a trial in the event of other means failing. Subcutaneous Division of Muscles, Tendons, and Ligaments was pro- posed by Dieffenbach as a preparatorj' measure in the treatment of old dislocations; and by this plan that surgeon succeeded in effecting reduc- tion, in a case of luxation of the humerus of two years' standing. In the hands of others, however, the operation has not been successful, while it has occasionally given rise to extensive suppuration and sloughing. Treatment of Accidents occurring during Attempts at Reduction of Old Dislocations.—If a fracture occur in the effort to reduce an old disloca- tion, the attempt should be at once discontinued, and the broken bone placed in such a position as to favor union. The rupture of an im- portant muscle, such as the pectoralis major, would likewise oblige the surgeon to desist from further efforts at reduction. Rupture of the main artery, with formation of a traumatic aneurism, is a very grave accident when occurring under these circumstances ; it has been chiefly met with in the case of the axilla^ artery, in connection with dislocation of the humerus. There are two courses open to the surgeon in dealing with such a case, viz., to ligate the subclavian, or to resort to the " old operation," laying open the sac, and tying the vessel above and below the point of rupture. « The latter course would probably be the safest under these circumstances, the case herein differing from one of arterial rupture accompanying recent dislocation (see p. 274); there the effect of the " old operation" would be to convert the injury into a compound luxation of the worst kind, whereas in an old dislocation the connection with the joint would be less direct (from the effects of inflammatory action), and the prospects of the operation proportionably better. Liga- tion of the subclavian has been resorted to four times under these circum- stances, with a successful issue in only one case. Avulsion of the limb, as occurred in Guerin's case, would, of course, require immediate ampu- tation. Pathological and Congenital Dislocations.—In the treatment of these cases there is usually not so much difficulty in effecting, as in 276 DISLOCATIONS. maintaining reduction. Guerin, Brodhurst, and others have success- fully employed subcutaneous tenotomy and myotomy, followed by con- tinued extension, in the treatment of congenital luxations, and the same treatment might be adopted in cases of the pathological variety, pro- vided no active joint disease was present at the time of operation. In cases dependent on muscular paralysis, the difficulty would be in main- taining reduction, and here external support (in the form of carved or moulded splints, elastic bandages, or some of the ingenious devices which are used in the treatment of deformities, and which will be here- after alluded to) might be usefully employed. Special Dislocations. Dislocation of the Lower Jaw is a rare accident, occurring chiefly in early adult age, and rather oftener in women than in men. It is usually double or bilateral, though occasionally one side only is displaced. The most common cause of dislocated jaw is muscular action, though it may also result from a blow on the chin while the mouth is open, or from other forms of violence, such as the forcible introduction of a foreign body into the mouth, or the extraction of teeth. When the mouth is opened, the maxillary condyles ride forwards upon the articular eminences of .the temporal bones, and a very slight degree of force is then necessary to make them slip still further forwards into the zygomatic fossae, thus producing dislocation. The contraction of the external pterygoid muscles, and Fig. 137. perhaps of some fibres of the masseters, is thus quite sufficient to produce luxa- tion when the mouth is widely opened, the tonic contraction of the same muscles, combined with the position of the coronoid processes (which catch against the malar bones), being the principal obstacles to reduction. Symptoms.—The symptoms of a recent dislocation of the jaw are suffi- ciently obvious. There is prominence of the chin, the mouth being widely open, and the jaw almost immovable; there is likewise a marked depression over the seat of the articulation, with a slight fulness anteriorly. In uni- lateral dislocation the jaw usually in- clines to the opposite side—a symp- tom which serves for the diagnosis between luxation and fracture, but which, according to Hey and R. Smith, is not always present. There is gene- rally, but not always, pain; the patient speaks and swallows with difficulty; and there is a constant flow of saliva from the mouth. Prognosis__Even if the dislocated jaw be unreduced, the patient gradually acquires considerable use of the part, and is ultimately able to close the mouth, chew, swallow, and talk—much less inconvenience being felt from the displacement than would at first be supposed. Reduction in a recent case is easily accomplished, and has even been Double dislocation of the inferior maxilla. DISLOCATIONS OF THE FACE AND TRUNK. 277 effected (by Donovan) more than three months after the reception of the injuiy. Sometimes the ligaments are left permanently weakened, motion of the part being painful, and the joint liable to a reproduction of the dislocation. Treatment.—Reduction is effected by disengaging the coronoid pro- cesses from the malar bones, and the condyles from the zygomatic fossae, by pressing the chin upwards, while a fulcrum is placed upon or behind the molar teeth. The surgeon, standing behind the patient, whose head is supported on the operator's chest, may use his thumb (protected by a piece of leather or folded towel) as a fulcrum, pressing the angles of the jaw downwards, while he elevates the chin with his fingers; or pieces of cork or wood may be used as a fulcrum, in which case they should be provided with strings to facilitate their withdrawal. Ne'laton recommends simply pushing the coronoid processes backwards with the thumbs, applied either from within the mouth, or from without. In any case of difficulty, one side might be reduced at a time, taking care while manipulating the second, not to reproduce the luxation of the first. Anaesthesia is not usually required in these cases, though there would be no particular objection to its employment, if it were thought desirable. After reduction, the part should be supported for at least a week or ten days, by means of a four-tailed sling or other suitable bandage. Subluxation of the Jaw.—Under this name, Sir Astley Cooper has described a peculiar condition, met with chiefly in those of relaxed and feeble muscular frame, which is supposed to depend on the condyles slipping in front of the inter-articular cartilages, and thus rendering the jaw temporarily immovable. Whatever be the true nature of this affec- tion, it is undoubtedly accompanied by relaxation of the articular liga- ments, which allow the condjdes to slip about during the act of chewing, thus often producing a clacking sound, which is sometimes audible at a distance. The subluxation, if such it be, may be bilateral, or unilateral only; it is sometimes produced by the act of opening the mouth widely, as in gaping or laughing, but, in other cases, occurs without any apparent exciting cause; it may usually be reduced by the patient himself, by pressing the jaw sideways, or by lifting the chin slightly upwards. Some- times this condition appears to depend on spasm of the muscles of mastication, when it may be made to disappear by friction over the affected part. Tonics should be given, if the general condition of the patient appears to indicate their use, and the recurrence of the displace- ment may be prevented by wearing a sling, held in place by elastic bands. Hyoid Bone.—Cases of dislocation of this bone have been recorded by Dr. Ripley, of South Carolina, and by Dr. Gibb, of London: the treat- ment consists in throwing back the head, depressing the lower jaw, and pushing the luxated bone into position. Ribs, Sternum, and Pelvis.—Dislocations of the Ribs are described as occurring either at their vertebral articulations, or at the junction of their costal cartilages. The symptoms would be much the same as those of fracture in the same localities, except that, of course, crepitus would be wanting. The treatment would be the same as for fracture. Dislo- cations, or rather diastases of the Sternum and Pelvis, were referred to in connection with fractures of those parts. 278 DISLOCATIONS. Clavicle.—The clavicle is more frequently dislocated at the acromial than at the sternal end, the former injury occurring, according to Hamilton, about four times as often as the latter. Dislocation of the Sternal End of the Clavicle usually results from in- direct violence, and is almost always in a forward direction. Dislocation backwards, however, occasionally occurs, and sometimes gives rise to troublesome dyspnoea or dysphagia, from pressure on the trachea or oesophagus, or to cerebral congestion, from pressure on the cervical veins. In a few instances, the displacement has been in an upward direction. The diagnosis of these cases is usually easy, the subcutaneous position of the clavicle rendering the deformity very apparent. Reduction can commonly be effected without much difficulty, by placing the knee against the spine, and drawing the shoulders outwards and backwards, but the displacement is exceedingly apt to be reproduced. The apparatus most generally applicable, consists in a compress over the projecting end of the clavicle (in cases of forward or upward displacement), held in posi- tion by adhesive strips, or by an elastic band passing under the groin and perineum, the shoulder and arm being fixed as in a case of fractured clavicle. In case of backward dislocation, the compress should be omitted, the shoulders being simply drawn backwards by a figure-of-8 bandage, or some similar contrivance. Though the deformity in these cases (especially when the displacement is forwards or upwards) is seldom entirely overcome, yet the utility of the limb does not appear to be materially diminished by the accident. In one or two cases of back- ward dislocation, the pressure effects have been so serious, as to induce the surgeons in attendance to resort to excision of the displaced portions of bone. The Outer End of the Clavicle is usually dislocated in an upward direc- tion, resting upon the margin of the acromion process; the accident results from indirect violence, and the nature of the case is usually apparent, though, if there be much swelling, it may be mistaken for a downward dislocation of the humerus. Occasionally the acromial end of the clavicle is displaced downwards, by direct violence, such as the kick of a horse; and dislocation under the coracoid process has been described, though the cases on record are somewhat apocryphal. Dislocation of the acromial end of the clavicle may be commonly reduced without much difficulty, though, as in the case of luxation of the sternal end, reduction can be rarely maintained. The after-treatment would be the same as for fractured clavicle, with the addi- tion of a firm compress, held in place by adhesive Dislocation of the clavicle strips: although the deformity can be seldom en- on the acromion. tirely removed, the motions of the limb are less interfered with than might be anticipated. Scapula.—Under the name of dislocation of the scapula, systematic writers describe a projection of the inferior angle of this bone, due either to its escape from beneath the edge of the latissimus dorsi muscle, or to great relaxation of the fibres of that muscle or of the serratus magnus: the symptoms consist in the deformity, which is obvious, with some pain and weakness of the corresponding upper extremit}'. The treatment would consist in the application of external support, with the DISLOCATIONS OF THE SHOULDER. 279 administration of tonics, and, perhaps, the endermic use of strychnia, as recommended by Erichsen. Dislocations of the Shoulder.—The head of the humerus may be dislocated downwards, forwards, or backwards. Dislocation Downwards, or into the axilla (Subglenoid Dislocation), is usually clue to direct violence, such as a blow on the upper and outer part of the humerus, though it is occasionally caused by indirect force, such as a fall on the hand or elbow, the arm being abducted at the mo- ment of injuiy. In other cases the dislocation is produced bj' muscular Fig. 139. Dislocation of the humerus downwards, into the axilla. (Subglenoid.) action, the head of the bone being, as it were, pulled out of its socket. In this dislocation, the head of the bone rests below and slightly in front of the glenoid cavhVy of the scapula, being pressed forwards by the ten- don of the triceps muscle; the capsular ligament is widely torn, the long head of the biceps often ruptured or detached, and the supra- and infra-spinatus, subscapularis, coraco-brachialis, and deltoid muscles much stretched and sometimes lacerated, while the axillary vessels and nerves are compressed. The symptoms, in a recent case, are usually obvious: there is, beneath the acromion process, a marked depression, which can commonly be seen as well as felt, the arm is lengthened by nearly an inch, and the head of the humerus can be felt in the axilla, especially when the elbow is lifted away from the body. The arm is kept some- what abducted, and pain is developed by pressing the elbow to the side; the hand cannot be placed on the opposite shoulder when the elbow is in contact with the chest. The diagnosis in a recent case is thus usually very easy, but when swelling and inflammation have occurred, it becomes more difficult, if not occasionally impossible, to be again simplified upon the subsidence of the inflammatory condition. Hence, although by a careful and systematic examination, the true nature of the injury may 280 DISLOCATIONS. almost always be eventually determined, the surgeon should hesitate before criticizing another practitioner, for a mistake which may have been unavoidable under different circumstances. The prognosis should be somewhat guarded: although reduction is usually effected without diffi- culty, yet the arm not unfrequently remains permanently weakened, par- tially anchylosed, or paralyzed from injury to the axillary plexus of nerves. A certain degree of deformity may also remain in spite of reduction, the head of the humerus projecting anteriorly, probably on account of displacement or rupture of the long head of the biceps muscle. The laceration and stretching of the capsular ligament leave the joint predisposed to a recurrence of the dislocation. Dislocation Forwards.—Of this form of dislocation there are two varieties, the Subcoracoid and the Subclavicular: the latter maybe con- sidered as an aggravated condition of the former, which was, indeed, described by Sir Astley Cooper as a partial luxation. As the names imply, the head of the humerus, in these injuries, rests beneath the cora- coid process, or beneath the middle of the clavicle. These luxations, which more often result from indirect than from direct violence, are ac- companied by a great deal of muscular and ligamentous laceration, and are attended with even more pain than the dislocation into the axilla. The symptoms are much the same as those of the downward luxation, Fig. 140. Subcoracoid luxation of the humerus. except that the axis of the arm is even more altered, and that the head of the bone can be felt in a different position. The subcoracoid is more often met with than the subclavicular dislocation, and is said by Mr. Flower, and others, to be the most common form of luxation of the shoulder-joint. Reduction appears to be more difficult in cases of for- ward than of downward dislocation; at least there are, according to DISLOCATIONS OF THE SHOULDER. 281 Hamilton, proportionably more cases recorded of unreduced luxation of the former, than of the latter injury. Dislocation Backwards (Subspinous Luxation) is a rare accident, there being probably not more than twenty or thirty cases of it on record; it is usually caused by indirect violence or by muscular action, and differs in its symptoms from the dislocations already described, in that the elbow is brought forwards, instead of backwards, while the head of the bone can be felt more or less distinctly beneath the spine of the scapula. Reduction has usually been effected without much difficulty in these cases, but in one instance, mentioned by Cooper, it was impossible to maintain the reduction, on account of rupture of the subscapularis muscle. Partial Dislocation.—Under this name has been described an injury, which appears to consist in a rupture or displacement of the long head of the biceps muscle,1 allowing the head of the humerus to project ante- riorly, rather than in any positive luxation of the bone itself. As already mentioned, this condition occasionally remains after the reduc- tion of an ordinary downward or forward dislocation. Treatment of Dislocations of the Shoulder.—The subglenoid and the subcoracoid dislocations may be reduced by the same means, while the subspinous and subclavian varieties require slight modifications in the direction in which the force is applied. Thus, in the luxation beneath the clavicle, the head of the bone should be first drawn.downwards, out- wards, and subsequently backwards, so as to clear the coracoid process, while in the subspinous dislocation extension should be made down- wards, outwards, and subsequently forwards. A great many different Fig. 141. Reduction of dislocated shoulder-joint, by the foot in the axilla. plans have been devised for the reduction of dislocations of the shoulder, but they may all be classified in four divisions, as aiming to effect their object, 1, by extension and counter-extension alone; 2, by leverage alone; 1 This inward displacement of the biceps tendon, which Soden and others have considered traumatic, is believed by Canton to be due to the existence of chronic rheumatic arthritis, which may or may not be the result of injury. 282 DISLOCATIONS. 3, by a combination of these methods; and 4, by manipulation, in its technical sense (see page 273). 1. Extension may be made (1) more or less downwards, as in Cooper's method (Fig. 141),in which counter-extensionIs made by the heel, or rather the foot, in the axilla; as in Skey's method, in which the heel is replaced by an iron knob; or as in Hamilton's plan, in which the scapula is fixed by the ball of the foot, placed against the acromion process; (2) it may be made outwards, as recommended by Malgaigne; or (3) it may be made upwards, as directed by White, of Manchester, Mothe, and others, the Fig. 142. Reduction of dislocated shoulder by White's and Mothe's method. scapula being then fixed by the foot or hand placed above the acromion process. The latter, though painful, is probably the most efficient of any of the methods which professedly act by extension and counter- extension alone. 2. Leverage.—The arm may be simply used as a lever, to pry the head of the bone into its place over a fulcrum placed in the armpit, as in Sir Astley Cooper's method with the knee in the axilla. 3. Extension and leverage combined, are, I think, more effectual than either method separately. The plan which I am in the habit of employ- ing, in these cases, is essentially that which was described by Dupuytren, as a modification of Mothe's method, and which, according to Bromfield, was in common use in his day; it consists in placing the patient, thoroughly etherized, in a supine position, and then, having drawn the arm directly upwards, bringing it down fully extended in a broad sweep over an assistant's fist, placed in the axilla to act as a fulcrum—the scapula being at the same time steadied from above by the assistant's other hand. By this plan I have succeeded in reducing dislocations of the shoulder, which had defied prolonged efforts made in other ways, and, indeed, have as yet never failed in effecting reduction in a recent case. The same principle, that of extension combined with leverage, is involved in the methods recommended by Sir William Fergusson and by Prof. N. R. Smith, of Maryland, in which, however, the force is applied through the medium of extending lacs or bands. The peculiarity of Prof. Smith's method is that counter-extension is made from the oppo- site wrist, so as to insure the fixation of the scapula, by provoking the contraction of the trapezii muscles. 4. Manipulation.—The reduction of dislocations of the humerus by manipulation alone has been practised by various surgeons, among whom may be mentioned La Cour and Sir Philip Crampton, but the DISLOCATIONS OF THE ELBOW. 283 credit of reducing the plan to a system, and of prominently bringing it to the notice of the profession, in this country at least, is, I believe, due to Prof. H. H. Smith, of this city, whose method consists in first converting the luxation (if it be either forwards or backwards) into the ordinary downward or subglenoid variety, and then proceeding as follows: "Ele- vate the elbow and arm as high as possible, and flex the forearm at right angles with the arm, thus relaxing the supra-spinatus muscle. Then using the forearm as a lever, rotate the head of the humerus up- ward and forward, so as to relax the infra-spinatus, carrying the rotation as far as possible, or until resisted by the action of the subscapularis muscle, keeping the forearm for a few seconds in its position with the palm of the hand looking upward; then bring the elbow promptly but steadily down to the side, carrying the elbow towards the body, and keeping the forearm so that the palm of the hand yet looks to the sur- geon. Then quickly but gently rotate the head of the humerus upward and outward by carrying the palm of the hand downward and across the patient's body, and the bone will usually be replaced."1 After reduction, the arm should be fastened to the side and supported with a sling, for a week or ten days, so as to allow time for repair of the lacerated ligaments. Dislocations of the Elbow.—Both bones of the forearm may be dislocated at the elbow-joint, or either separately. The Head of the Radius alone may be displaced for- wards, outwards, or backwards, the Fig, 143. forward dislocation being much the most frequent, and the cause of the injuiy being usually a fall on the hand, though the luxation may occa- sionally result from muscular action. The head of the bone can ordinarily be felt in its abnormal position, and the diagnosis can thus, unless there be much swelling, be readily made. The forearm is kept in a semi-flexed position, and either pronated, or mid- way between pronation and supina- tion; any motion of the part is at- tended with great pain. Reduction is to be effected by making extension and counter-extension in the direc- tion in which the limb is found, the displaced bone being at the same time firmly pressed into its proper position; the arm should subse- quentby be fixed on an angular splint, with a compress over the head of the radius. It is alwa3rs difficult to maintain reduction in these cases, and reduction itself is occasionally impossible; fortunately the useful- ness of the limb does not appear to , , . ,, • -i i_ i.i • i Dislocation of head of radius forwards; be materially impaired by the persist- temal appearaiice of limb. ence of the displacement. 1 Packard's Minor Surgery, p. 204. 284 DISLOCATIONS. The Ulna alone may be displaced backwards, as the result of a fall on the hand, the olecranon then projecting behind the condyles of the humerus, while the head of the radius can be felt in its proper position. The elbow in such a case would be flexed at a right angle, and the fore- arm twisted inwards and pronated. Reduction may be effected by Sir Astley Cooper's method of flexing the elbow over the knee; by extension and counter-extension, combined with direct pressure upon the olecranon; or (as recently recommended by Dr. Waterman, of Boston) by extend- ing the forearm on the arm beyond a straight line, thus using the ulna as a lever of the second order (the olecranon being the fulcrum), to bring the coronoid process over the condyles, into its proper place. Both Bones of the Forearm may be dislocated at the elbow, backwards, to either side, or forwards. The dislocation backwards, which is the Fig. 144. Dislocation of both bones of the forearm backwards. most common, is usually caused by indirect violence, though occasion- ally by a direct blow, or by muscular action. Xot only are the bones displaced backwards, but they are drawn upwards by the powerful action of the triceps muscle. The diagnosis, if swelling have not occurred, can usually be made without difficulty; the arm is held in a slightly flexed position (rarely at a right angle), and the slightest at- tempt at motion causes great pain; the olecranon and head of the radius can be felt projecting backwards, while the condyles of the humerus form a hard and broad prominence on the front of the arm. The relative position of the olecranon and condyles is markedly altered, this being an important diagnostic mark between dislocation and frac- ture. Reduction in a recent case is usually easy, thougbTnstances are on record in which failure has attended the efforts of the most skilful surgeons; the prognosis is decidedly unfavorable as regards old dis- locations, though reduction has been several times effected at as late a period as six months after .the reception of the injuiy. The usual method of treatment is that recommended by Sir Astley DISLOCATIONS AT THE TNfRIST. 285 Reduction with the knee in the bend of the elbow. Cooper, which consists in forcibly but Fig. 145. slowly bending the arm over the knee, which is placed on the inner side of the elbow, so as to press on the radius and ulna, separating them from the humerus, and thus freeing the coronoid process from its abnormal position (Fig. 145). Another plan is to forcibly extend the arm so as to relax the triceps, making counter- extension against the scapula (as ad- vised by Liston and Miller); or the luxation may be reduced by simple ex- tension (Skey), or b}r extension com- bined with direct pressure on the olec- ranon, according to the plan of Pirrie. In a child, or in a person of feeble muscular development, reduction can usually be effected without the aid of anaesthesia; prolonged efforts at re- duction are, however, so painful, that in any case of difficulty an anaesthetic should be employed. Hamilton re- commends, as a test for reduction, to flex the elbow to a right angle; if this can be done without much pain, it proves that reduction is complete. Lateral dislocation of the radius and ulna at the elbow is rarely com- plete, but in the majority of cases is partial, and in an outward direc- tion. The cause is usually direct violence. The deformity in these cases is so marked and peculiar as to render the nature of the injury unmis- takable; reduction may be effected by making moderate extension, with direct pressure on the displaced bones, and counter-pressure on the lower end of the humerus. Lateral dislocation is sometimes found coexisting with the ordinary backward displacement; in dealing with such an injuiy, the lateral luxation should be first reduced, and the case then treated as one of simple backward dislocation. Luxation forwards of both bones of the forearm, without fracture of the olecranon, is a very rare accident, there being not more than six or seven well-authenticated cases on record. The injuiy appears usually to have resulted from direct violence, and the most striking symptom is elongation of the forearm, which is in a state of supination, the elbow being fixed at a right angle. Reduction maybe accomplished by making forced flexion, together with extension and counter-extension, the muscles being relaxed by the use of an anaesthetic. In a case recorded by my colleague, Dr. Forbes, reduction was effected by simply flexing the fore- arm, and fhen pressing it downwards and backwards. If the luxation were incomplete, the forearm making an obtuse angle only with the arm, reduction might be accomplished by making forcible extension. Dislocations at the Wrist.—The Lower End of the Ulna may be dislocated upon the radius, either forwards or backwards. These acci- dents (which are rare) are usually caused by muscular action, the dislo- cation forwards being due to violent supination, and that in a backward direction to violent pronation. Reduction is easily effected by fixing 286 DISLOCATIONS. the radius, and simply pushing the ulna back into place, the limb being then placed between anterior and posterior splints. In connection with fracture of the lower end of the radius, the backward dislocation of the ulna is not uncommon. The ligaments sometimes remain permanently stretched after the accident, so as to allow a certain amount of mobility of the ulna, and I have known such a condition to be mistaken for un- united fracture of this bone. The Carpus may be dislocated upon the bones of the forearm, either backwards or forwards. These injuries are, however, rarely met with, and in every case that has been submitted to the test of dissection, the luxation has been found complicated with fracture. The usual cause of either form of dislocation is a fall on the palm, though in a case of back- ward displacement recorded b}^ Hamilton, the injury resulted from a fall on the back of the hand, the wrist being strongly flexed. The diagnosis is made by observing the abruptness of the angle made by the displaced bones, their relation to the styloid processes, and (if the case is not complicated with fracture) the absence of crepitus. Reduction is easily effected by extension and pressure, and there is subsequently no ten- dency to reproduction of the displacement. Individual Bones of the Carpus are occasionally luxated in a backward direction, those bones which have been found thus displaced being the os magnum, semilunare and pisiform, to which some writers add the cuneiform and unciform. The treatment would consist in effecting re- duction by extension and pressure, supporting the part afterwards with splints and compresses. Chisolm reports a case of forward luxation of the semilunare, in which excision of the displaced bone was required. Hands.—The Metacarpal Bones, especially those of the thumb, index and middle finger, may be dislocated upon the carpus, the two latter bones backwards, and the metacarpal of the thumb either backwards or forwards. Reduction is effected by extension and pressure, the hand being afterwards secured to a straight splint with compresses. The Fingers may be dislocated at the metacarpophalangeal, or, more rarely, at the inter-phalangeal joints. The proximal phalanx of the thumb is not unfrequently dislocated backwards, reduction being some- times very difficult, owing, probably, to the head of the metacarpal bone being caught, either between the lateral ligaments, or between the heads of the flexor brevis muscle. In the treatment of these luxations, extension may be made with the ordinary clove-hitch, or with Dr. Levis's ingenious apparatus, or with the "Indian puzzle," as recommended by Prof. Hamil- Fig. 146. Levis's instrument applied to the first finger. ton and others. A better plan, perhaps, is that practised by Prof. Crosby, of >.'ew Haven, which consists, according to Gross, " in pushing the phalanx back until it stands perpendicularly on the metacarpal bone, when, by strong pressure against its base, from behind forwards, it is readily carried by flexion into its natural position." In extreme cases DISLOCATIONS OF THE HIP. 287 subcutaneous division of the resisting ligaments or muscles may pos- sibly be required. Forward luxation of the thumb is more rarely met with than the injury last described, and is to be reduced by forcibly flexing the thumb into the palm of the hand. Dislocations of the second phalanx of the thumb, or of the second or third phalanges of the fingers, may be reduced by simple extension and pressure, made with the surgeon's hands, or, if more force be required, with the apparatus of Dr. Levis. Dislocations of the Hip.—The subject of dislocation of the hip has been recently ably investigated by Prof. Bigelow, of Boston, of whose excellent monograph on the subject I shall not hesitate Fig. 147. to make free use in the following pages. To understand the pa- thology of these dislocations, and the mechanism of their re- duction, it is necessary to turn for a few minutes to consider the anatomy of the joint, and espe- cially of that portion of the cap- sule which is known as the ilio- femoral ligament, or ligament of Bertin, and for which Bigelow proposes the name of " Y liga- ment." This ligament "is more or less adherent to the acetabu- lar prominence and to the neck of the femur; but it will be found, upon examination, to take its origin from the anterior inferior spinous process of the ilium, passing downward to the front of the femur, to be inserted fan-shaped into nearly the whole of the oblique ' spiral' line which connects the two trochanters in front,—being about half an inch wide at its upper or iliac origin, and but little less than two inches and a half wide at its fan-like femoral insertion. Here it is bifurcated, having two prin- cipal fasciculi, one being inserted into the upper extremity of the anterior inter-trochanteric line, and the other into the lower part of the same line, about half an inch in front of the small trochanter." Both of these divergent branches remain unruptured in the ordinary dislocations of the hip, and their attach- ments must be borne in mind in attempting reduction of the various forms of displacement. The head of the femur may be dislocated in almost any direction; but there are three forms of luxation which occur so much oftener than the others as to be usually classed as regular dislocations, the other varieties being called irregular or anomalous. The regular dislocations are— 1, backwards; 2, downwards; and 3, upwards. The Y ligament; the inner fasciculus is known as the ilio-femoral ligament, or ligament of Bertia. (From Bigelow.) 288 DISLOCATIONS. 1. The Dislocation Backwards, or Ilio-sciatic Luxation, presents two principal varieties, viz., upwards and backivards or on the dorsum ilii, and backivards only, the dislocation into the ischiatic notch of Sir Astley Cooper, or, which is a better name, dorsal below the tendon (of the obtu- rator interims), according to Prof. Bigelow. These two forms of luxation, taken together, probably embrace more than three-fourths of the whole number of cases, Prof. Hamilton having found that of 104 cases, 55 were on the dorsum ilii, and 28 into the ischiatic notch. These injuries usually result from indirect violence: thus, the dislocation on the dorsum may be caused by any force which produces great adduction, or adduction with inversion, the head of the bone being driven at the same time upwards and backwards. A fall on the outside of the knee, or on the foot, while the limb is adducted, or a severe blow on the pelvis, while the body is bent forwards, may each in turn be a cause of this dislocation. The etiology of the ischiatic form of luxation is much the same, except that it is more apt to occur when the thigh is flexed at a right angle upon the body, the force then driv- ing the head of the bone more directly backwards, than backwards and upwards. The symptoms of these forms of dislocation are usually well marked. There is shortening of the affected limb, varying from about half an inch in the dislocation below the tendon, to one, two, or even three inches in that on the dorsum ilii. Inversion is present in both varie- ties, though most marked in the ordinary dorsal luxation. The hip itself is altered in shape, the trochanter being unduly prominent, and thrown forwards, while the head of the femur can often be felt rotating in its abnormal position. The axis of the limb is distorted, the thigh of the affected side crossing the other at its lower third in the dorsal dislocation, and just above the knee in the ischiatic variety -,1 in the former case the foot of the affected limb rests on the instep of the sound side; in the latter, upon the ball of the great toe. The diagnosis has to be made from sprain and from fracture. From sprain the case can be dis- tinguished by careful examination and measure- ment, the patient being etherized so as to obviate spasmodic muscular resistance. If the limb can be readily everted, the case is not one of luxation. From ordinary non-impacted fracture, a dislocation can be distinguished by the fact that in the former there is mobility, crepitus, and eversion; in the latter, immobility, no crepitus, and inversion. From the rare cases of impacted fracture with inversion, the diagnosis is more difficult, but may be made by observing that in such cases the trochanter is flattened, and the head of the bone still rotates in its socket, while in dislocation the trochanter is unduly prominent, and the head of the bone can be felt beneath the gluteal muscles. Backward dislocation of hip ; external appearances. 1 According to Bigelow, in the ischiatic variety (dorsal below the tendon), the axis of the luxated limb is more changed than in the ordinary dorsal variety, cross- ing the sound limb sometimes at a point as high as the middle of the thigh. The fact appears to be that-the distortion varies according to the position of the head of the bone at the moment of examination, these varieties of dislocation being readily interchangeable, and the exact position of the bone differing in different cases. DISLOCATIONS OF THE HIP. 289 Reduction of Backward Dislocations.—The capsular ligament is usu- ally widely lacerated in these injuries, except at its anterior part, where it is reinforced by what has been already described as the Y ligament. The ligamentum teres also, is usually,though not necessarily, torn in these dislocations. The attachments of the Y ligament are such that extension in the line of the axis of the body, can only effect reduction by violent stretching or rupture of that ligament; hence, the first step in any rational method of treatment, consists in flexing the thigh upon the pelvis, so as to relax the iliofemoral or Y ligament. The acknowledged difficulty which attends reduction of the ischiatic variety of this luxa- tion is due (as shown by Bigelow), not to the head of the bone being lodged in the sciatic notch, but to its being fixed behind and below the tendon of the obturator internus muscle, which separates it from the acetabulum, and which renders reduction, by extension in the line of the body, almost impossible. By flexing the thigh on the pelvis, the head of Fig. 149. Backward dislocation ; reduction by rotation ; the limb has been flexed and abducted, and it remains! only to evert it, and render the outer branch of the Y ligament tense by rotation. (From Bigelow.) the femur is unlocked from the grasp of the obturator tendon, and the luxation is then as easily reducible as one on the dorsum ilii. The Y ligament being relaxed by flexing the thigh on the pelvis, the dislocation may be occasionally reduced by simply lifting or pushing the head of the thigh-bone into the socket, the rent in the capsular ligament being if necessaiy enlarged by circumducting the flexed thigh across the abdo- men, and thus making the head of the bone sweep across the posterior aspect of the capsule. It will usually be better, however, to employ manipulation (see page 273), which, though practised empirically in these cases, for a great many years previously, was first reduced to a system by Drs. Nathan Smith, of New Haven, and Reid, of Rochester. In the form of dislocation now under consideration, the manipulation necessary 19 ..y"" 290 DISLOCATIONS. for reduction consists (1) in flexing the leg upon the thigh (to gain leverage), and the thigh upon the pelvis (to relax the Y ligament, and, in the case of an ischiatic luxation, to disengage the head of the femur from the obturator tendon); (2) in abducting and at the same time rota- ting outwards the thigh in a broad sweep across the abdomen; and (3) in finally bringing down the limb into its natural position. The process in fact embraces the three motions, of flexion, outward circumduction, and out- ward rotation. The mechanism of this mode of reduction is that, by the abduction and rotation, the outer branch of the Y ligament is made to wind around the neck of the femur, thus constituting a sliding fulcrum, by means of which the head of the bone is lifted into the acetabulum. In executing this manoeuvre, care must be taken not to flex the thigh too much, or the Y ligament will be unduly relaxed, and the effort at reduction will fail; and not to abduct the limb too widely, or the poste- rior part of the capsule will be unnecessarily torn, and the head of the bone may slip below the socket on to the thyroid foramen; the angle of extreme flexion should be from 50° to 60°, and that of extreme ab- duction from 130° to 140°. The first mistake (that of undue flexion) is readily remedied, by repeating the manoeuvre with the limb somewhat more extended; to remedy the second error, it is necessary, while making abduction, to lift the limb, when the head of the bone will usually slip readily into its socket. Fig. 150. Fig. 151. External appearances of down- Reduction of downward dislocation, by rotation and inward cir- ward dislocation. cumduction. (From Bigelow.) 2. Dislocation of the Head of the Femur Downwards, or downwards and forwards into the Thyroid Foramen, is produced by the application of force while the thigh is in a position of abduction, or by a blow on the back of the pelvis while the body is bent and the legs widely apart. The capsular ligament is extensively torn, particularly at its inner and DISLOCATIONS OF THE HIP. 291 back parts, the round ligament being also ruptured, and the head of the bone lodging usually on the external obturator muscle, over the thyroid foramen. The symptoms of this dislocation are very apparent: there is an elongation of about two inches, with abduction; the leg is advanced, and the foot straight or slightly everted; the trochanter is depressed, and, in a thin person, the head of the bone may be felt in its abnormal situation. Reduction is effected by a process exactly the reverse of that recom- mended for the backward dislocations ; the leg and thigh being flexed as before, the limb is brought up in a position of abduction, then adducted and rotated inwards1 in a broad sweep across the abdomen (Fig. 151), the inner branch of the Y ligament being in this case the sliding fulcrum by which the bone is lifted into its socket. Care must be taken, in this manoeuvre, to avoid excessive flexion, and excessive adduction, which would throw the head of the bone past the acetabulum, on to the dor- sum ilii. The manipulation majr be sometimes assisted by drawing the upper part of the thigh outwards with a towel. Fig. 152. Application of the rope windlass, for backward dislocation. 3. Dislocation Upwards, or upwards and forwards on the Pubes, usually results from indirect violence, such as falling on the foot while the leg is stretched backwards, or stepping into a hole while walking, the foot being arrested while the body goes forwards; it may also result from a blow or fall on the pelvis. In this luxation, the head of the femur rests on or above the pubes, being closely embraced by the inner branch of the Y ligament. The symptoms are shortening, abduction, great eversion, slight flexion (or, more rarely, extension), with great depression of the trochanter, and prominence of the head of the bone, which may be felt over the body of the pubes, and outside of the femoral vessels. The diagnosis from fracture is made by observing the absence of crepitus, the immobility, the impossibility or at least great difficulty of inverting the limb, and the presence of the head of the bone in its new position. 1 Dr. Markoe, in one case, succeeded in reducing a thyroid luxation by outward rotation (using, therefore, the outer branch of the Y ligament as a fulcrum), in- ward rotation having previously thrown the head of the bone on to the sciatic notch, from which it was immediately returned to its primitive position; as re- marked by Prof. Bigelow, inward rotation with less extreme flexion would, proba- bly, have succeeded in the first instance. 292 DISLOCATIONS. Reduction may be accomplished, according to Prof. Bigelow, " by much the same method as in the thyroid dislocation, except that in the pubic luxation the flexed limb should be carried across the sound thigh at a higher point. First, semi-flex the thigh, to relax the Y ligament, at the same time drawing the head of the bone down from the pubes. Then semi-abduct and rotate inward, to disengage the bone completely. Lastly, while rotating inward and still drawing on the thigh, carry the knee inward and downward to its place by the side of its fellow. As in the thyroid luxation, this manoeuvre guides the head of the bone to its socket by a rotation which winds up and shortens the ligament, enabling the operator, by depressing the knee, to pry the head of the bone into its place." As in the case of the thyroid luxation, this manipulation may be assisted by drawing the flexed groin directly outwards with a towel. I can testify, from my own experience, to the facility with which recent dislocations may be reduced by the methods above described, and believe, with Prof. Bigelow, that the period is not far distant " when longitudinal extension by pulleys to reduce a recent hip luxation will be unheard of." As, therefore, I cannot recommend the use of pulleys in these cases, I forbear to describe their application. Illustrations are, however, given to show the positions in which the pulleys may be applied, and the directions in which extension is to be made, in the various forms of hip luxation, according to the Fig. 153. Bloxam's dislocation tourniquet, applied for down- ward dislocation. teachings of Sir Astley Cooper, Erichsen, and other standard authorities (Figs. 152, 153,154). Besides the three regular forms of dislocation which have been above described, there are various anomalous forms, as (1) directly upwards (usually con- secutive upon the pubic dislo- cation), (2) directly downwards, between the sciatic notch and the thyroid foramen, (3) down- wards and backwards on to the body of the ischium, (4) down- wards and backwards into the lesser sciatic notch, and (5) downwards, inwards, and for- wards into the perineum. These various forms of downward dis- location may be either primitive or consecutive upon the ordi- nary thyroid variety. In these irregular forms of dislocation, there is usually great laceration of the capsular ligament, with, in some cases, rupture of the external branch, or even both branches, of the Y ligament. Reduction may usually be ef- fected simply by flexing the thigh, and then lifting and DISLOCATIONS OF THE HIP. 293 pushing the displaced bone in the direction of its socket; or the luxation may be converted into one of the " regular" varieties, when manipula- tion can be applied according to the methods already described. In cases of old dislocation of the hip, greater force may be sometimes required than can be applied by the surgeon's unaided hands, and under Mode of reducing upward dislocation with pulleys. such circumstances the apparatus recommended by Prof. Bigelow for effecting angular extension might be usefully employed. The difficulty, however, in these cases, will be often found to be not/so much in effecting, as in maintaining reduction, owing to the structural changes which occur in the acetabulum and head of the femur. To meet this difficulty, Prof. Bigelow suggests that the " limb should be fixed in the Fig. 155. position in which reduc- tion was effected, until the socket has become again excavated by absorption; the same plan should be adopted in cases of recent luxation, in which there is any tendency to reproduc- tion of the deformity after reduction. The complication of dis- location of the hip with fracture of the thigh, should be met by apply- ing firm splints, or Bige- low's "angular extension" apparatus, before attempt- ing manipulation. Should fracture occur during the effort to reduce an old dis- location, the attempts at reduction should be at once abandoned, but ad- vantage might be taken of the accident to obtain Union in SUCh a position Angular extension, in reduction of old dislocations of the hip as would diminish the de- (From Bigelow.) formity of the limb. 294: DISLOCATIONS. After reduction of a hip dislocation, it is usually sufficient to tie the knees together with a few turns of a bandage, keeping the patient in bed for a week or ten days. An unreduced dislocation, especially of the ischiatic variety, allows, after a time, much more use of the limb than would at first be supposed possible. Anaesthesia is almost always required for the reduction of hip disloca- tions in adults, though in cases of children, or of very feeble persons, it may be often dispensed with. Dislocations of the Patella.—The patella may be dislocated out- wards, inwards, or upwards, or it may be rotated upon its own axis, constituting the vertical luxation of Malgaigne. These accidents may result from muscular action, or from direct violence. The Outirard Dislocation is the most common, and ma}' be either partial or complete; it may be recognized by the undue prominence of the inner condyle, and by the patella being felt in its new position; the limb is usually slightly flexed. Reduction is effected by exteuding the leg on the thigh, and flexing the latter on the pelvis, so as to relax the quadriceps femoris muscle, when the patella can be easily pushed back into its proper place; Hamilton directs that the patient should be in a sitting posture, the surgeon sitting or standing in front of him, and raising the affected leg upon his own shoulder. If this manoeuvre fail, reduction may be accom- plished by alternately flexing and extending the knee, while lateral pressure is simultaneously made upon the patella. Dislocation Inwards is very seldom met with; its symptoms and treatment are (mutatis mutandis) the same as those of the outward variety. Dislocation of the Patella on its Axis is produced by the same causes as lateral dislocation, of which, indeed, it may be looked upon as an aggravated form; either edge of the patella may project anteriorly, or the bone may be entirely reversed, so that its posterior surface is in front. The leg is usually fully extended, more rarely slightly flexed: the prominence of the patella is so marked, as to render any mistake in diagnosis almost impossible. Reduction may commonly be effected as in cases of lateral dislocation, by direct pressure, aided by alternate flexion and extension. It has been proposed to divide the ligamentum patella? and tendon of the quadriceps extensor muscle, with a view of facilitating reduction in these cases, but the operation does not appear to have been productive of any marked benefit, while in one case it caused fatal suppuration. Dislocation Upwards can only result from rupture of the ligamentum patellae; the treatment would be the same as for fracture of the patella itself. Dislocations of the Knee.—The Head of the Tibia may be dis- located to either side, forwards, backwards, or in an intermediate direction, as backwards and outwards, etc. These aceidents may re- sult from direct or from indirect violence, such as twisting the thigh upon the leg, by stepping into a hole while walking. The lateral dis- locations are always incomplete, while the antero-posterior luxations may be either complete or partial. The symptoms of these injuries are very obvious; the complete luxations are usually accompanied with shortening. Reduction may be effected by forced flexion of the knee, with direct pressure, aided by rocking movements, to which, if there be shortening, extension and counter-extension may be usefully added. The antero-posterior luxations, if complete, are apt to be attended with serious injury to the popliteal vessels and nerves, a complication which DISLOCATIONS OF THE ANKLE. 295 may require amputation. After reduction, the limb should be placed at rest in a long fracture-box, or on a suitable splint, until the subsidence of all inflammation of the joint, the part being afterwards protected from sudden motion by the use of an elastic knee-cap or firm bandage. Compound Dislocation of the Knee is usually a case for amputation. ° Dislocation of the Semilunar Cartilages, or Internal Derangement of the Knee-joint (Subluxation of the Knee), consists, according to Erichsen, in the semilunar cartilages slipping either forwards or backwards from beneath the condyles of the femur, so that the latter come in direct contact with the articular surface of the tibia, pinching the folds of synovial membrane; most authorities, however, teach that in this acci- dent the cartilages themselves become wedged between the articulating surfaces, in such a way as to impede the motions of the joint, and give rise to the sickening pain which characterizes the injuiy. The accident is usually caused by twisting the knee, by tripping over a stone or other obstacle in walking, though it has occurred from simply turning in bed. The symptoms are inability to walk, or even to extend the limb, intense pain, and rapid swelling of the joint. Reduction is effected by alternately flexing and extending the knee, combining these movements with slight twisting and rocking of the joint. As the process is painful, ether may appropriately be used in these cases. After reduction, the patient should wear an elastic knee-cap, to prevent recurrence of the displacement. Dislocation of the Head of the Fibula is a very unusual accident, except as a complication of more serious injuries of the knee. The displacement may be either forwards or backwards, and the subcutaneous position of the bone renders the diagnosis easy. Reduction may be effected by extension and direct pressure, and a compress and a bandage should be subsequently applied to keep the bone in place. Dislocations of the Ankle.—These injuries are described by Sir Astley Cooper, Malgaigne, and Hamilton, as dislocations of the lower end of the tibia: I think, however, that it is better to speak of them, with Boyer and others, as dislocations of the foot upon the bones of the leg. The displacement occurs between the upper articulating surface of the astragalus, and those of the tibia and fibula, and the foot may be dislocated forwards, backwards, to either side, or, as in a case men- tioned by Druitt, directly upwards between the bones of the leg. The lateral luxations are usually attended with fracture of one or both malleoli, the outward dislocation being sometimes additionally compli- cated by fracture of the outer edge of the tibia into the joint, a circum- stance which, as pointed out by Hamilton, may render reduction impos- sible. The backward dislocation is usually accompanied with fracture of the fibula, and sometimes of the tibia as well. The forward disloca- tion is very rare, usually attended with fracture, and, according to R. W. Smith, always incomplete. These injuries may result from either direct or indirect violence, the particular form of the displacement depending upon the position of the foot at the moment at which the accident occurs. The antero-posterior luxations can be easily recognized by the characteristic deformity, the foot being lengthened in the forward, and shortened in the backward dislocation. True lateral luxation is a less frequent accident than is generally supposed, the majority of the cases which are called dislocation, being really instances merely of rotation of the astragalus, without actual separation of that bone from the articu- lating surfaces of the tibia and fibula. Reduction may be commonly effected in any of these varieties of luxation, by simple traction (the 296 DISLOCATIONS. leg being flexed on the thigh), combined with direct pressure, and flexion and rotation of the ankle in various directions, according to the nature of the displacement. After reduction, the limb should be placed in a fracture-box with suitable compresses, or on a Dupuytren's splint, until recovery is complete. Compound Dislocation of the Ankle is a very serious accident, and will usually require amputation, particularly when complicated with fracture. In some cases, if the condition of the patient and the state of the soft parts should permit the experiment, an attempt might be made to save the limb by sawing off the projecting ends of the tibia and fibula. Dislocations of the Tarsus.—The Astragalus may be dislocated at once from the bones of the leg and from the other tarsal bones, and may be thrust backwards (when it projects beneath the tendo Achillis), forwards and outwards, or forwards and inwards. These injuries result from falls upon the fooflf the particular form of the displacement depending upon the position of the foot as regards flexion, abduction, etc., at the moment at which the accident occurs. In the forward dis- locations the leg is shortened, the astragalus projects in front of one or the other malleolus, and the foot is somewhat extended and twisted to the opposite side. In the backward luxation, which occurs least often, the foot is in a state of extreme flexion, and the heel is elongated while the instep is shortened. Reduction should be attempted by making firm traction (the leg being flexed upon the thigh), and rotating and twisting the foot in the opposite direction to that in which it is found, while firm pressure is made upon the projecting astragalus. Subcutaneous division of the tendo Achillis has been found a useful adjuvant in cases of forward displacement, and in a case of great difficulty Desault's plan of dividing the attachments of the astragalus itself might be tried—or the surgeon might resort at once to excision. I should, however, prefer, in a case of irreducible, simple dislocation, to temporize, as advised by Cooper and Broca, reserving excision of the bone as a secondary operation, should sloughing or necrosis render it necessary. Backward dislocation of the astragalus is usually irreducible, the patient notwithstanding recovering with a very useful foot. In a case of compound dislocation, it would be proper (unless reduction were readily accomplished) to excise the astragalus at once, or to amputate, if the concomitant injuries were so severe as to forbid excision. Other Dislocations of Tarsal Bones are described, as of the calcaneum and scaphoid upon the astragalus, which remains in place below the arch of the malleoli; of the calcaneum upon the astragalus and cuboid, ' or upon the astragalus alone; of the scaphoid and cuboid upon the calcis and astragalus; or of the cuboid,scaphoid, or cuneiform bones, separately or together. Reduction in these cases may be usually accomplished by pressure and traction in different directions, according to the nature of the par- ticular displacement. Even if reduction cannot be effected, the limb will often be serviceable in spite of the deformity. Dislocations of the Metatarsus and Toes are of rare occur- rence except as the result of great violence, when amputation will often be required. In cases of simple dislocation, reduction may usually be effected simply by traction and direct pressure, the parts being after- wards fixed with suitable splints and bandages. EFFECTS OF HEAT AND COLD. 297 CHAPTEE XIY. EFFECTS OF HEAT AND COLD. Burns and Scalds. A Burn is usually defined as the disorganizing or destructive effect of the application of dry heat or flame, a Scald being considered as the corresponding effect of the application of a hot liquid, and it is often said that these two forms of injury may be distinguished by the fact that a burn singes the cutaneous hairs, which are, on the other hand, uninjured by a scald. It is evident, however, that though this dis- tinction answers well enough for the burns and scalds met with in every- day life, it is not strictly correct; for, in many cases, the two injuries are combined (boiling oil may be at the same time burning oil), and some of the most destructive burns are produced by hot liquids—such as molten lead or iron. Again, the injuries produced by caustic acids or alkalies are essentially burns, whether the agent be applied in a liquid or solid form. Effects of Burns and Scalds.—The effects of these injuries are both local and constitutional. The Local Effects vary according to the temperature of the body which inflicts the injury, and the length of time during which its application is continued. Thus a momentary contact with flame will produce a less degree of disorganization than prolonged contact with a substance the temperature of which may be much lower. Dupuytren divided burns into six classes or degrees, according to the extent of injury inflicted; and this classification, which is in some respects convenient, is still adopted by most surgeons. The first class embraces cases of very superficial burn, marked by redness and followed by desquamation of the cuticle. In the second class the injury extends more deeply, and is followed by the formation of numerous vesicles and bullae. In the third class the whole depth of the skin is involved, and is thrown off in the form of thin superficial sloughs. In the fourth class the destructive effect reaches the subcutaneous areolar tissue, the sloughs are firmer and deeper, and, on separating, leave granulating ulcers. In the fifth class the deeper-seated structures, muscles, tendons, etc., are affected; while in the sixth class of burns, all the constituents of the part, including the bones, are involved in destruction. The various changes which take place in a part that is burnt, are those that have already been fully described in the chapter on Inflammation, and the processes of granulation, cicatrization, etc., by which repair is accom- plished in these cases, are the same as in solutions of continuity from any other cause. The Constitutional Effects of burns vary according to the degree of the burn and the extent of surface involved. In almost all cases, the constitutional symptoms may be divided into three stages, viz., that of depression, that of reaction, and that of exhaustion. The stage of de- 298 EFFECTS OF HEAT AND COLD. pression is particularly well marked in cases of extensive burn, even though the depth of the injuiy be not very great. Many patients die in this stage, either from shock alone, or from this in combination with other causes, such as intense pain, or suppression of the physiologi- cal action of the skin. Thus, of ten patients received into the Pennsyl- vania Hospital from a fire at the Continental Theatre, in September, 1861, six died within twenty-four hours, some without any reaction, and others having reacted very imperfectly. The second stage is marked by the occurrence of inflammatory fever, accompanied often by violent traumatic delirium; the duration of this stage is usually from the second to the tenth or twelfth day, and during this period death majr occur from internal congestion, or from inflammation of the brain, air-pas- sages, or alimentary canal; the locality of the burn influences the seat of these secondary complications, a burn of the chest being followed by bronchitis or pneumonia, while one of the abdomen is more apt to cause inflammation of the bowels or peritoneum. A peculiar and very grave complication of this stage, which has been particularly insisted on by Long and Curling, is perforating ulcer of the duodenum. This, accord- ing to Curling, results from the irritation due to the vicarious action of Brunner's glands in attempting to replace the deficient action of the skin, but, according to Feltz and Wertheim, is, in common with the other visceral complications of burns, directly traceable to the occur- rence of capillary embolism. The duodenal ulcer usually proves fatal either from hemorrhage, or by perforating the abdominal cavity, and thus giving rise to peritonitis. In the third stage of burn, the patient is in the condition of one suffering from profuse suppuration and wide- spread ulceration, without regard to the particular cause of the injury; death ma}- occur from simple exhaustion, from secondary visceral degen- eration (probably of the so-called amyloid or albuminoid variety), or from pyaemia. Symptoms.—The Local Symptoms of burns are those of inflamma- tion of the tissue affected, without regard to the cause. The intensity of the inflammatory process varies in different cases, and in different parts of the body in the same case, so that we generally find the first four, and sometimes all of Dupuytren's degrees of burn, in the same individual. The Constitutional Symptoms vary according to the stage, as well as the extent and severity of the burn. The most prominent symp- torn in the first stage is a feeling of intense cold, resulting, probably, in part, from direct injury to the cutaneous nerves, and, partly, from the accumulation of blood in the central organs of the body. The pa- tient shivers, and complains of chilliness, the temperature of the surface is depressed, the features pinched, and the whole body in a state of partial collapse. With the development of the second stage, thirst becomes the most distressing symptom; there is an insatiable craving for liquids, which are rejected by vomiting as soon as they are swal- lowed. The patient is now very restless and feverish, and tosses off the bedclothes, which, during the first stage, could not be too closely ap- plied. In the third stage, the symptoms are those of exhaustion and debility; the patient does not suffer much pain, except from the neces- sary exposure of dressing, unless the burns are so placed as to be sub- jected to pressure. Troublesome cough and profuse diarrhoea are often the most annoying complications in this stage of the injury. Prognosis.—The prognosis, in any case of burn, depends chiefly TREATMENT OF BURNS. 299 upon the extent of surface involved: as a rule, it may be said that if one-half of the cutaneous surface be affected, no matter how slightly, the case will probably terminate fatally. Even if one-third, or one- fourth of the surface be burnt, the prognosis should be very guarded. Another point to be considered is the locality of the injury; a burn upon the trunk is more serious than one of similar extent upon the ex- tremities. The depth of a burn is of less prognostic importance than its extent, at least as regards life, which may often be saved (when the lesion is in one of the extremities) by a timely amputation. There is a popular idea that patients who are burnt often die from inhaling flame; it is, perhaps, scarcely necessary to say that such an occurrence is impossible; death, however, may occur from asphyxia (from the presence of smoke and noxious gases), or possibly from the flame enter- ing the mouth, thus inducing rapid oedema of the glottis, and consequent suffocation. Hot steam may be inhaled (as is sometimes done by chil- dren from the spouts of tea-kettles), when death ensues from inflamma- tion of the air-passages. The older writers spoke of critical days in cases of burn, and the third and tenth days were especially so regarded. According to Mr. Holmes, however (and this corresponds with my own experience), most deaths from burn occur during~the first forty-eight hours; of 194 fatal cases which were received into St. George's Hospital in sixteen years, 98 terminated during the first two days, 55 more during the first fort- night, and only 41 at a later period. Treatment.—The Constitutional Treatment of burns is of the greatest importance. The first thing to be done is to promote reaction. The patient should be placed in bed and covered with blankets, while foot- warmers, or hot bricks or bottles, are employed to maintain an elevated temperature. Brand}* and opium may be given pretty freely, care being taken, of course, not to intoxicate the patient; if he be already inebriated, reaction may be promoted by the use of other stimulants, such as car- bonate of ammonia. As soon as reaction has begun, nutritive liquids, such as beef-tea or milk-punch, should be given, in small quantities, and at frequent intervals, taking care not to excite vomiting by overloading the stomach. Thirst may be allayed by permitting the patient to suck small lumps of ice, or by the moderate use of carbonic-acid water; but the patient should not be allowed to deluge his stomach with liquids, as the consequent vomiting and attending depression would of them- selves often suffice to insure a fatal result. During the first week or ten days of a burn, the patient is often con- stipated, and requires mild laxatives or enemata; diarrhoea is apt to supervene at a later stage, and must be met with chalk-mixture, astrin- gents, and opium. Retention of urine must always be watched for, during the early stages of a burn, especially with female patients, who, from a feeling of modesty, frequently conceal their sufferings in this respect. When a patient has thoroughly reacted, the treatment consists chiefly in the administration of food and stimulus. Two or three pounds of beef, in the shape of beef-tea, with ten or twelve fluidounces of brandy, and a quart or two of milk, is no unreasonable daily allowance for a bad case of burn. The only drug habitually required is opium: twenty minims of laudanum, or half a grain of sulphate of morphia, every six hours, is often not too much to relieve pain and promote necessaiy sleep. Trau- matic delirium, if it occur, is to be treated on the principles already laid down and other complications are to be met as they arise. During the 300 EFFECTS OF HEAT AND COLD. third stage, tonics are usually required, the best being iron, quinia, and the mineral acids. Secondary amputation may be required, either by the depth of the burn, or by the state of general exhaustion of the patient; if by the latter, the operation should not be too long postponed, on account of the risk, already referred to, of the occurrence of visceral degeneration, probably of the so-called amyloid or albuminoid variety. With regard to Local Applications to burns, I do not believe that it makes a great deal of difference what article is used, provided that the surface is thoroughly excluded from the air, and that the process of dressing is neatly and properly attended to. The application which I myself prefer in cases of recent burn, is the old-fashioned carron oil, made by stirring linseed oil and lime-water into a thick paste, which is then spread upon old linen or muslin, and covered with oiled silk. It is customary to speak of this as a filthy dressing, but I cannot see that it is any less clean than other applications, while it is certainly, accord- ing to my experience, extremely soothing and agreeable to the patient. Other dressings may, however, be used, if the surgeon prefer, and excel- lent results are doubtless obtained with raw cotton, flour, white paint, lard, glycerine, .or any other of the host of substances which have been recommended. More important than the particular article used is the mode of using it. Only a small portion of the surface should be uncovered at once, and the burn, if extensive, should thus be dressed, as it were, in detachments. Vesications, if there be any, should be punctured with the point of a sharp knife, the contained serum being allowed to drain away of itself, so as to preserve the cuticle as a covering for the parts beneath. The dressings should be covered with oiled silk or waxed paper, to prevent evaporation, and should be held in place with roller bandages, the injured parts being supported in an easy position, with soft pillows covered with oiled silk, or with pads of cotton wadding. The dressings should be entirely renewed, as a rule, once in two days; while unnecessary disturbance of the patient is to be deprecated, the discharge is usually so profuse and offensive, that to delay a change of the dressings longer than this, does more harm than good. When the sloughs have separated, the remaining ulcers may be dressed with lime-water, dilute alcohol, or zinc, or resin cerate, as in the case of any other granulating sur- face. While the dressing is to be conducted with all gentleness, it must be neat and thorough; especial care should be taken to wipe clean the newly-formed skin around the healing ulcer, which may be advan- tageously stimulated from time to time by light touches with lunar caustic or blue stone. During the healing process, care must be taken to guard against undue contraction of the cicatrix, by the use of appro- priate splints and bandages. This contraction is particularly apt to occur at the flexures of the joints, and in the neck, where it draws the chin down to the sternum, or ties the head to the shoulder, producing the most frightful deformity, which may be irremediable except by operative interference. Operations for Contracted Cicatrices.—In the early stages, be- fore healing is completed, or afterwards, if the cicatrix be still soft and pliable, it may be possible to prevent deformity by the use of splints and careful bandaging, or by means of elastic rings and bands, so applied as to counteract the contractile tendency. In dealing with old cicatrices, in which the contraction is firm and long established, severer measures are necessary. In the hand or foot, the deformity may be so great, and the OPERATIONS FOR CONTRACTED CICATRICES. 301 cause of so much inconvenience, as to require amputation. In the neighborhood of the joints, as of the elbow, it may be sufficient to divide the cicatrix, by a free incision carried into healthy tissue on both sides of, and beneath the scar; the after-treatment consists in making exten- sion by means of screw apparatus, or, which I think better, the ordinary weight extension, applied to the limb below the scar, with lateral sup- port by means of side-splints or a fracture-box, the wound being allowed to heal while the limb is in the extended position. These operations are not entirely free from risk, for important vessels and nerves some- times adhere very closely to the cicatrix, and may be wounded in its division, or may themselves be shortened in the general contraction, when their integrity will be endangered by the process of extension. Simple division of the cicatrix is not sufficient in the case of burns about the face and neck, and here various plastic operations have been practised by Mutter and others, to remedy the deformity, which is both annoying and painful. Xo general rules can be given for the manage- ment of these cases, which must be left to the ingenuity and skill of the surgeon in each particular instance. It may be said, however, that when the extent of the injur}- permits it, flaps of sound tissue should be brought, by twisting or by sliding, to cover the space left by free division and dissection of the cicatrix. In cases, on the other hand, in which this cannot be done, an attempt may be made to utilize the cicatricial tissue itself, as has been ingeniously and successfully done by Butcher, of Dublin. Mr. Butcher's operation, which has for its object the restoration of the elasticity of the cicatricial flap, consists in scoring subcuta- Fig. 156. neously the hardened tissue, with numerous incisions made with a long, narrow-bladed knife. The surgeon is thus enabled to unfold, as it were, the matted cicatrix, and render it available for autoplastic purposes. When the deformity is limited to dragging down and eversion of the lower lip, Teale's modifi- cation of Buchanan's cheiloplastic operation Will be found Very Useful; this Consists in Teale's operation; the flaps in dissecting up flaps from the sides of the lower place. lip (Fig. 156, a), and then joining these flaps together, and to the freshened edge of the central portion (b), which affords a firm basis for their support; the triangular spaces (c) which are left are allowed to heal by granulation. James, of Exeter, has supplemented the use of the knife, in these cases, by the employment of a screw collar, which gradually pushes the chin away from the sternum. Anchylosis, or at least Immobility of the Jaw, occasionally occurs as a result of burns upon the cheek and side of the neck; under such cir- cumstances, operations analogous to those of Barton and Sayre in the case of the hip-joint have been proposed by Rizzoli and Esmarch. Riz- zoli's operation consists in simply dividing the jaw with a narrow saw in front of the cicatrix, so that mastication may be accomplished by means of the natural articulation on one side, and the artificial false joint on the other. Esmarch meets the same indication by excising a wedge-shaped portion of bone, three-quarters of an inch wide at its upper part, and an inch below. Dr. Buck, of New York, has recently performed Esmarch's operation (in a case of cicatricial contraction resulting from cancrum oris), but though an inch and a half of bone was removed, the parts became reapproximated, and the operation seems to have been only 302 EFFECTS OF HEAT AND COLD. partially successful: a better plan is, according to Durham, to separate the jaw with a screw-lever, and then endeavor to restore the functions of the part by practising passive motion. The cicatrix of a burn sometimes assumes a peculiar warty appear- ance resembling keloid, this condition being more common in children than in adults. When the nature of the case permits, excision should be practised, but the cicatrix is sometimes too large to admit of this remedy; the itching may be relieved, according to Erichsen, by the in- ternal administration of liquor potassa?. Occasionally a true cancerous formation appears to be developed in an old cicatrix, rendering excision (if practicable) still more imperative. Effects of Cold. The effects of cold are both constitutional and local. The Constitu- tional Effects of prolonged exposure to cold consist in the development of a state of drowsiness and indisposition to exertion, which, if not inter- fered with, will terminate in coma and death. Hunger, great fatigue, or any circumstance which impairs the general tone of the system, may increase the susceptibility to the effects of cold, and hence the liability of soldiers in a winter campaign to suffer from this cause. The treatment of a person apparently dead from cold, consists in placing him in a room of low temperature, and in practising systematic but gentle friction, with snow, or with flannel wrung out of tincture of camphor or dilute alcohol, together with a resort to artificial respiration. These means should be continued until reaction is well established, when the body may be wrapped in blankets, stimulating draughts administered, and the temperature of the room gradually raised. Efforts at resuscitation in such cases should not be prematurely discontinued, as patients have occasionally been saved, even when apparently dead for several hours. The Local Effects of cold are divided, according to their intensity, into Pernio or Chilblain, and Frost-bite. Pernio or Chilblain is a very common affection, and is caused rather by sudden alternations of temperature, than by intensity of cold. It affects principally the extremities, especially the toes, heel, and instep, though it is also met with in the hands and face. The part affected is more or less deeply congested and swollen, and the seat of intense itch- ing and burning. Vesication sometimes occurs, and may leave ulceration of an intractable character. A patient who has once had chilblains is very apt to suffer from a recurrence of the affection, upon even slight changes of the weather. The treatment consists in plunging the part into cold water or rubbing it with snow, following this application by the use of local stimulants, such as the nitrate of silver, tincture of iodine, or soap liniment. The remedy which I am in the habit of employing is the nitrate of silver in weak solution (gr. iv or v—f^j), frequently painted upon the part, which is then wrapped in raw cotton. The nitrate of silver seems to obtund the local sensibility, and certainly relieves the burning and itching, which in these cases are so distressing. The ulcera- tions which sometimes attend chilblain require stimulating applications, such as resin cerate, or dilute citrine ointment. T. Smith has called attention to the periodicity with which the paroxysms of itching in chil- blain are developed, and which he is disposed to attribute to the time at which the patient's principal meal is taken. The daily paroxysm may FROST-BITE. 303 be anticipated, if the patient's convenience so dictate, by immersing the part for a few minutes in a mustard bath. Frost-bite results either from exposure to an intense degree of cold, or from prolonged exposure to a less degree. The parts most often affected are the nose, lips, ears, fingers, and toes, though occasionally the effect is more extensively diffused, whole limbs becoming frost-bitten. The first effect of cold is the production of a dusky redness, with some tin- gling and pain; but further exposure causes a tallowy whiteness of the affected part, which is also shrunken, insensible, and motionless, presenting much the appearance of gangrene from arterial occlusion. Mortification may be induced directly by the intensity of the cold de- priving the tissues of vitality, though more usually death of the part follows from the violent inflammation, which results from undue reaction. Thus, Larrey found numerous cases of frost-bite caused by a sudden thaw, when the previous severe cold had given the affected persons no inconvenience. The treatment of frost-bite consists in moderating the intensity of the reaction, and thus endeavoring to prevent the occurrence of mortification. For this purpose the affected part should be rubbed with snow or ice, or covered with wet cloths, which are kept cold by means of irrigation, the patient being meanwhile kept in a cold room. By assiduously persevering in this mode of treatment, gradual reaction may be obtained, and the patient may escape with moderate inflammation, manifested by slight swelling and tingling, with perhaps some vesication, and desquamation of the cuticle. In this stage advantage may be derived from the use of stimulating washes, such as the tincture of iodine, or soap liniment. Even if mortification occur, the use of cold applications should be continued, as long as the gangrene manifests any tendency to spread. The occurrence of mortification is manifested by the part be- coming black, dry, and shrivelled, a line of demarcation and separation forming as in gangrene from any other cause. If the mortified parts be of small extent, their removal should be left to nature, the process of separation being simply hastened by the use of fermenting poultices; the reason for this is that the vitality of all the neighboring tissues is impaired, and that the use of the knife might therefore be followed by a recurrence of gangrene. When the mortification has extended further, involving the greater portion, or the whole of a foot or hand, a formal amputation will probably be ultimately required ; even in such a case, howeAyer, it may be better, at first, simply to remove the gangrenous mass by cutting through the dead tissue below the line of separation, waiting to improve the shape of the stump by a regular amputation at a subsequent period, when the patient's general condition has been im- proved by appropriate constitutional treatment. 304 INJURIES OF THE HEAD. CHAP TEE XV. INJURIES OF THE HEAD. * Injuries of the Scalp. Contusions of the Scalp are chiefly of interest in a diagnostic point of view, the sensation which they communicate to the fingers of the surgeon being often deceptive, and leading to the supposition that the case is one of fractured skull. There is in both affections a rim of indurated tissue with a central soft depression, but in a contusion, firm pressure will usually detect the bone at the bottom of the cavity. The most skilful surgeons may, however, be deceived by these cases, and incisions have been made with a view of elevating depressed bone, the operation showing that no fracture existed. Large collections of blood, either coagulated or fluid, may result from contusions of the scalp, re- maining apparently without change for a considerable period. As a rule, no incision should be made in these cases, but the surgeon should encourage absorption by the use of evaporating lotions, or of moderate pressure. If, however, suppuration occur, the pus must be evacuated by a free incision. Cephalhsematoma, or Caput Succedaneum, is a bloody tumor of the scalp in new-born children, resulting from pressure during birth. The blood is usually effused between the scalp and pericranium, though more rarely beneath the latter. The treatment is the same as for similar ex- travasations resulting from other causes. Wounds of the Scalp.—Scalp wounds do not differ materially from similar injuries in other parts of the body, as regards their pathology and treatment. The tissues of the scalp are extremely vascular, hence the hemorrhage in these cases is often profuse ; on the other hand, the vascularity of the scalp is of advantage, in enabling the parts to pre- serve their vitality after injuries which, in other tissues, would be cer- tainly followed by extensive sloughing.. In all ordinary wounds of the scalp, whether incised or lacerated, the detached flaps should be care- fully replaced (the parts being cleanly shaved), and held in position with strips of isinglass plaster, or, which is better, with the gauze and collodion dressing, or one of its modifications (see page 140). A firm and broad compress should then be placed over the seat of injury, and secured by a suitable bandage; bleeding is thus readily checked, and the flaps are held in such a position as to favor union. I do not advise the use of either sutures or ligatures, in ordinary cases of scalp wound, simply because I do not believe them to be necessary. They are, indeed, thought by many surgeons to act as exciting causes of erysipelas, when applied to the scalp, but there is no proof, so far as I am aware, that they exert any such influence. They are, however, usually unnecessary, and therefore, of course, undesirable. If a wound of the scalp be accompanied with so much contusion and WOUNDS OF THE SCALP. 305 laceration that sloughing appears unavoidable, it would be proper simply to support the flaps with adhesive strips, and apply to the wound some warm and soothing application, such as olive oil or diluted alcohol. As in every case of scalp wound there is at least a possibility of some concomitant injury to the brain, a patient with such an injury should be carefully watched during the entire course of treatment; the diet should be regulated (all irritating or indigestible substances being avoided, while at the same time easily assimilable nutriment is provided in sufficient quantities), and attention should be given to the condition of the various secretions and excretions of the body. Erysipelas and Diffuse Inflammation of the Subcutaneous Areolar Tissue are usually said to be especially apt to follow upon wounds of the scalp. Such has not been my own experience, though I can readily understand that a patient should be predisposed to these affections, when treated by the plan of excessive depletion formerly in vogue in the management of these cases. The proper course to be pursued in the event of such complications arising, would be to remove all pressure or sources of tension, by reopening the lips of the wound, and making counter-incisions, if necessaiy, for the evacuation of pus or sloughs. Necrosis of the outer table of the skull usually, though not necessa- rily, follows in cases of scalp wound in which the bone is denuded of pericranium. Such a case should be treated upon ordinary principles, the sequestrum being removed as soon as it has become loose. Fig. 157. Fig. 158. Severe scalp wound. (From a patient in the Episcopal Hospital.) The accompanying cuts (from photographs) illustrate the severest case of scalp wound which I have ever known to be followed by reco- very. The patient was a girl of fifteen, an operative in a cotton mill, who was caught by her hair between rollers which were revolving in op- posite directions, her scalp being thus, as it were, squeezed off from her head and forming a large horseshoe-shaped flap. The linear extent of the wound was fourteen inches, the distance between its two extremities being but four inches. This large flap was thrown backwards, like the lid of a box, the skull being denuded of its pericranium for a space of two and a half inches by one inch in extent. The anterior temporal artery was divided, and bled profusely, and the patient, when admitted 20 306 INJURIES OF THE HEAD. to hospital, was extremely depressed by shock and hemorrhage. A liga- ture was applied to the bleeding vessel, and the flap, after it had been gently but carefully cleansed, replaced and held in position with the gauze and collodion dressing. A large compress soaked in warm olive oil was then placed over the entire scalp, covered with oiled silk, and fixed with a recurrent bandage. A considerable portion of the wound healed by adhesion, and the patient was discharged cured after fifty-four days. No exfoliation of bone occurred. Cerebral Complications of Head Injuries. The principal risk attending all injuries of the head is from simul- taneous or subsequent implication of the brain, and I shall, therefore, before speaking of fractures and other lesions of the skull, consider the various cerebral complications which are met with in these injuries, and which may be classified, as a matter of convenience, under the heads of concussion, compression, and inflammation. Concussion of the Brain.—It is a rather mortifying confession, that the ideas of surgeons of the present day, as to this condition, are much less definite than those of their predecessors. We have, how- ever, advanced so far, that we are now enabled to say pretty clearly what concussion is not, and thus to separate it from other conditions with which it was, formerly, habitually confused. Thus, we now know that cerebral -concussion is not shock (see page 133), and that it is not a purely functional, apart from an organic condition. The older writers had no hesitation in declaring that a man might die frqim concussion of the brain, without the existence of any physical lesion whatever, but the fallacy of this opinion has been ably exposed by modern authors, among whom should be specially mentioned Prescott Hewett, the well-known surgeon of St. George's Hospital. In fact, while there is no evidence that cerebral concussion is ever a cause of instant death, there are inva- riably found after death from this cause, signs of contusion, compression, extravasation, laceration, or inflammation. Concussion of the brain, as its name implies, consists in a shaking or, to use a Johnsonian word, a tremefaction of the cerebral mass, and it is easy to understand that such a trembling might be attended by a more or less temporary arrest of cell-action, by capillary stasis, and by functional inactivity, without -any persisting lesion, or permanent ill result. Such, indeed, is probably the condition of affairs in the slight cases of con- cussion or stunning which are not unfrequently met with, especially among children; though, these cases not proving fatal, our knowledge of their morbid anatomy must, of course, be purely conjectural. A more violent concussion of the brain may cause contusion or lace- ration of the cerebral structure itself, or rupture of the cerebral vessels, giving rise to extravasation with or without compression, and more remotely followed by inflammation, suppuration, or softening. Contusion and Laceration of the brain, like the same conditions in other organs, may vary from the slightest bruising or separation of fibres, to the most extensive crushing and tearing, sometimes amounting to complete pulpefaction and disorganization of the whole cerebral mass. The symptoms and prognosis of these injuries depend upon their extent, and upon the particular part of the brain which is affected; thus, Mr. Callender has shown that pain is especially connected with lesions of qONCUSSION OF THE BRAIN. 307 the'outer gray matter of the brain, and convulsions with lesions in the neighborhood of the middle cerebral arteries. A laceration involving the medulla oblongata would, of course, be more apt to prove fatal than one of similar extent in a less vital part. The extravasation which invariably accompanies cerebral contusion, presents various appearances in different cases; thus there may be numerous points or specks of extravasation, each not larger than a millet-seed (miliary extravasation), or the blood may be poured out in larger masses, forming collections the size of a split pea. The latter form of extravasation is easily recognized, but the former may be mis- taken for the appearance presented by the cut surface of the cerebral vessels—from which, however, it may be distinguished by the fact that the points of extravasation are not easily wiped away, and, if picked out, leave behind them small but distinct cavities. Contusion of the brain, with its attendant extravasation, may be cir- cumscribed or diffused; the former condition is frequent, and the latter rare. Certain parts of the brain are more exposed to contusion than others; thus the base of the brain is more often affected than the upper part; the middle and anterior, than the posterior lobes; the cerebellum, than the pons and medulla. The reason for this difference is, doubtless, as pointed out by Brodie, the greater or less irregularity of the surface of the various portions of the skull. When extravasation takes place on the surface of the brain, or into its ventricles, or even (in large amount) into its substance, the characteristic symptoms of compression are developed—a condition which will be presently considered. Causes of Cerebral Concussion.—Concussion of the brain, may be caused by various forms of external violence, such as a direct blow or fall, by violence resulting from counter-stroke, as a fall on the loins, buttocks, or feet, or even by sudden and violent agitation of the sur- rounding air, as by an explosion in a patient's immediate vicinity. Symptoms of Cerebral Concussion.—Every case of concussion is, I believe, accompanied with shock, and in many instances the symptoms of the latter condition alone can be recognized. The patient, after a blow on the head, becomes pale and somewhat collapsed, with a cool surface, small and feeble pulse, diminished power of sensation and motion, and partial unconsciousness; after a variable period these symptoms pass off, vomiting may or may not occur, and the patient is apparently quite as well as before the accident. The symptoms here are evidently those of shock (with the exception of unconsciousness), and cannot be considered as in any degree characteristic of the brain lesion. So, again, in cases in which death follows in a few minutes or hours after an injuiy to the head, the patient lying meanwhile senseless and collapsed, the fatal result may be due to shock, or to intra-cranial hemor- rhage, or to laceration of a vital part of the brain; but there is no symptom which we can point out, as pathognomonic of concussion, apart from other conditions. Even in the intermediate cases, which are often spoken of as typical instances of concussion, though, as a matter of con- venience, we may trace their clinical history, and divide it into stages, we cannot point to any symptoms which definitely characterize the lesions of concussion, apart from those of other cerebral inj uries. Indeed it would be better, I think, if we could dispense altogether with the term concussion as denoting a condition, and look upon it as merely indicating the cause of what have been described as concussion lesions^ 308 INJURIES OF THE HEAD. viz., cerebral contusion, laceration, extravasation, etc. With this ex- planation and reservation, the clinical history of a typical case of so- called concussion of the brain may be said to present three stages, the symptoms of which are as follows:— In the first stage the patient lies motionless, senseless, nearly pulse- less, pale and cold, breathing feebly but naturally, the pupils dilated or contracted, fixed or acting freely (according to the particular seat and form of lesion),1 with perhaps involuntary discharge of feces and urine. From this first stage the patient may recover without any further trouble, or he may gradually sink and die without reaction. Or the first stage may be very evanescent, so that when the surgeon first sees the patient he has already passed into the second stage, which Mr. Erichsen regards as an entirely independent condition, and graphically describes under the name of Cerebral Irritation. The disappearance of the first stage, whether by passing into the second or by direct recovery, is com- monly marked by the occurrence of vomiting. In the second stage the patient is no longer unconscious, though much indisposed to speak or pay attention to surrounding objects. If roused by a question, he will answer, but peevishly or angrily, turning away as if displeased at the interruption. The posture of the patient is peculiar; he habitually lies on one or other side, curled up, with all his joints more or less flexed, and if a limb be touched, draws it away with an air of annoyance. The eye- lids are kept firmly closed. The pulse during this stage, at first small and weak, becomes gradually fuller and more frequent, while the breath- ing is easier, and the surface regains its natural warmth and color. The symptoms now may be masked by those of the second stage of shock (see page 135), and thus, instead of being morose and taciturn, the patient, though still irritable, may be voluble and loquacious. The con- dition of cerebral irritation which marks the second stage of concussion, gradually subsides, after having lasted several hours or days, the patient almost invariably complaining of severe headache as he regains ability and willingness to communicate with those around him. The third stage varies in different cases : in some, there is positive inflammation of the brain and its membranes; in others, as irritability subsides, fatuity takes its place, and a state of weakmindedness supervenes, which may end in recovery, or in cerebral softening and death. Prognosis.—From what has been said, it is evident that the prognosis in any case of cerebral concussion or contusion should be very guarded: the patient may die, as we have seen, in the first stage, from the shock of the injuiy; or, if he escape this risk, from intra-cranial congestion or inflammation; or, at a still later period, from softening of the brain or cerebral abscess. As a rule, however, if the first stage be slight, we may expect the others to be so likewise, and, numerically, the proportion of deaths to the number of cases of slight concussion, or stunning, is very small; still, it is not always possible to be sure that the amount of brain lesion is as slight as it at first appears, and every case of concussion must be, therefore, a subject of grave interest to the surgeon. Treatment of Cerebral Concussion and Contusion.—There is a popular notion that a person who has received a stunning blow on the head should not be allowed to sleep, or even to lie quietly in bed: need I say that this is as unreasonable as it is cruel? The first indication for treat- 1 Cerebral compression appears to be marked by fixed or slowly moving pupils; mere laceration does not affect their free action. (See Mr. Callender's paper in St. Bartholomew's Hosp. Reports, vol. v. p. 25.) COMPRESSION OF THE BRAIN. 309 ment is certainly to place the injured organ at rest, and it would be no more unphilosophical to insist that a man should walk with a contused foot, or write with a lacerated hand, than to expect him to exert the mental faculties when suffering from concussion of the brain. A patient thus affected should be placed at rest, in bed, in a cool and moderately darkened room, and should be disturbed as little as possible. If the state of shock be so great as to threaten death from asthenia, the patient must be stimulated, preferably, however, as far as possible, by external applications, such as sinapisms or hot bottles, and by those internal remedies which are most evanescent in their effect, such as the spirit of hartshorn or carbonate of ammonia. As a matter of fact, it is very seldom indeed that a case of concussion requires any stimulus at all. Reaction usually begins in the course of an hour, or two or three hours, some- times much earlier, and as the pulse rises, the stimulants, if any have been given, must be discontinued. The risk now is from congestion or extravasation, with subsequent inflammation, and the treatment must be directed accordingly. It is in this stage that cold, and especially dry cold, is particularly useful as a local application. In the first stage it would have added to the existing depression, but it is now eminently indicated, and is a most valuable remedy. Esmarch's ice-bag or Petit- gand's apparatus may be employed, or, in the absence of these, cloths wrung out of cold water should be assiduously applied. The secretions and excretions should be regulated, the bowels being opened with enemata, or occasional mercurial or saline purges, and the bladder relieved by catheterization if necessary. The diet should be very light, and administered in small quantities at a time; there is no article of food better, under these circumstances, than milk, to which lime-water should be added if there be vomiting. Rest, both mechanical and phy- siological, should still be enforced; and if the patient be restless, the surgeon need not fear to give opium. I am aware that there is a good deal of difference of opinion as to the propriety of administering opium in injuries of the head, but surely there is nothing to contraindicate it in what we know of the pathology of these cases, while its soothing and calming effect is exactly what is required. Metaphorically speaking, it puts the brain in splints, and thus places it in the most favorable posi- tion for the repair of its injuries. Of course, opium in these, as in all other cases, should be used with discretion, and if there be any threat- ening of coma, should not be given; but in such a case the restlessness which calls for it would not be present. By perseverance in this plan, the patient will, in most cases, be tided over the second stage, and may then be allowed gradually, and with great caution, to resume his usual mode of life. For a long time, how- ever, he should live by rule, guarding against all sources of irritation, eating and drinking very moderately, and in fact remaining, if not under treatment, at least under surgical supervision. If, on the other hand, the case progresses less favorably, and the contused and lacerated brain becomes inflamed, the chances of recovery are much diminished; trau- matic encephalitis is, however, of such importance as to demand separate consideration. Compression of the Brain.—It is not my purpose to enter into a theoretical discussion as to whether the brain is susceptible of being actually compressed, or whether, in the condition known as compression, it merely changes its form, expanding at other parts to compensate for its apparent contraction at the seat of lesion. The term cerebral com- 310 INJURIES OF THE HEAD. pression is so universally employed by surgeons, and is in many respects so convenient, that I shall not hesitate to use it, although it may not exactly describe the condition which it is meant to represent. Causes.—Compression of the brain may be caused by various circum- stances: thus, it may be due to the pressure produced by a foreign body, as a bullet or piece of shell; by a portion of displaced bone; by effusion of blood, either on the surface of the encephalon or within its mass; or by what are ordinarily called the products of inflammation, lymph, serum, and pus. Symptoms.—The symptoms of compression are as follows: the patient lies unconscious and comatose; the breathing is slow, and accompanied by stertor, and by a peculiar blowing motion or whiff at the corners of the mouth; this sign, which is very striking, appears to be due to para- lysis of the cheeks, and is compared by the French writers to the act of a man smoking a pipe. The pulse is full and rather slow, the decubitus dorsal, and the skin usually cool, though sometimes hot and moist. There is retention of urine, and the feces are passed unconsciously. The pupils are fixed and immovable, usually midway between contrac- tion and dilatation, sometimes widely dilated, and rarely contracted; or one pupil may be contracted, while the other is dilated; the difference in different cases depending, as shown by Callender, upon the part of the brain involved. There is paralysis of motion, usually affecting the side opposite to the seat of injury. The period at which the symptoms of compression are developed, depends on the particular source of the pressure: if this result from depressed bone or a bullet, the symptoms will be instantly manifested, and the patient will probably continue in a completely comatose condition, from the moment of injury, either till the pressure is removed, or till the case ends in death; this, it will be re- membered, was the course of events in the case of President Lincoln. If, however, compression be caused by extravasation, it will begin gradu- ally, and slowly increase during several hours, until the intra-cranial bleeding has spontaneously ceased, or has been artificially arrested; while compression from lymph, serum, or pus comes on at a still later period of the case. Diagnosis.—I regret that I cannot agree with those surgeons who con- sider the diagnostic marks between compression and concussion to be plain and easily recognizable. Unfortunately, as our knowledge of the pathology of concussion has increased, the several symptoms which we formerly regarded as pathognomonic are shown to be often common to both conditions; and this is not surprising when we remember that extravasation is an almost constant lesion of concussion, and a frequent cause of compression, thus rendering the difference between the two conditions, in many cases, one of degree only. It used to be said that the symptoms of concussion were immediate and temporary; those of compression, often not immediate, but permanent. We have, however, seen that the first stage of concussion presents no definite symptoms, none in fact which might not be due to shock and syncope (conditions which might equally complicate compression)—while, if concussion be attended with much extravasation, compression itself may result. Again, if compression be caused by a foreign body, or by displaced bone, the symptoms will be immediate—while in many cases of slight compression, the brain in a short time becomes habituated to the source of pressure, when the symptoms may pass off without surgical interference. And so with the other symptoms which used to be considered diagnostic, there is not one, I believe, which can be implicitly relied upon. A man TRAUMATIC ENCEPHALITIS. 311 was brought into the Episcopal Hospital with a compound, comminuted, and depressed fracture of the frontal bone, with rupture of the mem- branes, and escape of brain substance. When I saw him he was coma- tose, and evidently suffering from compression of the brain; I removed those fragments of bone that were loose, and elevated the remainder; the patient breathed somewhat less stertorously, and turned on his side; the next day he was conscious, and rapidly recovered. Here there was manifestly compression from an obvious cause—depressed bone; and yet the only change in symptoms produced by relieving this compression (the accompanying concussion remaining), was a diminution in stertor, and the substitution of lateral for dorsal decubitus. Hence, though in certain cases we can say without hesitation, in view of the one-sided paralysis, profound coma, and other symptoms mentioned, this is com- pression or that is concussion, there are other cases in which it is impos- sible to draw such a distinction; compression may disappear sponta- neously, leaving concussion, while concussion, by a continuance of intra-cranial hemorrhage, may end in fatal compression. Prognosis.—Compression in itself is not a very fatal condition; in many cases, in which the pressure is not very great, the brain accustoms itself to the new state of affairs, and the patient regains consciousness, and goes on to recovery. In other cases it is possible by surgical inter- ference to relieve the compression, and then, if the brain itself be not structurally altered, there is a good prospect of recovery. The gravest forms of compression are those which result from intra-cranial hemorrhage or suppuration, the latter condition being particularly dangerous, and proving almost always sooner or later fatal. Treatment of Cerebral Compression.—When the cause of compression is recognizable, an attempt should obviously be made to remove it. Thus if compression be due to a fragment of bone, this should be elevated or removed, provided it can be done with safety; or if to hemorrhage, in a situation which can be reached, the surgeon may make an effort to evacuate the effused blood and secure the vessel; if, however, the cause of the compression is uncertain, and still more if the existence of com- pression itself be doubtful, it will, I think, be usually wiser to abstain from operative interference, and to treat the case on the general princi- ples which have been laid clown, in speaking of the management of the second stage of cerebral contusion (page 309). Purgatives may be em- ployed in these cases pretty freely; and, if the patient cannot swallow, a drop of croton oil in mucilage may be placed on the tongue, while the bowels are solicited by turpentine enemata. The question of trephining in these cases will be considered hereafter. Traumatic Encephalitis, or inflammation of the cranial contents as the result of injury, is a very serious complication, both of fractured skull, and of the severer forms of cerebral concussion and contusion. The brain substance itself may be affected, or the meninges, or both together; the arachnoid membrane is perhaps more commonly involved than any other part of the cranial contents. The meninges are injected with blood, while yellowish, or greenish, and sometimes puriform lymph occupies the cavity of the arachnoid and the meshes of the pia mater, the arach- noid itself becoming thickened, and assuming an opalescent appear- ance. According to Hewett, in cases of meningitis originating from injuries of the skull, lymph will be chiefly found on the dura mater and in the cavity of the arachnoid; while in those cases which originate from injury of the brain (as after concussion), the pia mater is chiefly affected, 312 INJURIES OF THE HEAD. the arachnoid cavity often escaping. Inflammation of the brain substance itself, chiefly affects the gray matter and superficial white substance, and is marked by great congestion, a dusky leaden hue, and softening, which comparatively seldom affects the central white parts, such as the fornix. Traumatic encephalitis may end in suppuration, cerebral abscesses not unfrequently following upon seemingly slight injuries, and occurring after long intervals of apparent health. Symptoms of Traumatic Intra-cranial Inflammation.—These are pain (especially referred to the seat of injuiy), heat of head, fever, contrac- tion of pupils, photophobia, and intolerance of sound ; at a later period there are added vomiting, jactitation, delirium, convulsions, stupor, subsultus, paralysis, and coma. The occurrence of suppuration is fre- quently marked by repeated rigors. The period at which encephalitis is developed varies in different cases; thus, after general and wide-spread concussion, inflammation may come on in a few hours; after limited laceration, probably not for several days— while inflammation resulting from contusion or fracture of the skull may occur at a still later period. No very trustworthy information as to the precise seat of inflamma- tion can be derived from the symptoms. The researches of Callender would seem to show that pain is especially connected with lesion of the gray matter, and convulsions with disease about the track or distribution of the great vessels, especially the middle cerebral arteries. Solly, how- ever, looks upon convulsions as characteristic of inflammation of the tubular portion of the hemispheres, and Dr. Watson, of the pia mater or arachnoid; while Brodie and Hewett have seen convulsions follow injuries of the head, when there was no evidence of any inflammation at all. Death may result from pressure of lymph or pus on the surface of the brain (in cases of arachnitis), from softening of the brain tissue, from the occurrence of intra-cranial hemorrhage, or from an abscess bursting into the ventricles; or it may result secondarily from thrombosis and pyaemia. Intra-cranial Suppuration may occur between the skull and dura mater (subcranial), in the cavity of the arachnoid and the meshes of the pia mater (intra-meningeal), and in the substance of the brain itself (intra- cerebral). Subcranial suppuration results from lesion of the bone, and is only met with at the seat of injury; the other varieties may also result from counterstroke, and may therefore be found at a distance from the point at which the violence was applied. The first and third forms of intra-cranial suppuration are circumscribed, the latter constituting the ordinary cerebral abscess, which may last for an indefinite time without producing any marked symptoms. Intra-meningeal suppuration is commonly widely diffused, occupying the region of the vertex, usually on the side of the external injury, but occasionally opposite to it. The symptoms of intra-cranial suppuration are those of cerebral irrita- tion and compression ; but I do not know of any signs which will enable the surgeon positively to distinguish the presence of suppuration from that of arachnitis. The prognosis in all these cases is very unfavorable; pus has been occasionally evacuated from beneath the cranium, the patient recovering; and incisions have been made through the dura mater, and even into the brain substance, in search of pus. Dupuytren, and Detmold, of New York, thus opened cerebral abscesses, the patient of the former recover- ing, and that of the latter surviving the operation about seven weeks. INJURIES OF THE SKULL. 313 Treatment of Traumatic Encephalitis.—Intra-cranial inflammation is to be treated on the general principles laid down in Chapter II. Bleed- ing was formerly considered absolutely necessary in these cases, and is still resorted to by some surgeons. I have already expressed my views so fully as to the employment of venesection in the management of in- flammation, that I shall not revert to the subject here, further than to say that I have never had occasion to bleed for encephalitis. Purging is doubtless a most valuable means of treatment in these cases, but should be employed with due caution, and not pushed so far as unneces- sarily to weaken the patient. Desault derived advantage from the use of large doses of tartar emetic, but the remedy is a dangerous one, and is now seldom employed. Calomel and opium are, I think, of great service in the treatment of these cases, and may be given in doses of a quarter of a grain of the former, with a sixth of a grain of the latter, every three hours, till the gums are slightly touched, when the mercurial should be suspended, and iodide of potassium may be substituted. Cold to the head is a valuable remedy, and is very grateful to the patient, as relieving the headache, which is one of the most painful symptoms of intra-cranial inflammation. In the later stages, a blister to the nape of the neck, or even to the entire scalp, is recommended by some authorities. The diet should consist of fluids, and should be light and unirritating; if the general condition of the patient require it, however, the surgeon must not hesitate to administer concentrated nutriment, or even stimulus. After injuries of the head, the brain often appears to be left in an irritable condition, the patient suffering from headache, vertigo, in- somnia, etc. Under these circumstances, I have derived benefit from the use of the bichloride of mercury (in very small doses), or of the bromide of potassium, which may be given freely, and seems to act well as a hypnotic. The state of the bowels should always be looked to, in these cases, care being taken to avoid constipation. The question of trephi- ning, for intra-cranial suppuration, will be discussed in its proper place. Injuries of the Skull. Contusion.—Contusion of the skull, without fracture, is a very serious injury, being commonly accompanied with grave lesions of the brain ; the part of the skull which is bruised may become necrosed, and eventu- ally exfoliate; or, from separation of the dura mater, subcranial suppu- ration may occur and prove fatal. These injuries are chiefly met with as the result of gunshot wounds, though occasionally resulting likewise from the accidents of civil life. The treatment consists in combating cerebral irritation, by the means already described, and in removing sequestra, in case of exfoliation. If a patient with contused skull be- come comatose, it is usually recommended to apply a trephine, with the hope of being able to evacuate pus from beneath the skull; the facts already referred to, viz., that it is impossible to distinguish intra-cranial suppuration from arachnitis, and that, even if the existence of pus were certain, its locality could not be determined, are, however, sufficient to show how slight would be the prospect of benefit from such an opera- tion. Thus, in a case of gunshot contusion of the left parietal bone, which proved fatal at Cuyler Hospital, there was found after death arachnitis of the right side, and abscess of the left hemisphere of the brain, at a point corresponding to the seat of injuiy—showing that tre- phining on either side would have been utterly useless. 314 INJURIES OF THE HEAD. Fracture of the Skull.—Fractures of the skull may be simple or compound, comminuted, etc. They may be conveniently classified as fractures without displacement (fissured fractures), and fractures with displacement (depressed fractures), the latter class being again subdi- vided into impacted and non-impacted depressed fractures.1 In some rare cases, the fracture may be limited to the outer table, which is depressed upon the inner; in other instances, the inner or vitreous table is alone broken, the outer escaping. As a rule, the inner table is more exten- sively shattered than the outer, the exception being when the force is applied from within, as in the discharge of a pistol into the mouth. The cause of this difference is to be found, as pointed out by Teevan, in the well-known fact in mechanics, that fracture begins uniformly in the line of extension, and spreads further in this than in the line of compression, and that (in the case of gunshot fracture) the bulk of the fracturing body is absolutely augmented in its passage through the bone. Any part of the skull may be broken by either direct or indirect vio- lence, the parietal and frontal bones being most often affected in fractures of the vault, and the temporal and sphenoid bones in those of the base of the skull. Fracture of the base of the skull is the most fatal form of simple fracture, usually resulting from indirect violence, such as a blow on the top or side of the head, or a fall from a height on the feet or hips ; it is generally, if not (as believed by Aran and Hewett) universally, complicated by one or more fissures extending upwards into the vault. Depressed fracture of the skull is very rarely met with except in the vault, and results from direct violence. Symptoms of Fractured Skull.—A Simple Fissured Fracture of the vault of the skull presents no symptoms which can be considered diag- nostic. If there be an external wound, the line of fracture can be usually recognized, though a mistake has arisen, even under these cir- cumstances, from an abnormal position of one of the cranial sutures. Fracture with Displacement, if compound, is readily recognized; but, if unaccompanied by an external wound, may, as already mentioned, be confounded with a simple scalp contusion (p. 304). In some rare instances the displacement is outwards, but much more commonly inwards, consti- tuting the ordinary depressed fracture of the skull. The displacement in the impacted fracture is slight, the depression being less than the thickness of the skull; in the non-impacted variety it is usually much greater, fragments being often deeply imbedded in the substance of the brain itself. Fracture of the Base of the Skull may be suspected in any obscure case of injuiy to the head, which presents marked brain symptoms; and there are two signs in particular, which, though they cannot perhaps be considered pathognomonic, are unquestionably very significant, and render the existence of fracture at least extremely probable. These signs are the occurrence of intra-orbital ecchymosis and of bloody and watery discharges from the ear. 1. Fracture, involving the anterior fossa of the base of the skull, may cause hemorrhage from the nose, or into the deep parts of the orbit. The blood may flow backwards through the posterior nares into the mouth, and, being swallowed, may subsequently cause hsematemesis, giv- ing rise to a suspicion that some lesion of the abdominal viscera may have occurred. Hemorrhage into the orbit and areolar tissue of the eye- 1 Other subdivisions are sometimes made, sucb as the starred fracture, and the camerated fracture (a form of the depressed variety). INJURIES OF THE SKULL. 315 lids, constituting in the former position what is known as Intra-orbital Ecchymosis, may be considered as presumptive evidence of the existence of fracture of the anterior fossa, though this symptom might, of course, be due to the giving way of a bloodvessel, without lesion of the bony structures. This form of ecchymosis is easily distinguished from the subconjunctival and subcutaneous palpebral ecchymosis, which consti- tute the ordinary "black eye," by the fact that it is more deeply seated, that it is unaccompanied by contusion of the superficial struc- tures, and that it is not a primary phenomenon; it is, indeed, caused by the gradual leakage of blood from within, and frequently does not reach •its point of greatest intensity until several days after the time of injury. The hemorrhage is usually venous, probably resulting from laceration of the cavernous sinus, though it may be arterial, going on to the forma- tion of a circumscribed traumatic aneurism, and eventually requiring ligation of the carotid artery—an operation which has been successfully done under such circumstances by Busk, Scott, and others. 2. Hemorrhage from the Ears cannot, of itself, be considered a sign of much importance, as it may arise from any injuiy which ruptures the membrane of the tympanum, without necessarily implying the existence of fracture. If, however, it be profuse and long continued, the blood which remains in the meatus pulsating, and other symptoms of cerebral injury being simultaneously present, it becomes probable that a fracture of the petrous portion of the temporal bone has occurred, and that the blood proceeds from one of the large venous sinuses in that neighbor- hood. The occurrence of a Discharge of Thin Watery Fluid from the ear or nose, or through a wound of the scalp, is very significant of fracture: this discharge appears, in most cases, to be due to the escape of cerebro- spinal fluid, though instances have occurred in which the secretion of the tympanic cavity, and even saliva (leaking backwards through a per- foration of the meatus, produced by the fragment of a broken jaw), have been mistaken for the characteristic discharge of fracture at the base of the skull. If, however, a profuse watery discharge occur from the ear immediately after the accident, or if it follow a profuse and continued aural hemorrhage, there can be little doubt that the cerebro-spinal fluid is indeed escaping, and that a fracture, therefore, is necessarily present. Watery discharge from the nose is, of course, much less significant, and as an accompaniment of fracture is less often met with than that from the ear. Compound fracture of any part of the cranial vault may be attended by a discharge of cerebro-spinal fluid, provided there be a com- munication between the external wound and the sub-arachnoid cavity. It is stated by Robert, who has given much attention to this subject, that cases of fracture accompanied with discharge of cerebro-spinal fluid are always fatal; this is probably a mistake, for several well-authen- ticated cases are on record, in which recovery has taken place in spite of the occurrence of these discharges, though, of course, in any case which recovers, there is always the possibility of an error having been made in the diagnosis. A sudden cessation of the watery discharge is apt to be quickly followed by fatal coma. Prognosis.—As far as the injury to the bone is concerned, there is very little risk from fracture of the skull: osseous union commonly occurs without difficulty, unless there has been loss of substance, in which case the gap is filled by means of a firm and dense membrane. If necrosis takes place, the sequestrum is thrown off by a process of ex- foliation, and, if both tables of the skull be involved, the dura mater may 316 INJURIES OF THE HEAD. be seen covered with healthy granulations, and pulsating at the bottom of the wound. Very large portions of the skull may be lost, either at the time of the accident, or at a later period by necrosis, without injury to the patient; and, indeed (paradoxical as it may seem), those cases often appear to do best, in which the skull has suffered most extensively, the force of the blow or other injury spending itself, as it were, upon the bone, and the brain escaping with comparatively little harm. The danger in any case of fractured skull depends upon the amount of injuiy done to the cranial contents, this injury consisting in contusion, laceration, and subsequent inflammation, conditions which have already been con- sidered. Treatment.—The treatment of a fracture of the skull must have refer- ence to the condition of the cranial contents. The question of tre- phining in these cases will be most conveniently considered hereafter; after the operation, if it be resorted to, or in cases in which operative measures are not required, the treatment should be conducted on the principles already laid down for the management of cerebral contusion and laceration, and traumatic encephalitis. Gold to the head, opium, purgatives, liquid food, calomel (in cases of arachnitis), with perhaps blisters or local bloodletting, if coma be threatened, will be found the most useful remedies in the majority of these cases. In cases of compound fracture, loose fragments and foreign bodies should be removed if pos- sible, and depressed but adherent portions of skull elevated, provided this can be effected without too much disturbance. The danger is, how- ever, less from compression than from inflammation, and hence rough handling or careless probing of the brain must be rigorously avoided. Injuries of the Cranial Contents. Wounds of the Brain and Meninges.—The brain or its mem- branes may be wounded, and portions of the cerebral mass itself driven out of the skull in cases of fracture, recovery yet ensuing; it is indeed surprising to see what serious wounds may occasionally be inflicted upon the brain and its membranes, without a fatal result. I saw, at Cuyler U. S. A. Hospital, a soldier who had survived a perforating gunshot fracture of the skull, and Dr. O'Callaghan gives the case of an officer, who lived seven years with the breech of a fowling-piece within his cranium; perhaps, however, the most remarkable cases on record, of recovery after wound of the brain, are those narrated by Prof. Bigelow, and by Dr. Jewett; in the former case an iron bar, three and a half feet long, and weighing thirteen pounds, passed through the head, and in the latter, a somewhat similar injury was produced by a gas-pipe. The symptoms and prognosis of brain wounds will of course vary with the particular part involved. Lesion of the optic tract may cause blindness; or a wound in the neighborhood of the fourth ventricle, sac- charine diabetes. Wounds of the base of the brain are more dangerous, and more quickly fatal, than those of its convexity. The treatment of brain wounds consists in the adoption of the measures which have already been so often referred to, as appropriate in all cases of injury to the contents of the cranium. Hernia Cerebri.—Under this name have been included several dis- tinct conditions, which have merely in common the protrusion of a fun- gous-looking mass through an opening in the skull. This mass may be merely a collection of coagulated blood, or may consist of exuberant TREPHINING IN INJURIES OF THE HEAD.. 317 granulations, proceeding from the dura mater or from the wounded brain itself, but the true hernia cerebri consists of softened and disin- tegrated brain matter, mixed with lymph, pus, and blood. The mass projects through the dura mater and skull, and the superficial portions, which slough and are cast off, are usually replaced by fresh protrusions, until the patient dies exhausted. More rarely the patient may recover, the whole projecting mass being disintegrated and removed, or slowly shrinking without the occurrence of sloughing. It was taught by Guthrie that hernia cerebri was more likely to occur through small openings in the skull, than through large apertures. This view, how- ever, is not confirmed by the experience of all observers, and the occur- rence of the affection appears to depend more upon the condition of the brain, than upon that of the skull. Hernia cerebri usually manifests itself in the course of the first or second week of the injuiy, the period varying with that of the development of cerebritis. The treatment is that of ence- phalitis in general. I doubt if advantage can be obtained from any local treatment, though it is said that in the early stages slight pressure has proved useful. Avulsion, excision, and ligation are all to be reprobated, as more apt to add fresh irritation, than to be productive of benefit. As the affection seems often to result from the imbedding of spiculse of bone in the brain, we should be careful to remove all loose fragments that can be detected; while, on the other hand, as hernia cerebri cannot occur without wound of the dura mater, this membrane should be scru- pulously respected in all our operations upon the skull. Trephining in Injuries of the Head. The objects sought to be attained by the use of the trephine are the removal of compression, whether caused by extravasation, by displaced bone, or by the presence of pus, and the prevention of inflammation, by the removal of foreign bodies, such as sharp spiculse of bone, musket- balls, etc. Trephining is also occasionally employed in the treatment of epilepsy, when it appears probable that the disease is caused by a morbid condition of the skull. Trephining for Extravasation.—If it were possible to be sure that the seat of extravasation were between the brain and dura mater, and that there were no other lesions, operative interference might be employed with some hope of benefit. When it is remembered, however, that the seat of extravasation can very rarely be determined, and that these cases are almost invariably complicated with grave injuiy of the brain substance, it ceases to be a matter of surprise that, as Mr. Hutch- inson puts it, " the modern annals of surgery do not . . . contain any cases in which life has been saved by trephining for this state of things." There are, indeed, a few cases on record, in which blood has been evacu- ated from between the dura mater and skull, or even from the cavity of the arachnoid, the patients recovering; but in the immense majority of instances, the operation, which is now seldom performed under these circumstances, has been useless, or has even hastened death. Hence, I cannot but think that, as a rule, the surgeon will do wisely to abstain from the use of the trephine in these cases, relying upon medical treat- ment, as in dealing with ordinary apoplexy. If the trephine be employed, a large circle of bone should be removed, in order to give room for the evacuation of coagula, and to afford a fair opportunity to secure any vessel that may be found bleeding. 318 INJURIES OF THE HEAD. Trephining for Depressed Bone.—Probably few surgeons, at the present day, would think of operating in a case of Simple Depressed Fracture, without symptoms of compression. Even if there be such symptoms, the advantages to be derived from trephining are, at least, very problematical, for (1) the symptoms, if due to the depressed bone, will probably pass off by the brain accustoming itself to the pressure ; and (2) if the compression persist, it will, most probably, be found to be due to extravasation from laceration of the brain itself, a condition which evidently would not be benefited by trephining. Indeed, Hutchinson goes so far as to consider compression of the brain as the result of de- pressed fracture "an imaginary state," and declares that he has "never seen a case in which there seemed definite reason to think that depres- sion produced symptoms." Although the rule is still given, in most of our surgical works, that trephining is indicated in simple fracture accompanied with marked symptoms, there can be no doubt that hospital surgeons are becoming more and more averse to operating in these cases; and for my own part, I can only say that I have never seen a case of this kind in which I thought the use of the trephine justifiable, nor an autopsy which showed that the operation could possibly have saved life. With regard to Compound Depressed Fractures, it seems to me that the course to be pursued should vary, according as they are or are not impacted. In an impacted fracture the depression is necessarily incon- siderable, and if symptoms of compression are present in such a case, they are due to extravasation or laceration, and not to the depression; moreover, the impaction prevents the access of air to the cranial con- tents, and thus lessens the risk of disorganizing inflammation following the injury. Hence, in impacted fracture, though compound and de- pressed, I would not advise an operation, even if symptoms of compres- sion were present. For one case like Keate's, in which by a happy acci- dent the operator might discover a wound of a large artery, and thus relieve the compression, there are many cases in which trephining could be productive of no benefit, but would, by admitting the atmosphere, seriously complicate the prospects of reco- very. In the case of a non-impacted fracture, the rule has already been given, to remove the loose fragments, and elevate the remainder. In most cases this can readily be done by means of the elevator and forceps, without enlarg- ing the opening in the skull. If, however, the aperture be too small to admit of safe manipulation, there can be no objection to enlarging it, either with a Hey's saw, with cutting pliers, or with a small trephine. The risks of atmo- spheric contact are unavoidable in such a case as this, and the best that the surgeon can do is to clear the wound as well as possible, by the removal of osseous spiculse and foreign bodies. It will thus be seen that I would restrict the use of the trephine within very narrow limits; it is not to be used with the idea of relieving compression, nor with the idea that there is any special virtue in the operation, to prevent encephalitis. The trephine should be used merely as Hey's saw is used, mechanically, to enlarge an opening which would be otherwise too small to allow the surgeon to carry out plain therapeutic indications. The surgeon should cautiously explore every compound non-impacted fracture, and if there be loose spiculse, remove them, whe- ther there be symptoms of compression or not. As the Fig. 159. OPERATION OF TREPHINING. 319 inner table is often more extensively involved than the outer table (especially in punctured fractures), it may be necessary slightly to en- large the opening in the skull in order to remove these spiculse, and this enlargement may be done with or without the trephine, accord- ing to the nature of the case. All this must be accomplished, however, with the utmost caution and gentleness; and I believe, with Brodie, that it is better to leave, imbedded in the brain, a foreign body, or even a fragment of bone, than to add to existing irritation by reckless attempts at its removal. Trephining for Intra-cranial Suppuration.—Some years ago, under the influence of the teaching and example of the celebrated Per- cival Pott, this operation was more frequently resorted to than it is at the present day. As we have already seen, there is, in the large major- ity of cases, no symptom which renders it certain that pus is present; and, as Hutchinson remarks, if we adopt the rule of trephining in all cases in which, after bruise or fracture of the skull, the patient has become hemiplegic or comatose, with inflammatory symptoms, we will operate in twenty cases of arachnitis, for one in which we will find any pus to be evacuated; while even if pus be found, and can be removed, in the immense majority of cases arachnitis will coexist, and cause death in spite of the operation. " I have repeatedly," says Hewett, " seen the trephine applied under such circumstances, and matter evacuated, but without any permanent benefit. Indeed, the successful issue of a case of trephining for matter between the bone and dura mater is, I believe, all but unknown to surgeons of our own time." When the chances of a successful issue after operative measures are so slight, the surgeon will, I think, do wisely to abstain from the operation ;* more especially as these cases will occasionally recover, at least temporarily, under expectant treatment. Even if pus be present, it is impossible to know that it is within reach, and cerebral abscess may continue for many years, producing little or no disturbance; while, though recovery has occasionally followed trephining under these circumstances, the ope- ration has in many more cases but superadded a new injury to those already existing. Chassaignac has proposed to trephine as a prophy- lactic against pyaemia, in cases of contused skull; but the operation is surely not justified, either by experience, or by what we know of the eti- ology of the affection meant to be prevented. With regard to Trephining for Epilepsy, I can only say that I consider the operation unadvisable. Its risks are not inconsiderable, sixteen out of seventy-two cases collected by Billings having proved fatal; and when we remember the well-known fact that epilepsy is apparently and temporarily curable by very various remedies, which have at least the merit of being harmless, we should pause before recommending an ope- ration which may not improbably itself cause death, and of which the prospective benefits, as regards permanence, are certainly doubtful. Operation of Trephining.—The form of trephine ordinarily em- ployed is shown in the accompanying illustration (Fig. 160). It is to be 1 Unless, as in cases successfully trephined by Watson, of Edinburgh, and N. E. Smith, of Baltimore, an orifice in the skull should plainly communicate with an intra-cranial abscess. Under such circumstances, if the opening were insufficient, the operation would of course be indicated. 320 INJURIES OF THE HEAD. applied evenly on the surface of the skull, with the centre pin1 slightly projected, and is to be worked cautiously by light turns of the wrist from left to right and from right to left, until a groove is formed, when the centre pin must be withdrawn, lest it puncture the skull and wound the dura mater. The surgeon then proceeds slowly and gently, brushing away the bone- dust, from time to time, and testing the pro- gress made by means of a fine probe or toothpick. When the diploe is reached (if there be any), the trephine works more freely, and blood escapes with the bone-dust. As the inner table is approached, the sur- geon must renew his precautions, lest undue pressure, or an accidental slip of the instru- ment, should wound the dura mater, an occur- rence which would be very apt to prove fatal. The disc of bone which has been separated will often come away in the crown of the trephine, or may otherwise be readily removed with the elevator (Fig. 161) and for- ceps. If the external wound be not large enough to allow the applica- Common trephine. Fig.161. Different forms of elevator. tion of the trephine, more room may be afforded by means of a crucial or T incision, the flaps of the scalp being held out of the way, and care- fully replaced when the operation is completed. The wound should then be lightly dressed, and the constitutional treatment of the patient carried out in accordance with the principles already laid down for the management of cerebral injuries. There are certain regions of the skull to which the trephine should not be applied, if it can be avoided; these are the various sutures, the lines of the large venous sinuses, the anterior inferior angle of the parietal bone (where there would be risk of wounding the middle meningeal artery), and the frontal sinus; if it should be neces- sary to operate in the latter situation, the outer table should be removed with a large trephine, and the inner table with a smaller instrument. The Conical Trephine (Fig. 162) is an old instrument, the use of which has been recently revived by Gait, of Virginia. It has the advan- tage over the common instrument, that its peculiar shape prevents the possibility of its unexpectedly plunging into the brain; it, however, has the disadvantage that it divides the skull obliquely, and thereby exposes the part to greater risk of necrosis. The results of the operation of trephining are very unfavorable, the pro- 1 If the use of the centre pin be undesirable, the crown of the trephine may be steadied by applying it through a piece of perforated pasteboard, as suggested by Dr. P. H.Watson, of Edinburgh. INJURIES OF THE BACK. 321 portion of recoveries having been in the New York Hospital only about 1 in 4, and in University College Hospital (London) 1 in 3, while in Paris almost every case operated on of late years has, according to Nelaton, proved fatal. The majority of Fig. 162. deaths after trephining are, however, due, not to the operation, but to cerebral lesions on which the opera- tion could have no effect, so that statistics are yet wanting to show the absolute mortality of the opera- tive procedure. During our late war,1 107 cases of trephining gave 60 deaths and 47 recoveries; 114 cases of elevation of fragments, without trephining, gave 61 deaths and 53 recoveries; while 483 cases treated by expectancy gave 384 deaths and only 99 recoveries. As, however, the latter group of cases contained almost all the instances of penetrating and perforating frac- ture, it would be manifestly unfair (as the reporter very justly remarks) to found upon these statistics any argument as to the value of the operation of trephining. Perhaps we can most nearly approach a correct estimate of the risks of the operation itself, by con- sidering the statistics already referred to, of trephining for epilepsy. In these cases the only traumatism, to borrow a Gallicism, is that due to the operation itself, and here we find that 72 cases gave 16 deaths, a mor- tality of about 22 per cent. But, even with this com- paratively small figure, it behooves the surgeon to be conical trephine. very cautious not unnecessarily to employ an opera- tion which of itself kills one out of every four or five patients, more especially as, upon consideration of the pathology and natural history of brain injuries, the probability of benefit from the operation is seen to be limited to an exceedingly small number of cases. CHAPTEE XYI. INJURIES OF THE BACK. Wounds or other injuries of the soft tissues of the back present no peculiarities requiring special comment. It is, indeed, only in conse- quence of the liability of the vertebral column and its important contents to be involved in lesions of the back, that injuries of this region acquire the interest which they possess in the eyes of the surgeon. In entering upon the important subject of spinal injuries, I shall consider, first, the traumatic lesions of the spinal cord itself, reserving for a later page what I have to say with regard to sprains, fractures, and dislocations of the vertebral column. 1 Circular No. 6, S. G. O., 1865, p. 9. 21 322 INJURIES OF THE BACK. Injuries of the Spinal Cord. Concussion of the Spinal Cord.'—This may vary, like concussion of the brain, from the slightest jarring or shaking, up to complete disor- ganization. Unlike concussion of the brain, however, it is very seldom that the spinal injury is so severe as to prove immediately, or even rapidly fatal (except when accompanied by fracture or dislocation), death as a result of spinal concussion usually occurring after a considerable interval, and being preceded by inflammation of the spinal meninges or of the cord itself, or by progressive softening without inflammatory symp- toms. The reason for this difference is, as pointed out by Lidell, Shaw, and others, that the spinal cord floats loosely in an elastic medium (the cerebro-spinal fluid), and is therefore not so readily exposed to injury as the brain, which fits comparatively closely to its bony investment. I do not believe it possible for death to occur from concussion of the spinal cord, without lesions demonstrable by post-mortem inspection. Though several cases have been recorded by Boyer, Frank, and others, in which such an event has been supposed to occur, it is probable that, with the more accurate means of examination which are now possessed, posi- tive lesions could have been discovered. Death may, of course, occur from shock, which is an occasional complication of spinal injuries ; or from concomitant lesions of other organs—lesions which may readily escape detection, if attention be directed chiefly to the condition of the spine.2 The post-mortem appearances, in fatal cases of spinal concussion, may be classed as (1) extravasation of blood—which may occur in the substance of the cord itself, between the cord and its membranes, or between the latter and the vertebral column ; (2) laceration of the membranes, or of the cord ; (3) inflammatory changes—meningitis or myelitis—with or without compression of the cord from the so-called products of inflam- mation, lymph, pus, etc.; and (4) degeneration of the structure of the cord, without any evidences of pre-existing inflammation. Hemorrhage into the Vertebral Canal is a not unfrequent occurrence in severe cases of spinal injury. If in small amount, it may give rise to but transient paralysis, the effused blood becoming coagu- lated and partially absorbed, and the compressed cord becoming gradu- ally accustomed to its presence; in other cases it may remain in a fluid condition, or may possibly be clotted and subsequently reliquefied. In some cases it would appear that slow extravasation may continue for a considerable period, fatal paralysis not coming on for some time after the injury (in Mr. Heaviside's case nearly a year), and death thus result- ing, as pointed out by Aston Key, from the cumulative effect of spinal compression. I do not know of any sign by which the surgeon can positively determine the exact seat of extravasation, in cases of spinal hemorrhage; in the majority of instances the effused blood is found outside of the membranes, or between the latter and the cord; and it is probably in one of these positions that extravasation usually occurs, when the symptoms are slow and progressive in their development, and 1 The term concussion is retained from motives of convenience. It is not, how- ever, scientifically correct, the various conditions which are designated by the term concussion, being really instances of contusion, partial rupture of the cord fibres, etc. See remarks on Concussion of the Brain, in Chap. XV. 2 See, in connection with this subject, an interesting paper by Dr. W. Moxon, on thrombosis of the renal vessels through injury to the lumbar spine (Guy's Hosp. Reports, 3d s., vol. xiv. pp. 99-111). INJURIES OF THE SPINAL CORD. 323 when the power of motion is more affected than that of sensation. Ex- travasation into the substance of the cord itself, would probably cause instant paralysis, both motor and sensory, which might be permanent, or in a favorable case might subsequently disappear. This is the most plausible explanation of the symptoms in the remarkable case recorded by Hughes, of Dublin, in which an injury of the cervical spine caused instant but temporary loss of both motion and sensation, in the lower extremities, followed by gradually developed but long-persistent motor paralysis, in the upper extremities. Instant loss of both motion and sensation, if temporary, may be supposed to be due to a slight hemor- rhage into the substance of the cord itself; while gradually developed paralysis, especially affecting the motor power, may be reasonably at- tributed to hemorrhage upon the surface of the cord, or even outside of the membranes. The upper limit of paralysis will, of course, indicate clearly the height at which the extravasation has occurred. Laceration or Rupture may occur in the spinal membranes (par- ticularly the pia mater, allowing a hernia of the medulla), or in the fibres of the spinal cord itself. These lesions are, however, more fre- quently produced by violent twistings or bendings, or by fractures or dislocations of the spinal column, than by any injury to which the term concussion can be properly applied. Inflammation of the Spinal Membranes (Meningitis), and of the Cord (Myelitis), are very frequent secondary occurrences in cases of spinal injury. In spinal meningitis there is great congestion, and often effusion of serum, or formation of lymph or pus. Myelitis may affect the whole thickness of the cord, or principally the gray matter; though, if consecutive to meningitis, the white portion may alone be involved. Inflammation of the cord substance is commonly attended with softening, which may end in total disappearance of the nervous structures at the part affected—nothing but connective tissue remaining; more rarely induration occurs, the nervous substance being increased in bulk, and of a dull whitish color. The occurrence of inflammation, in cases of spinal injury, is attended with great pain, distressing sensations, as of a cord tied around the waist or limbs, tetanic spasms, general con- vulsions, etc. Progressive Disorganization of the Cord may occur as the result of injury to the spine, without the manifestation of any evidence of inflammation, either during life, or upon post-mortem inspection. Pa- ralysis, both motor and sensory, sometimes accompanied with muscular rigidity, gradually creeps upwards, until death ensues from interference with the respiratory function. The autopsy shows diffused white soften- ing of the spinal cord, without evidence of either meningitis or myelitis. In other instances the cord, to the unaided eye, appears perfectly healthy, though marked changes are subsequently discovered by careful micro- scopic inspection (H. C. Bastian, Med.-Chir. Trans., vol. 1. pp. 499-542). Wounds of the Spinal Cord.—The spinal cord may be wounded by sharp cutting instruments, by pistol-balls, etc., without any, or with very slight injuiy to the vertebral canal. The symptoms of such a lesion are those which we shall presently consider as common to all spinal injuries, though there may be some modifications, owing to the 324 INJURIES OF THE BACK. greater limitation of the injury to certain parts of the cord, than in cases of spinal concussion, or of vertebral fracture or dislocation; thus, while in the latter classes of cases paralysis is usually bilateral, and involves both motion and sensation, in cases of wound of the cord we not unfrequently find paralysis only of the side injured, as in instances recorded by Vigne"s, Peniston, and others, or loss of motion on the injured, and loss of sensation on the opposite side, as in cases narrated by Boyer, and by Hughlings Jackson. Symptoms of Spinal Injuries.—The following account of the symptomatology of injuries of the spine is to be understood as applying to all forms of injury in which the cord is involved, whether the vertebral column itself has or has not escaped: as we shall see hereafter, the differential diagnosis of the various forms of spinal injury is often im- practicable, and always difficult, a fact which is not surprising when we reflect that the rational symptoms are the same in the various forms of lesion. I shall adopt the classification of symptoms, which I em- ployed in my monograph on Injuries of the Spine, published in 1867, and which is pretty much the same as that used by Brodie, in his classical paper in the Medico- Chirurgical Transactions, vol. xx. Motor Paralysis.—The most striking, and probably the most constant symptom in cases of spinal injuiy, is paralysis of the voluntary muscles below the seat of lesion. When the injuiy is below the second lumbar vertebra, there may be no paralysis, or if it exist, it is usually partial and temporary, the spinal cord itself not usually extending below this point, and the cauda equina appearing to be comparatively free from risk of injury. In lesions below the eleventh dorsal vertebra, the paralysis is usually less complete than in those at a higher point, the cord being protected in this part by the roots of the cauda equina. Paralysis, ordi- narily, does not extend to parts which derive their nervous supply from the portion of the cord above the seat of injury, and the exact point of lesion can be thus determined in most cases: the apparent exceptions reported by Stafford, Brodie, and others, are probably explicable by the fact that a second lesion, such as contusion or extravasation, existed at the higher point, as the result of indirect violence, to which the older writers would have given the name of counterstroke. The extent of the spinal lesion in a downward direction, may be determined by means of the electrical test, proposed by M. Landry. This surgeon found, in a case of luxation of the fifth dorsal vertebra, that the muscles of the thigh ceased to respond to electricity, while those of the leg, though equally paralyzed, continued to contract in response to the electric stimulus. The autopsy showed that the part of the cord which supplied nerves to the femoral muscles was disorganized, while that whence arose the nerves going to the leg was quite healthy. Thus the fact that each segment of the cord constitutes a separate nerve centre, affords a means of accurately determining the extent of that portion which has been injured. Motor paralysis is usually symmetrical: when unilateral (as in a case of fractured spine observed by Liston), it indicates that one side only of the cord is involved, as in the instances of wound of the cord already referred to. Motor paralysis after spinal injuries may be due to various causes, as to division of the cord fibres, to compressions (either from extravasation, or from the products of inflammation), or to progressive disorganization of the nervous structures. If the paralysis be immediate, complete, and permanent, the cord is probably divided; if the paralysis be immediate, but not permanent, the case is one of so-called SYMPTOMS OF SPINAL INJURIES. 325 "concussion"—the lesion probably being a slight extravasation into the substance of the cord, though this is, of course, mere matter of conjec- ture; paralysis coming on gradually, and subsequently diminishing, is probably due to compression on the surface of the cord, from extravasa- tion or from inflammatory changes; while slowly but continually extend- ing paralysis gives reason to fear progressive disorganization of the cord—a condition which, almost always, ultimately proves fatal. A few cases are referred to by Velpeau, in which the cord is said to have been completely divided, without any paralysis having existed during life; it is scarcely necessaiy to say that these cases admit of but two explanations—either, as believed by Brodie, that they were incorrectly observed, the division of the cord fibres not being complete—or, as sug- gested by Prof. Brown-Sequard, that the division was at a point below the origin of most of the spinal nevres. Muscular Spasms or Convulsions after spinal injuries were believed by Brodie to indicate compression of the cord, and I believe this state- ment to be correct, as regards the spasms met with in the early stages of these cases. The value of this symptom for diagnostic purposes is, however, diminished by the fact that the cord is often found compressed, after death, without spasms having been observed during life. The occurrence of convulsions, at a later period (as already mentioned), may denote the onset of spinal meningitis; while again, in cases which recover, muscular twitchings not unfrequently accompany the return of motor power. Loss of Sensation usually accompanies and is coextensive with motor paralysis, in injuries of the spine. So complete was the loss of feeling in a case recorded by Purple, that the patient submitted to amputation of both thighs, without the use of an anaesthetic, and without manifesting any emotion during the operation. Occasionally sensory precedes motor paralysis, while, on the other hand, in favorable cases, the power of feeling is not unfrequently regained, while that of motion is still very imperfect. Hyperesthesia is occasionally observed in connection with motor paralysis. South saw a case of fracture of the cervical spine in which there was loss of motion with hyperaesthesia on the right side, and anaesthesia on the left. On the other hand, in a case reported by Gama, intense hyperaesthesia followed a bayonet wound of the posterior columns of the spinal cord, there being absolutely no paralysis; a circumstance which, as pointed out by Brown-Sequard; would indicate that the anterior portion of the cord had escaped injury. A zone of hyperaesthesia some- times marks the upper limit of sensory paralysis, due probably to irrita- tion of the spinal nerves, before their exit from the vertebral canal. Pain is a symptom of frequent occurrence in spinal injuries ; it may be felt at the seat of lesion, or may be referred to various other parts of the body. Unusual and often most distressing sensations, as of burning, constriction, etc., may be referred to parts, the nervous con- nection of which with the sensorium is entirely destroyed. Dyspnoea.—This is a marked and distressing symptom of injuries of the cervical and upper dorsal regions of the spine. It is often said that, in lesions of the cervical cord, respiration is performed by the diaphragm alone; this is not strictly correct, for, as pointed out by Shaw, in many cases the diaphragm is helped by the serratus magnus muscle (supplied by the external thoracic nerve), which, when the shoulders are fixed, tends to lift and expand the chest. If the spinal cord be destroyed above the origin of the phrenic nerve, death is instantaneous. The oc- 326 INJURIES OF THE BACK. currence of dyspnoea in dorsal injuries depends upon two causes: first, the abdominal muscles being paralyzed, the act of expiration is neces- sarily incomplete; and, secondly, paralysis of these muscles allows the bowels to become distended with gas, thus thrusting the diaphragm up- wards, and mechanically impeding its motion. The occurrence of dyspnoea at a late period of spinal injuries is attributable to progressive disor- ganization of the cord, extending upward to the cervical region. Dysphagia and Vomiting have been observed in injuries of the cervical spine, as has Jaundice in those of the dorsal region, without any hepatic lesion having been discovered after death. Involuntary Fecal Discharges are met with in those cases in which the injury has involved the lowest portion of the cord—that which pre- sides over the sphincter muscle of the rectum; when the lesion is at a higher point, this part, having escaped injuiy, continues to act, for a time at least, as a separate nerve centre, and Costiveness ensues. In some cases there may be temporary fecal incontinence, depending on shock, which is coincident with, though not necessarily dependent upon, the spinal lesion. Retention of Urine is present in most cases of spinal injury, being followed after a time by Overflow, and subsequently by true Incontinence. A few cases are recorded by Morgagni and others, in which incontinence was present from the outset. Suppression of Urine is a more serious, but, fortunately, a rarer symp- tom than retention. Several remarkable instances of this occurrence have been recorded by Brodie, Dorsey, Comstock, and others. Hsematuria, from coincident contusion or partial laceration of the kidneys, is not unfrequently met with in cases of sprain of the lumbar spine. This symptom is not usually one of serious import, though Mr. Shaw reports a case in which the bleeding was so profuse as to render the patient anaemic. There is, according to Le Qros Clark, no reason to believe that organic disease of the kidney ever ensues in these cases. Glycosuria has been met with in connection with injury of the cervical spine; the circumstance is interesting, in view of the experiments which have been made as to the artificial production of diabetes. Changes in the Urine Occurring after Spinal Injuries.—Within a short time, varying from the second to the ninth day after a severe injury to the spine has been received, the urine, from being clear and acid, becomes turbid, ammoniacal, and loaded with mucus, and at a later period with phosphate of lime. This condition may continue indefinitely, or may disappear, or acidity and alkalinity of the urine may alternate, without any very obvious reason. In some rare cases, according to Brodie, the urine first secreted after a spinal injury, though acid and free from mucus, has a peculiarly offensive and disgusting odor. In other cases, it is highly acid, having an opaque yellow appearance, and depositing a yellow amorphous sediment, which, in one instance, stained the mucous membrane of the bladder, though the latter presented no marks of inflammation. Cystitis is an almost constant sequence of severe spinal lesions; it is probably due, chiefly, to the mechanical injuiy to the bladder, from over-distension and the frequent use of the catheter, but is, no doubt, further aggravated by the altered character of the urine. This altera- tion, however, is itself usually secondary, depending on the inflamed state of the lining membrane of the bladder, though, in some cases, according to Hilton, the urine is alkaline as it comes from the kidneys. SYMPTOMS OF SPINAL INJURIES. 327 Priapism—This curious symptom is occasionally met with in con- nection with lesions of all portions of the spinal cord, except the lowest. It is totally unconnected with any voluptuous sensation, and is only found in cases accompanied by motor paralysis. In some cases, par- ticularly when the injury is in the cervical region, priapism may occur spontaneously, immediately after the accident, and is then due (as pointed out by Hilton) to the excito-motor function of the portion of the cord below the lesion being unduly excited, because deprived of the regu- lating influence of the brain. In other instances this symptom is devel- oped—also spontaneously—at a later period, owing to central irritation, generally from slight extravasation into the substance of the cord ; while in still other cases it occurs merely as a reflex phenomenon, and may be excited by touching the scrotum or by passing the catheter. The ex- istence of priapism is usually evidence of severe and permanent injury to the spinal cord, though that this symptom may occur in connection with simple concussion is shown by a case recorded by Le Gros Clark, in which sensation returned on the ninth day, though the power of mo- tion was not restored for several months. Flushed Face, usually accompanied by Lachrymation, and by Contracted or merely Myotic Pupils, is, I believe, only met with in cases of injury in- volving the cervical portion of the cord. It appears to be due to a par- tial paralysis of the sympathetic nerve, which derives its cervico-cephalic branch from the so-called " cilio-spinal region" of the spinal cord. This symptom is one of very grave import. Alteration of Vital Temperature is a symptom which has been par- ticularly investigated by Chossat and Brodie. The temperature of the paralyzed parts frequently rises much above the normal standard, this symptom being probably most frequent in lesions of the upper portion of the cord, though a temperature of 100° has been noted by Hutchin- son, in a case of fracture of the lumbar spine. In a case of injury of the cervical region, observed by Brodie, the thermometer placed between the thighs rose to 111° Fahr., and this elevated temperature persisted even after the patient's death. This symptom, to which Hutchinson gives the name of Paralytic Pyrexia, is probably due, like the flushing of the face, to a paralyzed condition of the sympathetic or vaso-motor nerve. Per- sistent elevation of temperature, in spinal injuries, is a very grave symp- tom, and always affords grounds for a gloomy prognosis. In the later stages of spinal injuries, the temperature of the paralyzed parts often becomes greatly reduced; and even when there is no real diminution of temperature, the patient often experiences a distressing sensation of coldness. Nutritive Changes in Paralyzed Parts.—In patients who survive the first risks of spinal injury, the paralyzed extremities usually, but not always, become flabby and atrophied; the skin assumes a sallow hue, and often desquamates in flakes; the joints are often contracted and stiff. Partly from the lessened vitality of the tissues, but more prob- ably from the patient's insensitiveness to pain, and inability to change his position, gangrene and sloughing are apt to occur in parts that are exposed to pressure; large bed-sores are thus formed over the sacrum, hips, knees, or any part that touches the bed, and may slowly exhaust the patient's strength, or, more rarely, may give rise to pyaemia, and thus quickly induce a fatal result. Bed-sores are most frequently met with in cases of injury of the lower portion of the cord, simply, I be- lieve, because in these cases life is more often prolonged, than when the upper part of the spine is involved. 328 INJURIES OF THE BACK. Tetanus, contrary to what might d priori be expected, is rarely met with in cases of spinal injury; in a case at St. Thotnas's Hospital, it occurred three weeks after a blow on the spine, the patient recovering; while in a fatal case which occurred during our late war, the autopsy showed, in addition to the spinal lesion, a contusion of the anterior crural nerve. Cerebral Complications.—Concussion of the Brain may complicate injuries of any portion of the spinal cord, resulting either from direct violence simultaneously inflicted on the head, or from counterstroke. Delirium, Coma, and Insomnia have each been occasionally noted in cases of spinal injury, the latter symptoms* however, I believe, only in instances in which the cervical region has been involved. Cerebral Menin- gitis, as observed by Ollivier, often complicates inflammation of the spinal membranes. Concussion of the Spine from Indirect Causes; Railway Spine.—Under these, or similar names, is described by Erichsen, and other English surgeons, a peculiar morbid condition characterized by very varied nervous symptoms, both physical and mental, which, accord- ing to these authors, are all directly traceable to the state of the spine. This subject has excited a great deal of interest, and a great deal of controversy, chiefly because of the numerous suits for damages, which have been brought against railway companies, on account of alleged injuries received in collisions. The symptoms appear to be rather those of general nervous prostration and debility, than the definite spinal symptoms which have been discussed in the preceding pages, and are often accompanied by remarkable perversions of the special senses, double vision, photophobia, tinnitus aurium, loss of tactile sensibility, etc. Many of the symptoms resemble those of ordinary progressive loco- motor ataxia. "The state of the spine," says Mr. Erichsen, "will be found to be the real cause of these symptoms. On examining it by pressure, by percussion, or by the application of the hot sponge, it will be found that it is painful, and that its sensibility is exalted at one, two, or three points. These are usually the upper cervical, the middle dorsal, and the lumbar regions. The exact vertebrae that are affected vary ne- cessarily in different cases; but the exalted sensibility always includes two, and usually three, at each of these points. It is in consequence of the pain that is occasioned by any movement of the trunk in the way of flexion or rotation, that the spine loses its natural suppleness, and that the vertebral column moves as a whole, as if cut out of one solid piece, instead of with its usual flexibility." Other writers of eminence are disposed to doubt the necessary connection of these symptoms with any particular morbid condition of the spine, looking upon "these cases of so-called railway spinal concussion as, generally, instances of nervous shock, rather than of special injury to the spinal cord."1 There is, so far as I know, but one case, in which the post-mortem appearances after death from "railway concussion" have been recorded, and that is Mr. Gore's case, which has been successively published by Dr. J. Lock- hart Clarke, Mr. Erichsen, Mr. Le Gros Clark, and Mr. Shaw. The con- dition of the cord in this case closely resembled, as pointed out by Le Gros Clark, that which, according to Dr. Radcliffe, is found in ordinary cases of locomotor ataxia, so that there is at least room for suspecting, with Mr. Shaw, that the spinal injury was a mere coincidence—particu- 1 Le Gros Clark, Lectures on the Principles of Surgical Diagnosis, etc., p. 152. INJURIES OF THE VERTEBRAL COLUMN. 329 larly as Mr. Gore, the attending surgeon, did not see the patient until a year after the injury. "On the whole, it may be affirmed," says Mr. Shaw, " that what is most wanted for the better understanding of those cases commonly known under the title of 'concussion of the spine' is a greatly enlarged number of post-mortem examinations. Hitherto our experience has been derived almost wholly from litigated cases, deformed by contradictory statements and opinions; and the verdicts of juries have stood in the place of post-mortem reports." In view of the great obscurity which is thus seen to surround this subject, I think the surgeon will do wisely to exercise great caution in declaring that a patient is suffering from "concussion of the spine from indirect causes," whether the result of railway, or of other injury; at the same time there can be no doubt that grave morbid changes in the spinal cord do result from comparatively slight blows upon the back, and, of course, in a rail- way collision, it is very possible that an injury might be received, which would induce such changes. This fact has long been recognized in a general manner, but is clearly proved by a case which Dr. H. Charlton Bastian has published in the fiftieth volume of the Medico-Chirurgical Transactions, and which has been already referred to (see page 323). Injuries of the Vertebral Column. Sprains.—When we consider the number of joints in the vertebral column (nearly eighty), it is not surprising that twists and sprains in this part are occasionally met with, but rather that they are not more frequent than experience shows them to be. The part of the spine most exposed to sprains is the lumbar region, next the cervical, and lastly the dorsal, which is rarely affected. Apart from the risk of concomitant lesion of the cord, these injuries, though quite painful, are not commonly attended with danger. They may be caused by various forms of acci- dent, as by falls or sudden twists, and are not unfrequently met with as the result of railway collisions. The symptoms, provided the cord be not involved, are those of sprains in other parts of the body, local ten- derness, pain on motion, etc. In most instances the ligamentous and other affected tissues gradually return to a healthy condition, but under other circumstances, if great stretching and laceration have occurred, permanent weakening of the part may ensue, requiring the constant em- ployment of artificial means of support. An occasional but more dan- gerous consequence is the extension of inflammation to the structures within the vertebral canal, fatal meningitis or myelitis thus sometimes supervening upon what at first was a simple sprain. In other instances, particularly in the case of the occipito-atloid and atlo-axoid articulations, the accident becomes the exciting cause for the development of chronic disease (white swelling) of the joint, an affection which in this situation may prove suddenly fatal, through the occurrence of secondary dislo- cation. The treatment of vertebral sprains, unaccompanied by cord lesion, is essentially that of sprains in other parts of the body. Rest, mechani- cal support, soothing applications at first, and at a later period stimu- lating embrocations, with friction, and perhaps the cold douche, will usually be found sufficient to effect a cure. It is often desirable to con- tinue the use of mechanical means of support, such as a moulded gutta- percha splint, or leather belt, for some time after apparently complete recovery. The treatment of the cord complications, when present, is the same as in other forms of spinal injury, and will be considered when we 330 INJURIES of the back. have disposed of the remaining varieties of mechanical injury to the vertebral column. Fractures and Luxations of the Vertebral Column.—I shall consider these two forms of spinal injury together, because, in the first place, they are very commonly associated in the same case, and because, secondly, it is often quite impossible to determine whether a given injury of the spine be a fracture or a dislocation, until a post-mortem examina- tion reveals the exact nature of the lesion. The possibility of luxation occurring in the vertebral column has been denied by many surgeons, and Sir Astley Cooper, with his large experience, declared that he had never met with a case of this nature; other writers, however, have con- sidered them comparatively frequent, and Mr. Bryant states, that of seventeen autopsies made at Guy's Hospital in cases of spinal injury, during six years, no less than six showed the lesion to have been pure dislocation. I have not myself met with any instance of absolutely uncomplicated spinal dislocation, but the elaborate tables which I have published in the monograph, already referred to, show that 124 of 394 recorded cases of spinal injuiy were believed by the surgeons who reported them to have been of this nature. I cannot help suspecting, however, that in many, if not most, of these cases there was some slight bone lesion which escaped attention, so that perhaps the term diastasis would, in many instances, be more strictly applicable than dislocation. The large majority of reported cases of vertebral luxation have involved the cervical spine, the smallest proportion being found in the lumbar region. Causes.—The causes of these injuries of the vertebral column are very various: in most of the instances, met with in civil practice, the alleged causes have been falls or blows, acting sometimes by direct, but probably more often by indirect violence. In the cervical region, these injuries have resulted from falls upon the head, or the buttocks, from plunging headlong into shallow water, from falls in turning somersaults, from the head being twisted, in executions by hanging, etc. It is popularly believed that hanging usually causes death by dislocating the cervical spine— breaking the neck, as it is called—but this is an error. Unless the head be after suspension wrenched to one side (as, according to Louis, was formerly done by the Lyons hangman, who sat on the shoulders of his victims, and twisted their necks until he heard a crack), dislocation does not commonly occur. Fractures and luxations of the vertebrae are, as might be expected, more frequent among men than women, in the pro- portion of nearly seven to one. No age is entirely exempt from these injuries, though most cases occur among those in early adult life. Maschka has recorded a case of dislocated axis, in a child killed by its mother, when it was only eight days old, while Arnott saw a fracture of the same bone, produced by falling down stairs, in a man aged seventy- four. Symptoms.—The rational symptoms of vertebral fracture and dislo- cation, are due to the accompanying lesions of the spinal cord, and are those which have already been described as common to all forms of spinal injury. The physical signs, or those which are peculiar to the mechanical disturbance of the vertebral column, are deformity, increased or diminished mobility, and crepitus. Local pain and tenderness on pres- sure, though often present in these cases, are in no wise distinctive, for they are frequently more strongly marked in sprains, than in these more serious injuries. INJURIES OF THE VERTEBRAL COLUMN. 331 Fur. 163. (1.) Deformity is usually more perceptible in the dorsal or lumbar, than in the cervical region. A depression in the position of one or more spinous processes may be generally taken to indicate fracture, which may involve the vertebral arches, or merely the spi- nous processes themselves. Fracture of the body of a vertebra, by allowing the approximation of the vertebrae above and below, usually causes angular deformity marked by undue prominence of the spinous process of the affected vertebra, or of that next above. Rotatory defor- mity, or twisting of the spinal column upon its long axis, may be considered indicative of luxation, which may or may not be accompanied by fracture: it is seldom recognized, I believe, during life, except in the cervical region. Bilateral dislocation, an injuiy almost exclusively confined to the neck, would be marked by angular deformity, and, if in a backward direction, probably could not in most cases be distinguished from fracture of the vertebral body. Though deformity, when "present, is probably the most sig- nificant of all the physical signs of these varieties of injuiy, its absence by no means proves that fracture or luxation has not occurred. Indeed, my tables of spinal injuries show that deformity has only been noted in about one-fourth of the whole number of cases, and it is easy to understand, in view of the deep-seated position of the ver- tebral column, that fatal displacement might occur, which yet might not be revealed except by careful post-mortem dissection. (2.) Undue Mobility has been occasionally observed in cases of verte- bral injuiy, chiefly in the cervical region, and, on the other hand, Immo- bility has been noted in about the same number of instances. I do not know that either of these symptoms can be relied upon to distinguish the injury, in any given case, from simple sprain of the vertebral column, and the surgeon should exercise great caution in his tactile investiga- tions upon this point, as very slight force, or even an unwary movement, might induce displacement, which in the cervical region would probably cause instant death. (3.) Crepitus, if present, would of course warrant the diagnosis of fracture, though it could not indicate in what part of the vertebra the lesion existed. Statistics show, however, that crepitus has been ob- served in about two per cent, only of recorded cases. Diagnosis.—From what has been said, it will be perceived that, as already observed, the differential diagnosis of spinal injuries is always difficult, and often impossible. This is, however, fortunately a matter of no practical moment, for, as we shall presently see, the treatment is essentially the same, whatever may be in any case the exact nature of the injury. Prognosis.—The prognosis of fracture or luxation of the vertebrae, while always grave, is not by any means so gloomy as is ordinarily Bilateral forward dislocation of the fifth cervical vertebra. (Ayres.) 332 INJURIES OF THE BACK. represented. Sir Astley Cooper, and more lately Prof. Brown-Sequard, have surmised that the proportion of recoveries in these cases is less than one per cent., while Mr. Erichsen goes so far as to declare that "fractures of the spine through the bodies of the vertebrae, with displace- ment, are inevitably fatal." The opinion of these authors is not, how- ever, borne out by the results of statistical investigation, which show that the mortality of terminated cases met with in civil practice varies from 78 per cent, in injuries of the cervical region to so low a figure as 61 per cent, in those of the lumbar spine, the corresponding proportions of recoveries being 18 per cent, in the former, and 27 per cent, in the latter region. The chances of a fatal issue in these cases vary inversely with the distance of the point of injury from the brain. Lesions above the third cervical vertebra prove usually immediately, or very quickly fatal, though instances of long survival, or even of complete recovery, after fractures of the atlas or axis, have been recorded by Phillips, the elder Cline, Willard Parker, W. Bayard, of Canada, Stephen Smith, and several other surgeons. The prognosis in cases of gunshot fracture of the vertebrae is, how- ever, very unfavorable. Every case in which the spinal canal was in- volved, which occurred in the British army during the Crimean war, proved fatal; while, according to Circular No. 6, S. G. 0., 1865, only one instance was recorded during our late war, in which recovery followed such an injury. In a case reported by Drs. Mitchell, Morehouse, and Keen, exfoliation of numerous fragments (one of which included a por- tion of the anterior half of the vertebral canal) occurred, the patient eventually recovering; but the whole Fig. 164. history of the case forbids the idea that the spinal canal was primarily involved in the injury. Duration of Life in Fatal Cases.— With regard to this point, it may be said, in general terms, that of cases of fatal injury in the cervical region, two-thirds die during the first week; in the dorsal region, two-thirds dur- ing the first month; and in the lum- bar region, about the same proportion during the first year. Condition after Recovery.—Bony union is, according to Rokitansky, rarely met with after fracture of the vertebrae, though instances of its oc- currence have been recorded by Clo- quet, Aston Key, and others. The ac- companying cuts (Figs. 164,165,166), from photographs given me by Dr. Richard A. Cleeman, of this city, illus- trate very beautifully the occurrence of osseous union after spinal fracture. The specimen, which was derived from the body of a patient whom I saw in Bony union of fractured vertebra. consultation with Dr. Cleeman, is one of very great interest, showing, in ad- dition to a fracture of the lumbar vertebrae, unilateral dislocation, which is a rare lesion in this region of the spine. The case illustrates the INJURIES OF THE VERTEBRAL COLUMN. 333 difficulty of diagnosis in these injuries, for careful examination during life revealed merely prominence of one vertebral spine, with a correspond- ing depression below it—thus indicating fracture of a vertebral body, but giving no reason to suspect the existence of luxation. Fig. 165. Fig. 166. Fracture of vertebral body, and unilateral dislocation of a lumbar vertebra. With regard to the general condition of patients, after recovery from injuries of the vertebral column, the prognosis will, of course, depend chiefly upon the nature and extent of the lesion to the spinal cord. If any portion of the cord be completely divided or disorganized, the parts of the body which derive their nervous supply from below the seat of injury will necessarily be permanently paralyzed. Prof. Eve has col- lected seven cases, in which the cord was found by post-mortem inspec- tion to be for a greater or less space entirely deficient, and in which life was yet prolonged for periods varying from a few days to twenty-two years ;l and the only instance of these in which paralysis was not con- stant from the time of injury, was Mr. Shaw's case, in which the cord appears at first to have been comparatively slightly injured, its want of continuity, as found at the autopsy, having been due to subsequent dis- organization, which produced a return of paraplegia before death. The only case with which I am acquainted, in which complete recovery is sup- posed to have followed complete division of the cord, is one reported by Dr. Eli Hurd, of New York, in which, however, the diagnosis was not confirmed by post-mortem inspection. When the injury to the cord is less severe, the prognosis is of course more favorable. The proportion of recoveries, with restoration to a useful and comparatively active life, is, for injuries of the dorsal and lumbar regions, about 23 per cent, of terminated cases, but in injuries of the cervical region, if instances of partial luxation be excluded, the proportion is much less. ' Am. Journ. of Med. Sciences, July, 1868, pp, 103-112. 334 INJURIES OF THE BACK. Treatment of Spinal Injuries. The treatment of injuries of the spine involves attention to the state of both the vertebral column and the spinal cord. Treatment as regards Vertebral Column.—If in any case there be evident vertebral displacement, or marked deformity, with paralysis, so that the surgeon has reason to believe that he has to deal with a spinal luxation, whether complicated or not with fracture, he should at once proceed to attempt reduction by means of extension and counter-exten- sion, aided by cautious manipulation, rotation, and presswe. I am aware that this advice will be looked upon by many as injudicious; but statistical investigation shows that while there is but one case recorded (Petit-Radel's), in which efforts at reduction were the cause of death, there are many perfectly authentic instances, in which such efforts have been followed by the most gratifying success; and we should no more be deterred from attempting reduction, by the fatal result in one case of vertebral luxation, than we are from attempting to reduce dislocations of the shoulder or hip, by the fact that death has occasionally followed such attempts, in the hands of the most skilful surgeons. The mortality after spinal dislocation has been about four times as great when reduc- tion has not been attempted, as when this treatment has been employed. If manual extension and counter-extension should fail to remove the deformity, in a case of injured spine, it would, I think, be right to apply permanent extension, by means of the ordinary weight apparatus; the surgeon should, however, in such a case take great care, lest, from the pressure of the adhesive plaster or bandages, excoriation or sloughing should occur, and seriously complicate the patient's condition. Treatment as regards Spinal Cord.—In every case of spinal injury, the patient should be placed in bed, and kept at complete rest, both physical and physiological: a water-bed, if it can be obtained, or down pillows, will be found of great use in preventing the formation of bed-sores. If the vertebral column itself be not affected, the prone position, as advised by Erichsen, will probably be found the best, as facilitating the application of local remedies to the spine. In cases of fracture, however, the supine position is preferable, and the patient should not be incautiously turned upon his side, lest sudden displace- ment should occur, which might prove fatal. The patient should be kept scrupulously clean, and parts exposed to pressure should be fre- quently bathed with astringent or slightly stimulating washes. The bowels should be emptied from time to time by the use of enemata. It is usually recommended to draw off the urine at stated intervals, by means of a flexible catheter, and such has always been my own practice. It has, however, recently been recommended, by Mr. Hutchinson, to dis- pense with the catheter, except in the rare cases of spinal injury in which retention is painful, allowing the bladder to become distended, and then trusting to the mechanical overflow to prevent injurious consequences. Fatal ulceration of the bladder has undoubtedly been occasionally traced to the use of the catheter, which in any case must aggravate the cystitis produced by distension and the ammoniacal state of the urine; and hence, though not prepared to go quite so far as Mr. Hutchinson, I would urge the importance of great gentleness in catheterization, which should only be done with a flexible instrument, used without the stilette. If bed-sores form, they should be carefully and frequently dressed, with TREPHINING IN INJURIES OF THE SPINE. 335 as little disturbance as possible to the patient. The alternate applica- tion of ice and hot poultices, has been highly recommended by Prof. Brown-Sequard. Topical remedies are not of much value in the early stages of spinal injuries, though, if there be much tenderness and local pain, ice-bags might perhaps be used with advantage; at a later period, various forms of counter-irritation may be employed, with a view to a derivative action on the spinal cord and membranes. Constitutional Treatment.—The general treatment, during the early stages, should be such only as is indicated by the constitutional condition of the patient. Opium may be given at any period, to relieve pain or nervous irritation. Dr. McDonnell highly recommends the ad- ministration of belladonna, as a sedative to the spinal cord, and advises that it should be combined with opium, whenever the latter remedy is prescribed in these cases. On the onset of inflammatory symptoms, small doses of calomel, or of the corrosive chloride of mercury, may be employed, or the iodide, or bromide of potassium. Ergot has proved useful, in the hands of Prof. Hammond, in cases of myelitis following spinal injury. After the subsidence of inflammation, strychnia has often proved of the greatest benefit; at the same time, electricity, systematically applied to the paralyzed parts, with friction, and cold or warm douches to the spine, may often be serviceable. Tonics, especially iron, quinia, and cod-liver oil, which may be required at an early period, are peculiarly indicated in the later stages of spinal injuries. The diet throughout should be nutri- tious but unirritating, with or without stimulus according to the circum- stances of each individual case. Trephining or Resection in Injuries of the Spine.—This operation has been suggested and described by surgical writers for a very long period, its history reaching back, indeed, to the days of Paulus JEgineta. The first surgeon, however, who actually practised the operation on the living subject, was the elder Cline,1 in the early part of the present century, and his example has been followed by other sur- geons from time to time, the whole number of cases now on record being between thirty and forty. The object, of course, is to remove the verte- bral arches at the seat of injury, and thus, if possible, relieve the cord from pressure, which is supposed by the advocates of the operation to be the cause of paralysis in these cases. But, as a matter of fact, post- mortem inspection has shown that compression exists in but a small number—less than one-third—of fatal cases, and that even in these instances the cord is usually so much lacerated or disorganized, as to preclude any benefit from operative interference; moreover, compression, when it does exist, is almost always due to the pressure exercised by the body of the vertebra, so that all that resection could possibly do would be, as Dr. McDonnell has phrased it, to take away the "counter- pressure." The operation is by no means an easy one,2 and is in itself attended with no small danger to the patient; beside the inevitable risks which 1 Louis's operation, in 1762, often referred to as an instance of spinal resection, consisted merely in the removal of detached fragments in a case of gunshot injury; a perfectly legitimate and conservative procedure. 2 "I am satisfied," says Prof. Eve, "that this operation, in the dorsal vertebise, if not almost impracticable, is certainly one of the most difficult in surgery (Am. Journ. of Mei. Sciences, July, 186 J, p. 10G). 336 INJURIES OF THE BACK. must follow the conversion of the injury into a compound fracture, the exposure of the delicate structures within the vertebral canal, and the permanent loss of firmness and strength in the spinal column, consequent on the removal of one or more of the vertebral arches, the operation entails immediate peril upon the patient, death having occurred in one case (Willett's) before the operation could be completed. Finally, the statistics of the operation show beyond question that, far from increas- ing, it positively diminishes the chances of recovery. The following. table embraces a record of 38 cases, being, so far as I can ascertain, all in which the operation of spinal resection for fracture has been hitherto performed. Cases of Resection of the Spine. Result. Operator's name. Reference. 9 10 11 12 13 14 lo 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 pied. Relieved. Died. Died. Not improved. Died. Relieved. Died. Died. Not improved. Died. Relieved. / Cline, Sr. - Wickhani. v Oldknow. K" Tyrrell. x/ Id. Barton. Boyer. ,D. L. Rogers. Attenburrow. / Laugier. / Hols cher. /A. G. Smith. Mayer.- South. ' Blackman. Edwards. s Blair. 'r Goldsmith. Stephen Smith. Hutchison. ' G. M. Jones. H. A. Potter. Id. Id. R. McDonnell, Sam. Gordon. Tillaux. Willett. y / H. J. Tyrrell. Maunder. Eve. Cheever. Id. Nunneley. Id! Id. Chelius's Surgery; ed. by South, i. 590. Lancet, 1827. Hutchison, in Am. Med. Times, 1861. Malgaigne, Fractures et Luxations, i. 425. Ibid. Malgaigne (Packard's translation), p. 343. Heyfelder, Traite des Resections (trad, par Boeckel), p. 244. Am. Journ. of Med. Sciences, o. s., vol. xvi. Chelius and Heyfelder, op. cit. Malgaigne, op. cit. [256. Brown-Sequard, Central Nervous System, p. N. A. Med. and Surg. Journ., vol. viii., p. 94. Heyfelder, op. cit. Notes to Chelius, vol. i., p. 591, etc.. Hutchison, loc. cit. Brit, and For. Med. Review, 1838. Ballingall, apud Hutchison, loc. cit. Gross's Surgery, 2d edit., vol. i. Hutchison, loc. cit. Ibid. Brown-Sequard, op. cit., p. 255. Hurd, N. Y. Journ. of Med., 1845. Am. Journ. of Med. Sciences, n. s., vol. xlv. Ibid. Ibid., vol. 1. Med.-Chir. Trans., vol. xlix., p. 21. Brit, and For. Med.-Chir. Review, 1866. Med. Times and Gazette, Feb. 2, 1867, and St. Barth. Hosp. Rep., vol. ii., p. 242. Dub. Quart. Journ. of Med. Sci., Aug., 1866. Med. Times and Gazette, Feb. 23, 1867. Am. Journ. of Med. Sciences, n. s., vol. lvi. Boston City Hosp. Reports, 1870, p. 577. Ibid., p. 580. St. Bartholomew's Hosp. Reports, vol. vi. Med. Times and Gazette, Aug. 7, 1869. Ibid. Ibid. Ibid. In 34 of the above 38 cases the result is known: 29 patients died, 3 were relieved, and 2 received no benefit from the operation. The most successful cases which the advocates of spinal resection have yet been able to produce, are those of Dr. Gordon, and of Mr. Nunneley; in the INJURIES OF THE FACE. 337 J first, more than a year after the operation, the patient was " unable to stand or walk," while in the second, the patient, during the two and a half years which he survived, was, though strong in the arms, "weak and partially paralyzed in the legs." Considering, therefore, the not infrequent favorable issue of these cases under expectant treatment, and in view of the fact that the mortality after the operation has been over 85 per cent, of terminated cases, and that there is no well-authenticated instance of complete recovery after its employment, surely we are justi- fied in declaring, with Le Gros Clark, that we " cannot regard trephining the spine as brought within the pale of the justifiable operations in surgery." I would respectfully invite the reader, who is interested in the further investigation of this subject, to consult the elaborate statistical tables, embraced in my monograph on Injuries of the Spine, already referred to. If the operation of spinal resection is to be done at all, it can, proba- bly, be best accomplished, as recommended by Dr. McDonnell, by making a free and deep incision, and then dividing the bony lamina?, on either side of the spinous process of the injured vertebra, with strong cutting forceps bent at an angle—an instrument which would prove more service- able, in this position, than either a trephine, or a Hey's saw; a single arch having been removed, any additional portions of bone may be readily taken away with the ordinary gouge forceps.1 Dr. McDonnell recom- mends very highly the internal administration of belladonna, or atropia, during the after-treatment of these cases, in order to prevent the devel- opment of inflammation of the membranes or spinal cord. CHAPTER XVII. INJURIES OF THE FACE AND NECK. Injuries op the Face. Wounds of the Face present no peculiarities requiring different treatment from that of similar injuries in other parts. The tissues of the face are so vascular, that primary union is usually attainable, at least in the case of incised wounds. As it is desirable to avoid any disfigure- ment, in a part which is constantly exposed to observation, I think it best to dispense with sutures, in the treatment of superficial wounds of the face, approximating the parts as accurately as possible, by means of the gauze and collodion dressing. In certain localities, however, as in the eyelids or eyebrows, nose, ears, and lips, the employment of sutures is usually indispensable; in penetrating wounds of the cheeks, also, stitches, embracing almost the entire thickness of the parts, should be applied. Harelip pins, which may always be used with advantage in wounds of the lips, may be employed in any of these cases to control arterial bleeding, the pin being passed under the vessel, which is then compressed above it by means of the twisted suture. No matter how much contused and lacerated any part of the skin of the face may be, it 1 See Dr. McDonnell's paper in the Dublin Quarterly Journal of Medical Science, for August, 1866, pp. 31-33. 22 338 injuries of the face and neck. should not be removed, but should be replaced, after having been care- fully cleansed, in hope that reunion may occur. The deformity which sometimes results from such en injury, may often be remedied by a plastic operation—which may also be required in cases of deformity from burn, in which mechanical extension has failed to procure relief (see p. 301). Orbit and Eyeball.—Injuries of the Orbit may prove fatal through implication of the brain, either primarily, or, at a later period, by the extension of inflammation. Pointed' instruments, such as a sword, a stick, or the end of an umbrella, may be thrust through the orbital plate of the frontal bone directly into the brain. In a case recorded by Dr. Wm. Pepper, a knife was thrust through the sphenoidal fissure, wounding a large meningeal vein, and causing death from intra-cranial hemorrhage. In other instances, again, wounds of the orbit have been followed by the formation of arterio-venous aneurisms, as in a case of Ne*laton's, in which the point of an umbrella wounded the cavernous sinus and internal carotid artery of the opposite side—death ultimately re- sulting from the bursting of the aneurismal tumor. Deep-seated sup- puration may occur as the result of orbital injury, the abscess pointing in either eyelid, or proving fatal by extending backwards to the brain. Wounds of the orbit may cause blindness, without directly involving the eyeballs, either by injury to the optic nerves, or, possibly, by inducing a reflex condition, depending upon lesion of other neighboring nerves, as of branches of the fifth pair.1 In a case reported by Dr. Packard, imme- diate and total blindness followed a gunshot wound of both orbits, the patient surviving the injury for four years and a half, and eventually dying from other causes. Foreign Bodies lodging on the eye may be embedded in the cornea, or may be concealed between the ball and either eyelid. From the cornea the offending particle may be removed without much difficulty, simply by picking or gently prying it off with an ordinary cataract needle; if, in doing this, the cornea be superficially abraded, it is well, before dis- missing the patient, to apply a drop of castor oil, which will effectually protect the surface until the slight breach of continuity has been re- paired. A foreign body on the cornea can usually be readily detected, by carefully examining the part in a bright light; in any case of doubt, Fig. 167. Oblique illumination. however, oblique illumination should be employed (Fig. 167), a second convex lens being used, if necessary, as a magnifier. The conjunctival ' The possibility of such an occurrence is doubted by Holmes Coote, and other surgeons, who attribute the amaurosis in these cases to a "concussion of the retina," rather than to the effect of sympathy. injuries of the orbit and eyeball. 339 Fig. 168. Eversion of upper lid for detection of foreign bodies. fold of the lower eyelid may be explored, by simply drawing down the lid, and directing the patient to look upwards; to explore the fold of the upper lid it is necessary to evert the eyelid, which may be done either with the forefinger and thumb (Fig. 168), or with a probe, or the end of a pencil or quill, laid horizontally across the lid. This little operation, which is more difficult than it ap- pears, is done by firmly but lightly seizing the edge of the lid between the thumb and forefinger (the pa- tient looking downwards, and the lid being drawn well down, and slightly away from the ball), and then by a quick movement turning up the edge of the lid over the point of the finger, which is simultaneously depressed. If the probe be employed, the central eyelashes, or the edge of the lid, must be taken between the thumb and finger of one hand, while the probe is manipulated with the other. The eyelid being everted, its edge is pressed against the edge of the orbit, when almost the whole conjunctival fold comes into view. The foreign body may then be removed with delicate forceps, the smooth end of a probe, or a moistened camel's-hair brush; it is sometimes possible to feel the foreign body with the tip of the finger, when, from its transpa- rency, it cannot be seen. In some cases, in which the offending object has eluded both touch and vision, I have succeeded in dislodging it by sweeping out the fold of the eyelid with a camel's-hair brush; and in one instance, after I had failed to detect the foreign body by everting the lid, I succeeded by placing the patient in a bright light, with his head thrown very far backwards, when, by simply drawing the lid away from the ball, I was enabled to see almost up to the sulcus. Contusion of the Eyeball may cause temporary blindness, by inducing a condition of the retina analogous to concussion of the brain; in other cases, the loss of sight may be permanent, from detachment of the retina, hemorrhage, or inflammatory changes. The ordinary "black eye" of pugilists consists in an extravasation of blood, beneath the conjunctiva, and into the loose areolar tissue of the eyelids. In this situation absorp- tion is often very slow, the subconjunctival stain sometimes persisting for several weeks; the best application is cold water, or a mild alcoholic lotion. Contusion of the eyeball is sometimes accompanied by rupture of the cornea or sclerotic, allowing the escape of the humors of the eye, and causing permanent loss of vision; in other cases the rupture may be internal, extravasation occurring, and filling the anterior chamber of the eye with blood, the iris being sometimes torn from its ciliary attachment, or the lens dislocated from its position. The treatment consists in the frequent instillation of a solution of atropia, gr. ij-iv to f f j, and in the administration of calomel and opium, while the patient is kept in bed, in a darkened room, and upon milk diet. After the absorption of the effused blood, which is usually soon effected, vision may be restored, though it is often rendered imperfect by bands of lymph crossing the anterior chamber and the pupil. A dislocated lens usually becomes cataractous, and often causes intense pain and frequent attacks of iritis, by pressing upon the ciliary bodies and iris; in either case, extraction should be promptly re- sorted to. From the anterior chamber, the lens may be removed by simple 340 injuries of the face and neck. corneal section, and from the posterior chamber, by a similar operation, a preliminary iridectomy having been first performed. If suppurative dis- organization of an eyeball occur, excision may be necessary to prevent the other eye from becoming sympathetically involved. Non-penetrating Wounds of the Eyeball are not usually of a serious nature. The treatment consists in the removal of foreign bodies, fol- lowed by the application of a drop or two of castor oil, with the use of cold compresses if the injury be attended with much pain. Penetrating Wounds are attended with much greater risk, the chief dangers being from prolapse of the iris, escape of vitreous humor, and, at a later period, from inflammation. If the iris protrude, an effort- should be made to replace it by means of a fine probe; if this be impossible, the projecting portion should be snipped off with curved scissors, and if a staphyloma be subsequently formed, an iridectomy should be done oppo- site the most transparent part of the cornea; this operation is, according to Soelberg Wells, much preferable to the old mode of treatment, by the repeated application of nitrate of silver. Incised wounds of the sclerotic, if not very large, may be brought together with one or two fine sutures, any protruding portion of iris or vitreous humor being first cut away. In cases of extensive wound, with escape of a large portion of the contents of the eye, excision should, as a rule, be immedi- ately performed, especially in patients of the poorer class, to whom the time required for treatment is a matter of importance. If an attempt be made to save the ball, cold compresses should be applied, atropia being very freely used, and calomel and opium administered internally. It may be necessary at a later stage to make an artificial pupil, to extract the lens (if this have become the seat of traumatic cataract), or to per- form excision, if vision be lost and suppurative disorganization of the eyeball have occurred, particularly if sympathetic implication of the other eye be threatened. Nose.—Foreign bodies, such as beads, peas, bits of sponge, etc., are often introduced by children into the nostrils, where they occasionally become firmly fixed, and, if allowed to remain, cause a troublesome form of ozsena. The foreign body may usually be removed Fig. 169. without much difficulty, by means of delicate forceps, a ^» bent probe, a small scoop (such as is often placed at one end of a grooved director), or by means of Thudichum's douche, the current being of course directed through the opposite nostril. Ear.—Foreign bodies may be removed from the ex- ternal ear with forceps, scoop (Fig. 169), wire loop (as advised by Hutchinson), or, which is certainly the safest means, by long-continued, and, if necessary, repeated syringing with tepid water, the pinna being drawn up- wards so as to straighten the auditory canal. Prof. Gross uses a steel instrument, spoon-shaped at one end, and provided at the other with a delicate tooth, placed at a right angle. This instrument is doubtless very efficient and safe in skilful hands, but the general prac- titioner will, I think, do wisely to be satisfied with sim- ple syringing, which is indeed, according to Dr. Roosa, f^a much preferable to any other means of treatment. An Ear-scoop. ordinary hard rubber syringe of the capacity of three or injuries of the neck. 341 four ounces may be used, the returning water being received in a bowl held beneath the ear. Guersant prefers to ordinary syringing, irriga- tion, which may be conveniently effected with a Thudichum's douche, or by means of the double hand-ball syringe used for the administration of enemata. Cheek.—Wounds of the cheek occasionally result in the formation of troublesome fistulae. If very small, a cure may be effected by the appli- cation of nitrate of silver, of a red-hot wire, or of the electric cautery; if larger, the edges of the fistula should be pared, and closely approximated with sutures and a compress. If the wound involve the parotid duct, its opening into the mouth may be obliterated, and a true Salivary Fistula result. The treatment consists in establishing an artificial inner open- ing—by forming a seton, by means of a small trocar and canula passed in the natural direction of the duct, the external opening being subse- quently closed—or by the ingenious operation of the late Prof. Horner, which consists in cutting out the diseased tissues with a large and sharp saddler's punch, pressed firmly against a wooden spatula previously intro- duced into the mouth, the external wound being then immediately closed with the twisted suture. Mouth.—Wounds of the Lips should be treated by the application of harelip pins, with additional points of the interrupted suture, special care being taken to secure accurate adjustment of the prolabium. Addi- tional firmness may be afforded by the use of broad adhesive strips, pass- ing from side to side, or of Hainsby's cheek compressor, as after the operation for harelip. Wounds of the Tongue do not require sutures, un- less a considerable portion of the organ be nearly detached. Hemorrhage may require the application of ligatures, or of the hot iron. Wounds of the Soft Palate, unless very small, require stitches, which may be ap- plied as after the operation of staphyloraphy. Foreign bodies, such as pistol-balls, teeth, or pieces of tobacco-pipe, may be lodged deeply in the tongue or pharynx, giving rise in the latter situation to suppura- tion, and sometimes to fatal secondary hemorrhage. Injuries op the Neck. Wounds.—These injuries, which are usually of the character of Incised Wounds, are most commonly inflicted in attempts to commit suicide. It is occasionally a matter of some importance, in a medico- legal point of view, to be able to determine whether a given wound of the neck has been self-inflicted, or received at the hands of another; it is, of course, impossible to arrive at absolute certainty upon this point, but it may be said, in general terms, that suicidal wounds commonly begin on the left side of the neck (the person being right-handed), and pass transversely or obliquely downwards across the part, the extent of the wound on the right, being usually less than that on the left side. They rarely penetrate so deeply as to divide the great vessels; hence the prima facie probability with regard to a very deep wound, "pene- trating as by a stab perpendicularly towards the spine," and perhaps involving the vertebral column, would be that it was not self-inflicted.1 Wounds of the neck may be divided into—1, Non-penetrating Wounds, 1 See upon this point a paper by Dr. Taylor, in Guy's Hosp. Reports, 3d s., vol. xiv., pp. 112-144. 342 injuries of the face and neck. which do not involve the air-passage or oesophagus; and 2, Penetrating Wounds, which do involve one or both of those important organs. 1. Non-penetrating Wounds.—The danger of non-penetrating wounds of the neck, is chiefly from hemorrhage, which is often very profuse; if the carotid artery or internal jugular vein be wounded, death may be almost instantaneous, and even bleeding from comparatively small vessels may prove fatal in the depressed state, both physical and mental, which is usually present in patients who have attempted suicide. Another danger is from the entrance of air into the large veins in this region, which may cause sudden death, or, as in a case recorded by Le Gros Clark, may prove fatal at a later period, by the air becoming gradually mixed with the blood, and thus interfering with the heart's action. The pneumogastric or phrenic nerve may also be wounded in these cases, and either event would of itself almost certainly cause the death of the patient. The treatment of nonpenetrating wounds of the neck, consists in arresting hemorrhage, and in approximating the edges of the cut, in such a way as to favor union. Every bleeding vessel, whether artery or vein, should be secured by ligatures above and below the opening in its coats, or to either extremity if it be completely divided. In cases of arterial bleeding, in which the precise source of hemorrhage cannot be detected, the surgeon should not hesitate to ligate the common carotid, an opera- tion which, according to Pilz, has been done, in cases of punctured and incised wounds, in 44 instances with 20 recoveries, the total number of cases, in which the carotid has been tied for hemorrhage, being, according to the same author, 228, with 94 recoveries. Approximation of the lips of the wound is best effected by numerous points of the interrupted suture, the ligature threads being brought out at the angles of the wound, where they serve to secure drainage. The sutures should em- brace the skin and superficial fascia only, and the deeper parts of the wound should be approximated by means of broad strips of adhesive plaster, brought obliquely around the neck. The parts should be further relaxed, by bending the head forwards, with the chin almost touching the sternum, and by securing it in this position, by means of a night-cap, or sling, which should pass from the occiput, to a circular band around the chest. Primary union, though always to be sought, is rarely at- tained in cases of cut-throat, the whole surface of the wound not un- frequently sloughing, and eventually healing by granulation. 2. Penetrating Wounds of the neck may involve any portion of the air-tube, though the larynx is the part usually affected. The relative frequency of these wounds, in different situations, may be seen from the following table of 158 cases, collected by Mr. Durham :— Situation of wound. Number of causes. Above the hyoid bone.........11 Through the thyro-hyoid membrane......45 Through the thyroid cartilage.......35 Through the crico-thyroid membrane or cricoid cartilage . . 26 Into the trachea..........41 The special dangers of penetrating wounds of the neck, apart from such as are common to these injuries and to those which are non- penetrating, are the occurrence of asphyxia, or more correctly apnea, emphysema, dysphagia, and, at a later period, bronchitis and pneumonia. INJURIES OF THE LARYNX AND TRACHEA. 343 Difficulty of Breathing, ending, perhaps, in complete Suffocation or Apnea, in wounds of the throat, may depend upon several causes. It may result directly from the accumulation of blood, either liquid or clotted, in the air-passages; from displacement of divided parts, as from a portion of the tongue, the epiglottis, or a fragment of cartilage, falling backwards and obstructing the rima glottidis; or, if the rings of the trachea be widely separated, from the external soft parts being sucked inwards, and producing valvular occlusion of the air-tube. Again, suffo- cation may result from oedema of the glottis, from submucous emphy- sema, or from the pressure of an abscess. Emphysema is not usually a grave complication; it may, however, as already mentioned, produce suffocation, when seated beneath the laryn- geal mucous membrane, or, according to Hilton, may prove directly fatal, by pressure on the phrenic nerves. Dysphagia, sometimes amounting to complete inability to swallow, is occasionally a source of great danger. Either from a wound of the oesophagus—or, without this part being involved, from insensitiveness of the glottis—saliva, and even particles of food may escape into the air- tube, and make their appearance at the external wound. Bronchitis and Pneumonia may arise from the irritation produced by the presence of blood, pus, or food in the air-passages, from the admis- sion through the wound of cold and dry air to the lungs, or possibly from the direct extension of inflammation from the seat of injury. Among the occasional remote consequences of penetrating wounds of the throat, may be mentioned alteration or loss of voice, and the forma- tion of a traumatic stricture of the trachea or gullet, or of an aerial or oesophageal fistula. Treatment.—After the arrest of hemorrhage, as in cases of non-pene- trating wound, the surgeon may apply a few sutures to either extremity of the incision, leaving, however, the central portion, as a general rule, to heal by granulation; an exception should be made in those cases in which the air-tube is completely cut across, when, to prevent wide separa- tion, it may be necessary to apply a stitch on either side, so as to hold the parts in apposition. The sutures, which in such a case, should be of fine thread, may be passed through the superincumbent connective tissue, or even superficially through the cartilages themselves, one end being cut off, and the other brought like a ligature through the external wound. In other cases, from the persistence of venous oozing, or from the occurrence of dyspnoea on attempting to close the wound, it may be necessary to introduce, for a time at least, a tracheal tube, as after the operation of tracheotomy. If, at any time, apnea be threatened, the wound should be instantly reopened, and, if necessary, artificial respira- tion resorted to. Tracheal or laryngeal stricture may, at a later period, require the performance of tracheotomy, followed by systematic dilata- tion; aerial fistula may (provided the larynx be unobstructed) be closed by a plastic operation. Injuries of the Larynx and Trachea. A blow upon the larynx may prove fatal through shock, or by inducing spasm of the glottis; when the injury is less severe, temporary insensi- bility only may result. The treatment, in slight cases, consists in the adoption of such measures as may prevent subsequent inflammation, but if breathing have stopped, laryngotomy should be performed, and arti- ficial respiration at once resorted to. 344 INJURIES OF THE FACE AND NECK. Fracture of the Larynx is an exceedingly dangerous accident, the mortality, according to Durham's statistics, being over 80 per cent. No age is exempt, though the injury usually occurs among young adults; five of fifteen cases analyzed by Hunt' were in children, and only one in a person over forty-five years of age. The usual causes, apart from gunshot wounds, are, according to the same writer, "falls against hard and projecting substances, blows, kicks, and pressure." The symptoms are local pain and tenderness; swelling of the neck, with an alteration of its form, consisting either of flattening, or of undue prominence; mobility of the cartilages, and occasionally crepitus. There are besides, often, dyspnoea and lividity of face, with the ordinary evidences of collapse, emphysema, and expectoration of bloody mucus; the latter symptoms are considered by Hunt particularly unfavorable, as indi- cating laceration of the laryngeal mucous membrane. The annexed table, from Durham,2 gives a summary of 62 recorded cases, 52 collected by He'noque, and 10 added by Durham himself. It will be observed that death followed in every case in which the cricoid cartilage was involved. Cartilages fractured. Thyroid only.................., Cricoid only..................., Thyroid and os hyoides........ Thyroid and cricoid............ Thyroid, cricoid, and os hyoides Thyroid, cricoid, and trachea___ Cricoid and trachea............ Cricoid, trachea, and os hyoides. " Fractures of larynx"......... Total..................... No. of cases. Deaths. Recoveries. 24 18 6 11 11 4 2 2 9 9 2 2 2 2 2 2 1 1 7 3 4 62 50 12 The treatment, in cases in which the displacement is slight, and in which there is no dyspnoea, may consist simply in supporting the parts with compresses and strips of adhesive plaster. If, however, the respi- ration be embarrassed, and particularly if" there be bloody expectoration, no time should be lost, in resorting to tracheotomy, which, under such circumstances, affords almost the only chance of saving the patient. Eight of the twelve cases of recovery were saved by operation, while in the remaining four, from the absence of haemoptysis and emphysema, there is reason to believe, as remarked by Hunt, that the fractures were in the median line, and did not involve the mucous membrane. After the operation, an attempt may be made to restore the displaced parts to their proper position by manipulation. Rupture of the Trachea, without injury of the larynx, and without external wound, is an extremely rare, and very fatal accident. Cases are reported by Lonsdale, Berger, Beck, J. L. Atlee, Jr., Robertson, and Long—that seen by the last-mentioned surgeon, being the only instance of recovery. In this case, life was saved by tracheotomy, supplemented by removal of blood from the air-passages by suction, and by artificial respiration. 1 Amer. Journ. of Med. Sciences, April, 1866, pp. 378-383. 2 Holmes's Syst. of Surgery, 2d ed., vol. ii., p. 462. FOREIGN BODIES IN THE AIR-PASSAGES. 345 _ Burns and Scalds of the mouth, pharynx, and glottis are occa- sionally met with, especially among children, the most usual form of the injuiy resulting from an attempt to drink boiling water from the spout of a tea-kettle. It is probable that, in some cases, steam may reach the larynx itself, but in the majority of instances the air-passages become secondarily involved, by the extension of inflammation from the mouth and glottis. The dangers are those of submucous laryngitis and oedema glottidis, and the treatment consists in the application of leeches and ice to the throat, and in the administration of antimony, or of calo- mel and opium. The oedematous mucous membrane of the fauces and epiglottis may be scarified, with a long needle, or with a curved bistoury, wrapped almost to its point with a strip of sticking-plaster, and, if suffocation appear imminent, tracheotomy must be performed as a last resort, though its results under these circumstances are far from satis- factory, 23 out of 28 cases collected by Mr. Durham having ended in death. A similar injury may result from drinking corrosive liquids, such as the stronger mineral acids, or caustic alkalies. The treatment should be the same as in the case of scald of the glottis or larynx. Of three cases mentioned by Durham, in which tracheotomy was performed for such an injury, two died and one recovered. Foreign Bodies in the Air-Passages.—A great variety of sub- stances have been met with as foreign bodies in the air-passages, the most common being, according to Prof. Gross, grains of corn, beans, melon-seeds, pebbles, and cherry-stones. Several such objects, some- times of a dissimilar character, have been occasionally met with in the same case. Foreign bodies usually enter the air-passages through the glottis, being drawn in, in the act of inspiration, or simply dropping in, as in the case of coins tossed in the air and caught in the mouth, or—as has probably happened in some cases, in which suffocation having occurred during sleep or intoxication, the air-passages have been found to contain partially digested food — the foreign body may be regurgitated from the stomach, and may then make its way through the glottis, the sensi- bility of which is obtunded by the patient's condition. In other in- stances, foreign bodies have entered the air-passages through accidental wounds or ulcerations of the oesophagus, of the tissues of the neck, or of the walls of the chest. Finally, in one case referred to by Gross, a lym- phatic gland passed through an ulcer in one of the bronchi, and caused death by becoming impacted in the rima glottidis. Situation.—A foreign body may be arrested in any portion of the air- passages, or, more rarely, may be movable, changing its position from time to time. The parts in which extraneous substances are most apt to become impacted, are the larynx, and one of the bronchi, usually the right. Symptoms.—The primary symptoms, or those of Obstruction, are similar to those of inflammatory or spasmodic croup, only, if possible, more violent. The patient feels a sense of impending death, and is, indeed, for the time, in most imminent danger. The face becomes livid, the eyes apparently start from their sockets, the patient gasps and utters piercing cries, foams at the mouth, is perhaps convulsed, or falls insensible. The first paroxysm passing off, the symptoms of Irritation become prominent. There is a short, croupy cough, with pain, espe- cially referred to the top of the sternum, and mucous or bloody expecto- ration. Paroxysms of dyspnoea, with a sense of suffocation, recur from 346 INJURIES OF THE FACE AND NECK. time to time, and are due to the dislodgement of the foreign body, and to its being impelled against the larynx by the act of coughing. Auscul- tation will reveal various signs, according to the position of the foreign body; if this be loose in any part of the tube, it may be heard moving up and down with a flapping sound, and occasionally striking the wall of the trachea; if fixed in the larynx, there will be a harsh, rough sound in respiration, coinciding with croupy cough and the other symptoms of obstruction; if impacted in a bronchus, or one of its subdivisions, the respiratory murmur will be usually deficient, or quite absent, in the corresponding portion of the lung, and probably puerile on the opposite side, percussion giving an equally clear sound in both localities. Occa- sionally peculiar rales are due to the nature of the foreign body, as in a case referred to by Gross, in which an impacted plum-stone, perforated through its middle, gave rise to a strange whistling sound. Diagnosis__The diagnosis, though often very obscure, may, in most instances, be made, by careful inquiry into the history of the case, and investigation of its symptoms. From croup the diagnosis can be made, as pointed out by Prof. Gross, by observing that in that affection the dyspnoea is most marked in inspiration, while expiration is most affected in obstruction from a foreign body. Aphonia is, according to the same author, the most trustworthy sign of impaction in the larynx, as dis- tinguished from impaction in other portions of the air-tube. From pharyngeal, or oesophageal obstruction, the diagnosis is to be made by careful exploration with the finger and probang. In some cases, by means of the laryngoscope, the foreign body has been actually seen lodged in the larynx. Prognosis.—So long as a foreign body remains in any portion of the air-passages, the patient is in imminent danger; the causes of death are, suffocation (which may occur at any moment), hemorrhage, inflamma- tion, ulceration, abscess, or simple exhaustion. The annexed summary, taken from Mr. Durham's essay, shows compendiously the results in 554 cases—these being, I believe, the most comprehensive statistics which have yet been published. 1. Cases in which no operation was performed:— Result. Death without expulsion of foreign body.......... Spontaneous expulsion of foreign body......[cases) Expulsion after emetics (recorded as useless in 46 Discharge at late period through thoracic abscess... Total of cases not operated on..............j 271 2. Cases in which operative measures were adopted:— Operation. Laryngotomy, followed by expulsion not followed by expulsion, Tracheotomy........................... Laryngo-tracheotomy.................., Direct extraction......................., Inversion of body and succussion......., Total of cases operated upon................I 283 Total number of cases operated upon or not.. J FOREIGN BODIES IN THE AIR-PASSAGES. 347 The mortality therefore is, in general terms, as nearly as may be, 1 in 3, the death-rate after operation being less than 1 in 4 (24.8 per cent.), but without operation more than 2 in 5 (42.5 per cent.). The period during which a foreign body may remain in the air-passages, and yet be spontaneously expelled, varies from a few hours up to many years: in 64 of 124 cases of spontaneous expulsion with recovery, col- lected by Mr. Durham, this period was between one and twelve months. Treatment.—In a case in which the dyspnoea is not urgent, a careful laryngoscopic examination should be made, and if the position of the Fig. 170. Application of the laryngoscope. foreign body be recognized, attempts may be made to remove it by direct extraction with suitable forceps: the same means may be employed after opening the trachea, and will then be more likely to succeed, as the risk of strangulation is removed. Inversion and succussion, which, though occasionally successful before tracheotomy, are under such circumstances both dangerous and painful, may, after the operation, be of much ser- Fig. 171. Throat-mirror used in laryngoscopy. vice in facilitating the escape of the offending substance. In the large majority of cases the surgeon should, as soon as he is satisfied as to the nature of the case, perform tracheotomy, or if the symptoms be very urgent, laryngotomy, the latter operation being more quickly and more easily accomplished. If the foreign body be now found in the larynx, it should be dislodged and extracted, the surgeon, if necessary, dividing the thyroid cartilage in the median line (thyrotomy), or this and the cri- coid as well (crico-thyrotomy). If the foreign body be in the trachea or bronchi, it may be immediately expelled through the tracheal wound, or 348 INJURIES OF THE FACE AND NECK. more rarely through the mouth—though in other cases it may not be ejected until several hours or days, or even a much longer period after the operation. There is some difference of opinion, among surgeons, as to the propriety of endeavoring to extract foreign bodies through the tracheal wound, by means of forceps. Mr. Durham's statistics show, I think, conclusively, that such attempts are not only justifiable, but emi- nently proper, 41 cases, in which removal was effected by forceps, having given 39 recoveries, and but 2 deaths, neither of which appears to have been due to the use of the instrument. The best forceps for the purpose are those devised by Prof. Gross (Fig. 172), the blades of which are five Fig. 172. Gross's tracheal forceps. inches long, and which, being made of German silver, can be bent to suit any particular case, while they are so delicate as not materially to in- terfere with the passage of air during the necessary manipulations. After the exit of the foreign body, the wound may usually be closed at once, but, if there be much laryngeal irritation, a tube may be intro- duced for a few days, until this has subsided. Surgical Treatment of Apnea. Apnea, or as it is more commonly called, Asphyxia, may arise from various causes, such as drowning, inhalation of chloroform or of poison- ous gases, spasm or oedema of the larynx, or the presence of false mem- brane, of a morbid growth, or of a foreign body in any portion of the air-passages. The surgical operations employed in the treatment of apnea, are, artificial respiration and the various procedures which are included under the general term of bronchotomy. Bronchotomy is appli- cable to cases in which the air-passages themselves are in any way ob- structed ; Artificial Respiration to cases in which the air-passages are free, or in which apnea continues after the performance of bronchotomy. Artificial Respiration.—This may be effected in several ways:— 1. Mouth to Mouth Inflation, though objectionable as furnishing air which has already been expired, is occasionally the only method which can be employed in an emergency, and may be resorted to, in any case, while more efficient means are being procured. 2. Inflation with Bellows, provided with a suitable mouth or nose piece, may be efficiently used, provided that care is taken to secure expiration by manual compression, and that the instrument is worked gently, and not more than ten or twelve times in the minute. 3. Inflation with Oxygen Gas might be tried in extreme cases, or when other means had failed: the gas might conveniently be administered from a bladder, fitted with a mouth-piece. 4. Artificial respiration may readily be practised by alternately Com- pressing the Chest and Abdomen with the Hands, to imitate expiration, and SURGICAL TREATMENT OF APNEA. 349 then allowing the natural resiliency of the thoraeic walls to produce ex- pansion, and thus imitate inspiration. This method is very easily applied, and is particularly suitable in cases of apparent death from chloroform 5. Silvester's Method, which is that adopted by the Royal Humane Society, of England, consists in placing the patient in a supine posi tion, with the head and shoulders slightly elevated, then grasping the arms above the elbows, drawing them gently but steadily upwards till they meet above the head, keeping them thus for two seconds, and, finally, bringing them downwards, and pressing them for two seconds more against the sides of the cftest. This manipulation is to be repeated, fifteen times in the minute, until natural respiration is established, or until a sufficient time has elapsed to show that further efforts are useless. 6. Marshall Hall's "Ready Method."—This mode of treatment, under the name of "Prone and Postural Respiration," is thus described by its distinguished author:— " (1.) Treat the patient instantly, on the spot, in the open air, exposing the face and chest to the breeze (except in severe weather). "I. To Clear the Throat. " (2.) Place the patient gently on the face, with one wrist under the forehead. [All fluids, and the tongue itself, then fall forwards, leaving the entrance into the wind- pipe free. ] If there be breathing, wait and watch; if not, or if it fail— "II. To Excite Respiration. " (3.) Turn the patient well and instantly on his side, and "(4.) Excite the nostrils with snuff, the throat with a feather, etc., and dash cold water on the face previously rubbed warm. If there be no success, lose not a moment, but instantly— " III. To Imitate Respiration. "(5.) Replace the patient on his face, raising and supporting the chest and abdomen well on a folded coat or other article of dress. " (6.) Turn the body very gently on the side and a little beyond, and then briskly on the face, alternately; repeating these measures deliberately, efficiently, and per- severingly fifteen times in the minute, occasionally varying the side. [When the patient reposes on the chest, this cavity is compressed by the weight of the body, and expiration takes place; when he is turned on the side, this pressure is removed, and inspiration occurs. ] " (7.) When the prone position is resumed, make equable but efficient pressure, with brisk movement, along the back of the chest, removing it immediately before rotation on the side. [The first measure augments the expiration, the second com- mences inspiration.] " The result is respiration; and, if not too late, life! "IV. To Induce Circulation and Warmth. "(8.) Rub the limbs upwards, with firm grasping pressure and with energy, using handkerchiefs, etc. [By this measure, the blood is propelled along the veins towards the heart. ] " (9.) Let the limbs be thus dried and warmed, and then clothed, the bystanders supplying coats, etc. " (10.) Avoid the continuous warm bath, and the position on or inclined to the back." Whatever mode of treatment be adopted, should be perseveringly con- tinued for three or four hours, unless sooner successful; if secondary apnea come on after apparent recovery, artificial respiration should be again resorted to, together with the application of electricity to the base of the brain and upper part of the spinal cord. 350 INJURIES OF THE FACE AND NECK. Bronchotomy.—Under this name are embraced the operations of Laryngotomy and Tracheotomy, together with their modifications, Thyr- otomy, Crico-thyrotomy, and Laryngo-tracheotomy, the names of which sufficiently express their nature. 1. Laryngotomy.—In this operation the windpipe is opened through the crico-thyroid membrane. The larynx being steadied between the thumb and fingers of the left hand, the surgeon makes a vertical incision about an inch long, in the median line, over the lower half of the thyroid cartilage, the crico-thyroid space, and the cricoid cartilage. The sterno- hyoid muscles being now separated, and the intervening fascia and con- nective tissue divided, to the full extent of the cutaneous wound, the knife is at once thrust, with its edge upwards, through the crico-thyroid membrane and its mucous lining, into the larynx. The opening is then enlarged transversely as much as may be required, and the tube intro- duced. The only vessel likely to be cut is the crico-thyroid artery, which should, as a rule, be secured before opening the larynx. This operation, which is by no means difficult, may be performed either with, or without the aid of anaesthesia, the patient being in a recumbent position, with the head thrown backwards, and the neck rendered prominent by means of a pillow beneath the nucha. 2. Tracheotomy.—In this operation two or more of the tracheal rings are divided, or an elliptical portion of their anterior face cut away. The patient being in the position already described, and preferably under the influence of an anaesthetic, the surgeon makes a vertical median incision, from the bottom of the cricoid cartilage downwards, for an inch and a half or more, according to the length of the neck. The subcuta- neous fat and areolar tissue are similarly divided, care being taken to Fig. 173. Operation of tracheotomy. avoid any superficial veins; the sterno-hyoid and sterno-thyroid muscles being then cautiously separated with the handle of the knife, or with the director, the trachea, crossed by the isthmus of the thyroid gland, is ex- posed. The trachea may be opened above, through, or below the thyroid isthmus, the first being, in the case of children especially, the point to be preferred; if it be necessary to cut through the isthmus, a ligature must be first applied on either side of the point of division. Hemor- rhage having been arrested, the surgeon draws forwards the trachea AFTER-TREATMENT OF CASES OF BRONCHOTOMY. 351 with a single or double tenaculum, and thrusting in his knife, edge upwards, divides the necessary number of rings. The tube is then at once introduced, and when the respiration has become tranquil, the sur- geon may temporarily remove it, and proceed to cut away an elliptical portion of the front wall of the trachea; this step, though condemned by high authority, is not, I think, in itself objectionable, and is in many cases of positive advantage. The above description presupposes that the surgeon has time to make a careful dissection of the superincumbent parts, before opening the windpipe—and, in the immense majority of instances, enough time is afforded for this purpose. I believe, however, with Mr. Durham, that cases are occasionally met with, in which it is very important to hasten the steps of the operation; and, in such an emergency, would recommend a plan described by that author, and which he assures us he has advan- tageously employed in nineteen instances. In this method the operator (standing on the patient's right side) places the forefinger of the left hand on the left side of the trachea, and the thumb on the right, press- ing steadily backwards until he feels the pulsation of both carotid arteries. By slightly approximating the finger and thumb, he feels that the trachea is firmly and securely held between them, and knows that the safety of the great vessels is insured, while the tissues over the wind- pipe are rendered tense. The finger and thumb thus placed are not to be moved until the trachea is reached. By a succession of careful inci- sions, the surgeon now cuts boldly down on the windpipe, the finger and thumb on either side helping him to judge of the position of the median line (from which the knife must not deviate), and, by their pressure, causing the wound to gape, and the trachea to advance. The forefinger of the right hand is passed from time to time into the wound, to make sure that no important vessel is in the way, and when the trachea is reached the knife is introduced (guarded by the right forefinger), or the windpipe may be seized with a tenaculum and opened as in the ordinary operation. The chief danger from tracheotomy is from hemorrhage; instances are on record in which the carotid, or even the innominate artery has been wounded, while fatal bleeding has not unfrequently occurred from the division.of large veins. Arterial hemorrhage should, of course, be checked before opening the trachea, and bleeding veins should also be secured, provided death from suffocation is not likely to occur while this is being done. It must be remembered, however, that the venous con- gestion is due, in great measure, to the obstruction of the patient's breathing, and will be lessened as soon as free respiration is established; hence the surgeon should not fear, if necessary, to open the windpipe even while venous bleeding continues, introducing the canula, as has been forcibly said, "even through a very pool of blood." Laryngo-tracheotomy is, as its name implies, a combination of laryng- otomy, with tracheotomy above the thyroid axis. Its mode of perform- ance requires no special description. After-treatment of Cases of Bronchotomy.—In almost all cases, except those of foreign body in the air-passages, it is necessary to introduce a tracheal canula or tube, which must be worn until the power of breathing through the larynx is restored. The tube should be made of silver, with a curve of rather less than a quarter of a circle, double, so that the inner canula may be removed and cleansed, while the outer retains its position, the two being secured by means of a button attached 352 INJURIES OF THE FACE AND NECK. Fig. 174. to the neck-plate of the outer one. The neck- plate itself should be so arranged as to allow the canula to move freely with the motions of the trachea, and the inner tube should project beyond the outer one for about a quarter of an inch, at either extremity. The length of the canula should be from two to three inches, and its calibre from one-fourth to three- eighths of an inch, according to the age of the patient. For use after laryngotomy the canula may be a little flattened, the trans- verse being somewhat greater than the an- tero-posterior diameter of its section. The canula above described, which embraces the improvements of both Obre and Roger, is, I think, preferable to either the ordinary double tube, or the bivalve canula of Fuller. Mr. Durham has suggested a still further modification, by which the length of the tube can be regulated, by means of a screw, to meet the emergencies of any particular case. To facilitate the introduction of the tube, the edges of the wound may be held apart with two- or three-bladed dilating forceps, or, which is probably better, a blunt-pointed pilot trocar, as suggested by Dr. Gaird- ner, may be thrust in with the canula, to be withdrawn, of course, as soon as the latter is in place. The canula, being introduced, is held in position by tapes, attached to the neck-plate, and fastened around the neck. During the whole course of after-treatment, the atmosphere of the room should be kept moist, and rather warm; the inner tube should be frequently removed and cleansed, and if the operation have been done for pseudo-membranous croup or diphtheria, lime-water or dilute carbolic acid should, from time to time, be vaporized through the tube with an atomizer. As soon as the canula can be safely dispensed with, it may be removed, but this should not be done until, by keeping it plugged for several hours at a time, it has been proved that the function of the larynx has been re- stored. If it be necessary to perform bronchotomy in an emergency, and when a tracheal canula cannot be obtained, the surgeon must have recourse to excising an elliptical portion of the tracheal wall, and keep- ing the edges of the wound apart with retractors made of bent wire (the hooks of ordinary large " hooks and eyes" will answer), secured by an elastic band passing behind the neck. If apnea persist after a free opening has been made into the windpipe, the surgeon must at once resort to one or other of the methods of practising artificial respiration already described. Choice of Operation.—The relative advantages of laryngotomy and tracheotomy are still a matter of dispute among practical surgeons. Tracheotomy is preferred in all cases by Mr. Marsh, and laryngotomy, or laryngo-tracheotomy, by Mr. Holmes, especially among children. Mr. Erichsen recommends laryngotomy for adults, and tracheotomy, above the thyroid isthmus, for children; while Mr. Durham considers that the advantages of opening the trachea below the isthmus, as compared with its risks and difficulties, are greater than those afforded by making the opening higher up. While I do not believe that any rule of universal application can be safely laid down upon this question, I would advise, in general terms, that tracheotomy above the isthmus should be preferred, INJURIES OF THE (ESOPHAGUS. 353 in all cases in which time is afforded for a careful and deliberate opera- tion, but that if great haste be essential, laryngotomy, which may readily be converted subsequently into laryngo-tracheotomy, should be performed instead. When the operation is required by the presence of a foreign body in the windpipe, a more definite rule may be given. If the offend- ing substance be lodged in the larynx, that part itself must be opened; but if the foreign body be in any other part of the air-passages, trache- otomy is the operation to be chosen. Injuries of the Oesophagus. Wounds.—These have already been alluded to in describing pene- trating wounds of the neck, the treatment of which injuries is compli- cated by the oesophageal wound, through the difficulty thence arising in administering the necessary amount of nutriment. A patient with wound of the gullet, may be fed through an elastic gum catheter, intro- duced through the mouth, or, if, with suicidal intent, he refuse to sepa- rate the jaws, through the nose. By this means a pint of beef-essence, or of "egg-nogg," may be introduced two or three times a day, until the power of deglutition returns. If the wound is above the position of the larynx, suffocation may occur from the supervention of oedema of the glottis—an accident which would call for the immediate performance of laryngotomy. Foreign Bodies in the Pharynx or (Esophagus. — Foreign bodies not unfrequently become impacted in some portion of the food- passage, and produce not only great irritation and difficulty of swallow- ing, but may even induce suffocation by pressure on the windpipe. The symptoms vary with the nature, size, and position of the foreign body. A fish-bone, bristle, or pin may be caught between the tonsil and half- arches of the palate, and give rise to much discomfort, with tickling cough, dysphagia, and nausea. A pointed body in this situation may even perforate an important vessel, and thus cause death by hemorrhage. A bolus of food, arrested at the summit of the oesophagus, may suffo- cate the patient by pressure on the larynx; or, again, a hard body, such as a bone or tooth-plate, may, if impacted, produce ulceration of the oesophageal walls, and penetrate into the larynx, or other important structures in the neighborhood. Fig. 175. imii'h'vin Burge's oesophageal forceps-. The diagnosis is usually sufficiently evident from the sensations of the patient, but in any case of doubt, the surgeon, besides carefully inspect- ing the pharynx in a good light, should sweep his finger around the part as far as he can reach, and cautiously explore the oesophagus with a well-oiled probang. In some cases the laryngoscope may be used to facilitate the examination of the upper portion of the gullet. Though the foreign body can thus usually be discovered, if present, a small sub- stance, such as a fish-bone, may, from the peculiarity of its position, 23 354 INJURIES OF THE FACE AND NECK. Fisr. 176. elude detection even after careful and repeated exploration; on the other hand, the sensations of the patient may continue to indicate the impac- tion of a foreign body for a long period, when none is really present, and cesophagotomy has actually been performed, on more than one occasion, without any substance being found which could account for the patient's symptoms. Treatment.—If suffocation be threatened, unless the foreign body can at once be seized and removed, tracheotomy should be resorted to with- out delay. In every case an effort should be made to extract the foreign body through the mouth, and this can usually be clone, either by simply hooking it out with the finger (if lodged in the pharynx), or by the cautious use of oesophageal forceps (Fig. 175), or of the horsehair, or swivel probang. If the foreign body be of such a nature that it will not be likely to produce injurious consequences in the stomach and bowels, as a lump of meat or even a small coin, it may, if its extraction prove difficult, be pushed onwards into the stomach, with a sponge, or ivory-headed probang.1 If, as occasionally though rarely happens, a foreign body in the gullet can be neither extracted, nor otherwise disposed of, it should be removed through an external incision, by the operation known as pharyngotomy or cesophagotomy. (Esophagotomy.—If the foreign body can be felt externally, the operation should be done on that side which is the most prominent; otherwise the left side is to be chosen, as the oesophagus naturally inclines somewhat in that direction. The patient should be anaesthetized, and placed in a supine position, with the head and shoulders a little raised, and the face somewhat averted. An incision, four or five inches long, is made in the space between the trachea and the sterno-mastoid muscle, beginning above, on a level with the top of the thyroid cartilage. This incision is cau- tiously deepened, the omo-hyoid muscle, and the outer fibres of the sterno-hyoid and sterno-thyroid, being divided if necessary; the carotid sheath is carefully drawn outwards, and held with a blunt hook, the trachea and thyroid gland being simi- larly drawn inwards. If the foreign body can now be felt, the oesophagus may be incised directly upon it; otherwise a sound or curved forceps should be introduced through the mouth, and made to project in the wound, thus affording a guide to the point at which the gullet should be opened. The incision may be subsequently en- Horsehair probang, or Ra- larged, either upwards or downwards, and the ™<>neur- foreign body extracted with the finger or forceps. 1 An English surgeon, Dr. Stewart, has recorded a case in which a live fish was thus successfully disposed of. CONTUSIONS OF THE CHEST. 355 Special care must be taken, in this operation, not to wound either the inferior thyroid artery, or the recurrent laryngeal nerve. The incision should be allowed to heal by granulation, the patient being fed through a catheter, as after an accidental wound of the oesophagus. This opera- tion is essentially that which has been successfully performed by Syme, Cock, and Cheever, and seems to me in every way preferable to that by a median incision, which is recommended by Nelaton. The results of cesophagotomy for the removal of foreign bodies are quite encouraging, there being, according to Cheever's statistics, about twenty cases on re- cord, in which the offending object was removed, with only four deaths, none of which was justly attributable to the treatment employed. As further evidence of the innocuousness of the operation, it may be men- tioned that in three other cases, in which no foreign body was found, the patients likewise recovered. CHAPTER XYIII. INJURIES OF THE CHEST. Contusions. Contusions of the Thoracic Parietes, Unaccompanied by Visceral Injury, are usually of but trifling importance; if there be much pain attending the act of respiration, the surgeon should fix the injured side, with broad strips of adhesive plaster, precisely as in a case of fractured ribs. An occasional consequence of severe contusion of the chest, is the formation of an abscess beneath the pectoral muscle; suppuration in this situation may continue for a considerable time with- out being recognized, pointing at last probably in the axilla. The local symptoms are necessarily obscure, consisting mainly in great pain, and. general swelling of the whole pectoral region; should, however, these symptoms follow an injury, and coincide with the constitutional evidences of the existence of deep-seated suppuration, the proper treatment would be to cut down in the direction of the muscular fibres, enlarging the exploratory incision subsequently, as much as might be necessary. Contusion, Accompanied by Rupture of the Thoracic Viscera, without fracture, and without external wound, is a rare and dangerous accident, which may result from the contact of a spent ball or piece of shell, from being run over, from falls from a height, etc. Rupture of the Lung has been occasionally observed, under these cir- cumstances, and cases are recorded by Saussier and Gosselin, in which, in spite of the severity of the injury, the patients recovered. The symptoms are those of wounded lung—pneumothorax, with, perhaps, emphysema, haemothorax, haemoptysis, and, at a later period, pleurisy and pneumonia, with accumulation of pus or serum in the pleural cavity. The mechan- ism of the lesion in these cases is, doubtless, as pointed out by Gosselin, that, at the moment of injury, the lung is distended by inspiration, and the glottis spasmodically closed, thus preventing the lung from yielding to the sudden pressure. I have seen two cases of this kind, one at the Pennsylvania Hospital, under the care of Drs. E. Hartshorne and C. C. 356 INJURIES OF THE CHEST. Lee, in which the left lung was ruptured, and which proved fatal on the third day, and another at the Episcopal Hospital, in which the injury affected the right lung, death following on the fifth day. In the latter case the rupture was superficial, and there was no haemoptysis, though the symptoms of haemothorax, pneumothorax, and pleurisy, were well marked. This rare form of injury (of which I have been able to collect only 1G cases, recorded as occurring in civil life) is chiefly met with in young persons. Its treatment is that which will be presently described as appropriate to wounds of the lung. Rupture of the Heart, under similar circumstances, is, I believe, inva- riably, though not always instantly fatal. Gamgee has collected 28 cases of rupture of this viscus (including 1 observed by himself), in 9 of which there was no fracture, and "either no bruise of the thoracic parietes or a very slight one." The pericardium was intact in at least half of the cases, and of 22, in which the precise seat of lesion was noted, the right ventricle was ruptured in 8, the left in 3, the left auricle in 7, and the right in 4. The longest period during which any patient survived the injury was fourteen hours. Concussion of the Lung.—Le Gros Clark has described as a "serious functional derangement without organic lesion," a condition of the lung, resulting from external violence, and very analogous to con- cussion of the brain; the symptoms are dulness on percussion, with dimin- ished respiratory murmur, on the injured side, and puerile respiration on the other, attended with great dyspnoea, but without cough or expec- toration. The symptoms disappear in so short a time (forty-eight hours) as to forbid the idea of any very serious organic lesion. Other Complications, which are sometimes met with in connection with contusions of the chest, are Pleurisy and Pneumonia, Carditis and Pericarditis, Cerebral Congestion, from interference with the respiratory function, as when a man is partially buried beneath a falling bank of earth, and Inflammation and subsequent Suppuration in the Mediastina. It has been proposed to trephine the sternum, in order to evacuate an abscess in the anterior mediastinum, but the symptoms, while suppuration was confined to the substernal region, could hardly be sufficiently distinct to warrant the operation, while it would, of course, be unnecessary, if the abscess pointed on either side. Wounds. Non-penetrating Wounds of the chest usually present no features of special interest. The surgeon should be very cautious in his examina- tion of these injuries, lest he should unfortunately convert the wound into one of the penetrating variety. Hence the finger should be used in preference to the probe, and if foreign bodies are to be removed, this should be done with the utmost gentleness. The diagnosis must be founded chiefly on the absence of those symptoms which attend pene- trating wounds, though certain of these (as haemoptysis) may be present, without the thoracic cavity being directly involved. It is said by Mr. Poland, and some other writers, that traumatic emphysema may accom- pany non-penetrating chest wounds, the air being, as it were, sucked into the subcutaneous areolar tissue, by the motion of the thoracic walls in respiration; but while I would not deny the possibility of such an occurrence, it must at least be extremely rare, and the presence of em- WOUNDS OF THE PLEURA AND LUNG. 357 physema must certainly be considered as strong presumptive evidence that the pleural cavity is implicated. The treatment of these injuries must be conducted on those principles which guide the surgeon in the management of similar wounds in any other part of the body; ad- vantage may often be derived (especially in cases of oblique punctured, or gunshot wounds, burrowing subcutaneously for a considerable dis- tance) from the use of broad adhesive strips, to fix the chest, and thus lessen the chance of the formation of a fistulous track, the presence of which would greatly delay recovery. Non-penetrating wounds of the chest may be attended with trouble- some and even dangerous hemorrhage, from lesion of an intercostal, or of the internal mammary artery, though these vessels are more frequently involved in cases of penetrating wound. The treatment would consist in the use of ligatures, or, if these could not be employed, in the applica- tion of a compress and firm bandage. Penetrating Wounds.—These may be best studied by considering in succession—1. Wounds of the pleura and lung ; 2. Those of the pericar- dium and heart; 3. Those of the aorta and vena cava; and 4. Those of the anterior mediastinum. 1. Wounds of the Pleura and Lung.—The costal pleura alone may be wounded, the pulmonary pleura and lung being uninjured. This is more apt to occur with incised wounds, than with those of any other variety. There is no symptom, however, on which the surgeon can rely, to distinguish these cases from those in which the pulmonary tissue itself is involved, and which are certainly of more frequent occurrence. A wound of the lung may exist as a complication of fracture of the ribs, as was mentioned in a previous chapter; the injury in such a case, being of the nature of a subcutaneous lesion, is of a less serious character than a wound communicating with the external air. Symptoms.—These are usually well marked. The shock is in most cases very decided, there is great dyspnoea (the respiration being chiefly diaphragmatic), with pain at the seat of injury, and a short, tickling cough which is very distressing to the patient. Haemoptysis is usually, but by no means invariably, present, the expectorated matter being frothy mucus mixed with blood, or more rarely pure blood in considerable amount. Emphysema and pneumothorax (the former consisting in the diffusion of air through the areolar tissue, and the latter in an accumu- lation of air in the pleural cavity) are very constant symptoms of lung wounds, though they may accompany wounds involving the pleural cavity only, emphysema, indeed, according to some writers, being met with in cases of non-penetrating wound. Tromatopneea is, perhaps, more characteristic than any other single symptom of a wound of the lung, though I have witnessed it in cases in which there was every rea- son to believe that the pleura alone was injured, and it is said by Fraser to be occasionally present, in wounds in which even the pleural cavity is entirely unhurt; it consists, as its name implies, in air passing in and out of the wound during the act of respiration. External hemorrhage is of course present in greater or less amount in every case of penetrat- ing wound of the chest, but a more serious symptom is hemorrhage into the pleural cavity, giving rise to the complication known as haemothorax. Hernia of the lung, pneumocele, or pneumatocele is a rare sequence of penetrating wounds of the chest, and is more apt to occur after cicatri- zation of the external wound, than as a primary phenomenon. Pneu- 358 INJURIES OF THE CHEST. monia and pleurisy (usually limited to the track of the wound) probably occur in most cases of lung wound, which are not rapidly fatal, effusion of serum and emphysema being occasional and very grave complications of the later stages of the injury. Collapse of the lung is probably a less frequent occurrence in penetrating chest wounds than was formerly supposed. It appears, when present, to depend upon the compression caused by pneumothorax, or by the various forms of liquid effusion. Diagnosis.—This can commonly be made without difficulty, by noting the presence or absence of the various symptoms above enumerated. It is to be observed, however, that no one of them is in itself pathogno- monic, and the warning cannot be too often repeated, that no explora- tion with a probe or finger should be made in any case of doubt. Prognosis.—The prognosis in any case of wound of the lung should be very guarded, at least during the first three days, though in a person of healthy constitution, with care and judicious treatment, recovery may often be obtained. Of the different varieties of wound, the incised or punctured are less dangerous than the lacerated and contused, and of gunshot wounds, those which are perforating, or through and through, give more favorable results than those which are merely penetrating, the missile or other foreign body lodging in some part of the thoracic cavity. The mortality after gunshot wounds of the chest, accompanied by lesions of the thoracic viscera, was, in our army during the late war, 73 per cent. Wounds of the root of the lung are much more fatal than those of the surface. Treatment.—Under this head I shall first describe the treatment ap- plicable to lung wounds in general, considering afterwards such modifi- cations as may be required by those conditions which are sufficiently important to be regarded as complications. The Local Treatment varies according to the nature of the wound. If it be incised or punctured, the external opening should be, as a rule, immediately closed with sutures, and covered with a compress and bandage, which should not be removed for at least five or six days. By this time, in a favorable case, the visceral lesion will have been repaired, and, if the external wound itself have not united, it will have been converted into a comparatively superficial injury. In the case of a gunshot wound, as the part will necessarily slough, the surgeon should content himself with removing all foreign bodjes that can be discovered without dangerous interference, then applying a light dressing, of wet lint, or some similar substance. Dr. B. Howard has proposed, under the name of " hermetically sealing" chest wounds, to pare the edges, thus converting the external opening into an incised wound, and then to bring the edges together with sutures and collodion. The records of the Surgeon-General's Office, however, show that, though ingenious in theory, this method- is unsuccessful in practice; but one case, in which the plan was adopted, is known to have recovered, and in that instance the patient was extremely ill, until re- lieved by the spontaneous reopening of the wounds both of entrance and exit.1 Whatever be the nature of the wound, great comfort may often be afforded the patient by fixing the injured side of the thorax with broad strips of adhesive plaster, an opening being of course left opposite the wound. If haemoptysis be present, ice should be freely applied to the chest. With regard to the Constitutional Treatment appro- priate to cases of wound of the lung, considerable difference of opinion at present exists among practical surgeons. Until within a few years it 1 Circular No. 6, S. G. 0., 1865, p. 22. WOUNDS OF THE PLEURA AND LUNG. 359 was customary to advise venesection in almost all cases, both to arrest haemoptysis, and as a prophylactic against subsequent pneumonia. Ab- solute diet was invariably directed, and antimony or mercurials admin- istered on the first suspicion of inflammatory action. The credit of the first formal protest against the common practice of venesection in these cases is due, I believe, to Dr. Patrick Eraser, who gave the results of extended personal observation during the Crimean war, in an interest- ing monograph, published in 1859. The correctness of the views which Dr. Fraser advanced have been amply confirmed by the experience of military surgeons since that time, and, for my own part, I can testify that, in civil practice, I have found no reason to adopt a different mode of treatment, from that which has proved successful in the surgery of war. " In the treatment of penetrating wounds of the chest," says the author of Circular No. 6," venesection appears to have been abandoned altogether. Hemorrhage was treated by the application of cold, perfect rest, and the administration of opium. These measures seem to have proved adequate generally, and no instances are reported of the per- formance of paracentesis or of the enlargement of wounds for the evacu- ation of effused blood." Still more emphatic language is used by Con- federate Surgeons:— "Equally unphilosophical and more injurious, in our opinion, than even the use of the last class of sedatives [antimonials], is the time-honored absurdity of venesec- tion. It comes to us embalmed in the dicta of 'the highest authority,' and conse- crated by the owlish wisdom of ' the ancients,' and, until recently, the precept has met with submissive and unquestioning acquiescence. We are gratified to find that in all the cases of arterial hemorrhage collected in the office of the inspector, not one is reported wherein the expedient was practised by a surgeon of the Con- federate States. . . . For traumatic pulmonary hemorrhage the measure appears to us not only hazardous, but actually injurious."1 The constitutional treatment which I would recommend, in any case of wound of the lung, whether from gunshot or other form of injury, consists in the adoption of those measures which are adapted to facili- tate the work of nature in the reparative process. Profound quiet and rest, both physical and mental, should be rigidly insisted upon. The diet should consist of such substances as are most easy of diges- tion, and which are yet sufficiently nutritious. Milk is probably here, as in other severe injuries, the most generally suitable article of food. Opium should be freely administered in almost all cases, its constipating effect being obviated by the occasional use of mild laxatives or simple enemata. Diaphoretics may be employed if there be marked febrile reaction, and if pneumonia or pleurisy occur, they may be treated as if idiopathic affections, it being remembered that the inflammation in these cases is usually limited to the immediate neighborhood of the seat of injury, and is indeed a part of the natural process by which the existing lesion is to be repaired. Beef-tea and even brandy will, according to my experience, be more often required in cases of lung wound than calo- mel or antimony. Complications.—The complications of wounds of the lung which require special consideration, are (1) hemorrhage (which may be external, or into the pleural sac), (2) pneumothorax and emphysema, (3) hernia of the lung tissue, and (4) serous or purulent accumulations in the cavity of the pleura. (1.) Hemorrhage may arise from a wound of the lung itself, or of an 1 A Manual of Military Surgery, prepared for the use of the Confederate States Army, page 97. Eichmond, 1863. 360 INJURIES OF THE CHEST. intercostal, or the internal mammary artery: if from a lesion of an intercostal artery, the surgeon should enlarge the external wound, and, if possible, secure the injured vessel with double ligatures; if this be impracticable, compression must be employed, either by means of serre- fines, or, if these will not suffice, by means of manual pressure. It has been proposed to facilitate ligation of an intercostal artery by first excising a portion of the adjacent rib, but unless a fracture or other injury of the rib itself rendered such an operation necessary (p. 241), I should scarcely think the surgeon justified in its performance. Hemor- rhage from the internal mammary artery should be treated by ligation of that vessel, which in the upper intercostal spaces may be reached by an oblique incision, from £ to £ an inch from the border of the sternum, the costal cartilages being, if necessaiy, divided so as more fully to expose the artery. If hemorrhage proceed from a wound of the lung itself, the blood may escape at the cutaneous orifice, may be coughed up through the air-passages, or may accumulate in the cavity of the pleura, giving rise to the condition known as haemothorax. This condition may also arise, though more rarely, from wounds of the intercostal or internal mammary arteries. The rational symptoms of haemothorax are those which charac- terize loss of blood in general, such as faintness, dizziness, and pallor, with disturbance of the respiratory function, dyspnoea, restlessness, etc. None of these are, however, in any degree pathognomonic, and death from haemothorax may take place, without the previous occurrence of any symptom certainly indicative of wound of the lung. The physical signs, when present, are more trustworthy; they consist of enlargement of the injured side of the chest, with bulging of the intercostal spaces; absence of respiratory murmur, and dulness on percussion—gradually increasing in extent, and the line of dulness varying with the posture of the patient; the sensation of a wave of fluid, or of splashing, felt by the patient, or transmitted to the hand of the surgeon on succussion; and finally, accord- ing to Valentin and Larrey, ecchymosis in the lumbar region. All of these signs, except the last (which is by no means constant, and is, indeed, thought by Fraser to be somewhat apocryphal), may be equally present in cases of serous, or of purulent accumulation, and hence it is only by their appearance immediately after the injuiy, and in coincidence with other signs of hemorrhage, that the surgeon can satisfy himself as to the nature of the case. The treatment of hemorrhage, from wound of the lung, would consist in closing the external wound by means of a firm compress, in the application of ice, and in the administration of opium, with perhaps digitalis or veratrum viride; by these means, in a favorable case, coagulation of the effused blood, and subsequent occlusion of the bleeding vessels, may be obtained, the clot being gradually absorbed, and the patient recovering without further trouble; if, however, the bleeding continue into the pleural sac, as marked by increased dulness on percussion, with dyspnoea, and the other symptoms of haemothorax above enumerated, the original wound must be reopened, or, if it have already healed, paracentesis must be performed, as in a case of em- pyema. (2.) Pneumothorax and Emphysema usually coexist in the same case, though either may be present without the other. By the act of inspira- tion, the air is sucked into the pleural cavity, either through a cutaneous wound, or from the ruptured air-vesicles of the lung, while, in expiration, the orifice by which the air entered being closed by the valve-like action of the surrounding structures, it is pumped into the areolar tissue pneumothorax thus usually preceding emphysema. If, however, there be WOUNDS OF THE PLEURA AND LUNG. 361 old pleural adhesions, or if the external wound correspond exactly with that in the lung, the air may pass directly in and out (tromatopnea), without invading either the pleural sac, or the planes of connective tissue. Pneumothorax alone may result from rupture of the lung, without injury of the costal pleura, while emphysema alone may result from puncture of the lung through an old pleural adhesion, from rupture of an air-cell or bronchus into the posterior mediastinum (according to Hilton), or possibly, as taught by Poland and others, from a non-pene- trating wound of the chest. Pneumothorax is marked by great resonance on percussion, with absence of the respiratory murmur, by amphoric respiration, and occasionally by metallic tinkling; if excessive, it pro- duces much dyspnoea. Emphysema is characterized by a diffuse, puffy, colorless, perfectly elastic swelling, crackling under pressure; it can scarcely be mistaken for any other condition. It is very seldom that either of these complications requires special treatment. Pneumothorax, if existing on both sides, might threaten suffocation, and the proper treatment in such a case would be to evacuate the contained air by puncturing the chest with a very small trocar, closing the wound imme- diately afterwards with a strip of adhesive plaster. Emphysema, if very extensive, might require the application of a bandage, or even scarification of the most distended parts. (3.) Hernia of the Lung.—This may occur as a subcutaneous injury, the result of crushing violence to the chest, or even, it is said, of straining efforts during parturition. It may also occur in the site of a cicatrix, as in an instance mentioned by Yelpeau. The tumor under these cir- cumstances is soft, somewhat circumscribed, elastic, compressible, in- creasing in expiration and diminishing in inspiration, communicating a distinct impulse on coughing, crepitating when handled, and measurably disappearing when the patient holds his breath; the tumor is resonant on percussion, and the seat of a loud respiratory murmur; the limits of the aperture through which it has escaped, may often be distinguished by palpation. The treatment consists in effecting and maintaining reduction, by means of a compress and bandage, if this be possible, and if not, in the application of a concave pad, so as to protect the part from injury, and prevent further protrusion. Hernia of the lung sometimes takes place through an open wound, usually in the neighborhood of the nipple: if the projecting lung tissue be healthy, it may be cautiously pushed back, the orifice through which it escaped being slightly enlarged if necessaiy; if gangrene have occurred, however, the protrusion should not be inter- fered with, the part being left to be removed by sloughing. (4.) Hydrothorax and Empyema, the former term denoting a collection of serum, and the latter one of pus, in the pleural sac, are occasional com- plications of the later stages of wounds of this part. The symptoms are those of chronic pleuritic effusion, from whatever cause (the physical • signs being the same as those which were mentioned in speaking of haemothorax), and the diagnosis is to be made, principally, by observing the later period of occurrence and the more gradual increase of the symptoms, and, in the case of empyema, the tendency which is some- times manifested to the formation of an external opening. Empyema, according to Pepper, and other authors, is particularly marked by bulg- ing of the lower intercostal spaces, and dilatation of the superficial veins; but Bowditch doubts the possibility of more than suspecting the nature of pleuritic effusions, before operation, and founds even this suspicion, mainly, on the previous history of the case. It is doubtful if any advan- tage is to be obtained, in the treatment of these cases, from the use of 362 INJURIES OF THE CHEST. medicines designed to promote absorption, such as are employed in the cases of chronic pleuritic effusion, which come under the observation of the physician; hence, in any case in which the accumulation is so great as to give manifest tokens of its presence, the surgton should have recourse to the operation of Paracentesis, which should be performed before the lung has become so bound down by adhesions, as to have lost the power of expanding when the source of pressure is removed. Paracentesis Thoracis.—rBefore resorting to this operation, the sur- geon should confirm his diagnosis by the use of an exploring trocar and canula, or, which is perhaps better, a long-nozzled hypodermic sy- ringe, by which a small portion of the accumulated fluid may readily be obtained for examination. The particular operation to be chosen de- pends somewhat upon the nature of the effusion; if this be serous, the opening should be a small one, Fig. 177. and it is here important to guard against the admission of air, by using the suction trocar proposed by Dr. Wyman, and modified by Dr. Bowditch, the "aspirators" of Dieulafoy or Rasmussen, or, if none of these be at hand, a trocar fitted with a stopcock and gum-elastic bag (Fig. 177), or with a flexible tube so arranged as to evacuate the fluid under water. For the evac- uation of an empyema the same precautions need not be Paracentesis thoracis. taken, and it is here better to use a full-sized trocar, leaving the canula or an elastic catheter in the wound, or even introducing a drainage tube, one end of which projects at the point of tapping, the other being brought out through a counter-opening at the lowest part of the cavity. Drainage tubes (introduced by Chassaignac) consist of pieces of India-rubber tubing, about one-sixth of an inch in diameter, with numerous lateral apertures, made by notching the tube with scis- sors. The point at which paracentesis should be performed is a matter of dispute; that usually recommended is between the fifth and sixth, or sixth and seventh ribs, in a line nearly corresponding to the insertion of the serratus magnus muscle. Dr. Bowditch usually taps between the ninth and tenth ribs, while others go as high as the fourth intercostal space. Whatever point be chosen, the intercostal space should be, if not bulging, at least not contracted; the skin should be incised with a , bistoury or lancet, and the trocar thrust in at the upper edge of the lower rib, so as to guard against wounding the intercostal artery. If an ordinary trocar be used (in a case of hydrothorax), the admission of air may be further guarded against by drawing the cutaneous incision to one side before introducing the trocar, thus making a kind of valvular opening; but the calibre of the suction-trocar is so small that, if it be employed, this precaution is unnecessary. The patient, at the beginning of the operation, should be in a sitting posture, and as the fluid is with- drawn should be gently lowered into a supine position, and slightly turned on the affected side; an assistant should steadily compress the lower part of the chest, to prevent syncope, and further to guard against the entrance of air. WOUNDS OF THE PERICARDIUM AND HEART. 363 The after-treatment (as far as the operation is concerned) consists simply in closing the wound with a piece of lint and an adhesive strip. If it be determined (in a case of empyema) to employ a drainage tube, this is introduced as follows: a steel eyed-probe, bent like a sound, is passed through the wound of tapping, and made to project at the lowest accessible intercostal space; upon this, as a guide, a counter-opening is made, and the eye of the probe threaded with a strong ligature carrying the tube, which is thus readily brought into place when the probe is with- drawn ; the ends of the tube are then fastened together, and the wounds covered with wet lint, or other simple dressing. Boinet has recom- mended the injection of iodine into an empyemic cavity, and in one case, in which I saw this method employed, it certainly produced no undue irritation; I believe, however, that the advantages which were anticipated from this mode of treatment have been, in most instances, not altogether realized. The statistical results of the operation of tap- ping the chest are quite satisfactory; twenty-five cases reported by Dr. Hughes gave thirteen complete and two partial recoveries, the ten deaths being in no degree due to the operation, while complete recovery was obtained in twenty-nine out of seventy-five cases tapped by Dr. Bow- ditch, and decided relief afforded in all the remainder. In a case of Empyema following a Gunshot Wound, in which there was reason to suspect the presence of a foreign body, the surgeon should carefully explore the cavity with a probe, after, evacuating the contained fluid, when, if a ball, or other foreign body, should be discovered, it should be removed with suitable forceps, as was successfully done by Larrey. 2. Wounds of the Pericardium and Heart. — Wound of the Pericardium alone would not appear to be so fatal an injury as would naturally be supposed; at least 51 cases collected by Fischer gave only 29 deaths, and as many as 22 recoveries, the diagnosis in three of the latter being subsequently confirmed by post-mortem inspection, when the patients died from other causes. Wounds of the Heart are usually, though not necessarily, fatal; 401 cases, collected by Fischer, afforded as many as 50 recoveries, the diag- nosis in 33 of the latter being eventually confirmed by means of an autopsy. The symptoms of these injuries are not very definite; if the wound be large, there is, of course, profuse hemorrhage, which may prove almost instantly fatal; punctured wounds are, however, often attended with little or no bleeding, owing chiefly to a peculiar arrangement of the muscular fibres of the heart, described by Pettigrew, by which a wound which is transverse to one layer of fibres is in the direction of another layer, and therefore, to a certain extent, necessarily valvular. Syncope is often observed in cases of heart wound, occurring not unfrequently at the moment of injury. Pain, when present, is, according to Fischer, due to the pericardial lesion. If effusion of blood, or serum, take place into the cavity of the pericardium, the sounds of the heart and the car- diac impulse are diminished in intensity. A systolic bellows sound is the most usual abnormal murmur observed in cases of heart wound. Precordial anxiety, dyspnoea, and other symptoms are not distinctive, and, indeed, are occasionally entirely wanting. The diagnosis, which, as may be inferred from what has been said, is often obscure, may be additionally complicated by the coexistence of a wound of the lung, as happened in a case which I observed some years ago. The prognosis should, of course, be very guarded. Recovery, however, may occasion- 361 INJURIES OF THE CHEST. ally follow, and instances have been recorded by Ferrus, Latour, Four- nier, Randall, Carnochan, Balch, Hamilton, Hopkins, and others, in which patients have survived heart wounds for considerable periods, even though with foreign bodies lodged in the substance of the organ. The treatment of a suspected wound of the heart would consist in keep- ing the patient at absolute rest, and in the application of cold, the ad- ministration of opium, digitalis, veratrum viride, etc., and if death were threatened by pericardial effusion, perhaps the performance of paracen- tesis. Paracentesis Pericardii may be performed in the fourth or fifth intercostal interspace, with the same precautions that were recommended for the operation of tapping the pleural sac. 3. Wounds of the Aorta and Vena Cava are almost invariably fatal. Cases are, however, recorded by Pelletan and Heil, in which patients survived wounds of the aorta for two months and a year respectively. 4. Wounds of the Anterior Mediastinum are less serious than any other penetrating wounds of the chest: the symptoms are often rather obscure, being indeed in many instances chiefly negative, and the diagnosis depends on the absence of those signs which characterize wounds of the lung. Some of these signs may, however, be present; thus ^emphysema, and, according to Fraser, even tromatopnea, may ac- company wounds of the mediastinum which do not involve the lung or pleura. The chief dangers of these injuries are hemorrhage (from the internal mammary artery), diffuse inflammation, and suppuration. Death may result from pressure of the accumulated pus on the heart or lungs, or from pyaemia. The treatment of a wound of the mediastinum is that which has been directed for other penetrating wounds of the chest: if suppuration occur, the matter should be evacuated where the abscess tends to point, at one or the other side of the sternum. Injuries op the Diaphragm. The diaphragm may be ruptured by external violence, as by a fall on the chest or abdomen, by violent squeezing, as in railway accidents, or (as in a case referred to by Mr. Pollock) by spasmodic contraction of the part itself. The usual seat of laceration, in these cases, is the left side, in the fleshy portion of the muscle. If the injury be uncomplicated by lesion of abdominal or thoracic viscera, the prognosis is not so unfa- vorable as might be supposed: unless, however, the laceration be very limited in extent, protrusion of the stomach or other abdominal viscera into the cavity of the chest will almost inevitably occur, constituting the condition known as Diaphragmatic Hernia. Wounds of the diaphragm, resulting from stabs, gunshot injuries, etc., are usually complicated with other serious lesions, and it is from these, rather than from the wound of the diaphragm itself, that the danger in these cases chiefly arises. The symptoms of a wound of the diaphragm are very obscure ; in most instances there is great dyspnoea, breathing being principally carried on by the subsidiary muscles of respiration. Dr. C. T. Hunter has, how- ever, recorded a case of gunshot wound, in which the ball, after per- forating the stomach, bowels, and diaphragm, lodged in the thoracic cavity, but in which there was no difficulty of breathing until shortly before death, the dyspnoea even then evidently resulting mechanically, from great gaseous distension of the intestines. The treatment of a wound of the diaphragm is essentially the same as that recommended for penetrating wounds of the chest. CONTUSIONS OF THE ABDOMEN. 365 CHAPTEE XXX. INJURIES OF THE ABDOMEN AND PELVIS. Fig. 178. Contusions of the Abdomen. Contusions of the Abdomen, unattended by Lesions of the contained Viscera, are rarely attended with much risk. It is popu- larly believed that sudden death not unfrequently results from a blow on the epigastrium, no morbid appearance being discoverable on post-mor- tem inspection; the possibility of such an occurrence has, however, been shown, by Mr. Pollock's researches, to be at least doubtful, though there can be no question that rapid death may follow these injuries, either from concomitant shock, or from a condition of the solar plexus analo- gous to cerebral concussion. In either case, however, there would pro- bably be physical lesions which could be recognized after death. Rupture of the Abdominal Muscles may occur without the existence of any external wound: these ruptures have usually been observed in the recti muscles, though they may occur in any portion of the abdominal parietes. The accident is very apt to be followed by a form of ventral hernia, which may sometimes attain a very large size, as in the patient whose case is represented in the an- nexed figure, and who received his in- juries by being run over by the wheel of a cart. The treatment of such a case consists in the application of a truss with a broad and somewhat concave pad, to restrain the protrusion. There is little risk of strangulation, on account of the large size and yielding character of the hernial aperture. I liave several times seen, in soldiers, a ventral hernia in the median line, resulting from sepa- ration of the tendinous fibres in the linea alba, and caused, apparently, by the fatigue of long marches and the weight of the knapsack. The treatment consists in the application of a pad and elastic bandage. Ventral hernia, following rupture of the abdominal muscles. (From a patient in the Episcopal Hospital.) Abscess of the Abdominal Parietes occasionally follows contu- sion of the part, and may cause great destruction of tissue by extending between the muscular planes. The treatment consists in early evacuation of the pus, by means of free incisions, so arranged as to permit drainage. 366 INJURIES OF THE ABDOMEN AND PELVIS. Contusions of the Abdomen, attended -with Lacerations of the Abdominal Viscera, are very grave injuries. Rupture of the liver, spleen, kidney, omentum, or mesentery, may prove rapidly fatal from internal hemorrhage; while lacerations of the hollow viscera, as the stomach, bowel, or gall-bladder, or of the parietal peritoneum, are princi- pally dangerous on account of the peritonitis, which almost inevitably results. Intestinal obstruction occasionally follows apparently slight contusion of the abdomen, doubtless from injury to the peritoneum covering the affected portion of bowel. The degree of risk attending laceration of the solid viscera depends entirely upon the extent of the lesion: thus a superficial laceration of the liver may cause merely localized peritonitis, from which the patient may recover; injuries of the spleen are more dangerous, on account of the profuse bleeding which attends even slight lesions of this organ, and death usually results, if not from hemorrhage, yet at'a later period, from the supervention of diffuse inflammation and suppuration. Laceration of the kidneys offers a com- paratively favorable prognosis: as was mentioned in Chap. XVI., slight lacerations of these organs are not infrequent in cases of spinal injury, and do not appear necessarily to entail any serious consequences. Rup- tures of the stomach or bowel are almost invariably fatal: if the seat of laceration should be such, that extravasation of the contents of these viscera should take place elsewhere than into the peritoneal cavity (as between the layers of the mesentery, in the case of the bowel), it would be just possible that the resulting inflammation might terminate in an abscess which would point externally, and that recovery might thus follow; but it may be given as a general rule, that ruptures of the stomach or bowel are fatal injuries. Rupture of the gall-bladder is almost always followed by death, bile being found in the peritoneal cavity on post-mortem examination: that recovery is at least possible, would, however, appear from a case recorded by Dr. Fergus, in which the patient was considered convalescent, and was walking about, when, on the sev- enth day, peritonitis was suddenly developed, and proved fatal two days subsequently. Rupture of the ureter is a very rare injury: Mr. Poland has collected four cases, one of which recovered, after the evacuation by puncture, at intervals, of about two gallons of fluid resembling urine, the other cases terminating in death, during the first, fourth, and tenth weeks respectively. In none of the cases does it appear that peritonitis was present, the urinary extravasation having occurred into the cellular tissue behind the peritoneum. Symptoms.—The symptoms of these various forms of injury are rather obscure. There is usually marked shock, with pain, and a sensation of impending dissolution—but not more than is often observed in cases of abdominal contusion unaccompanied by visceral lesion: the persistence of collapse, however, with other evidences of internal hemorrhage, will give reason to suspect rupture of a solid viscus, or of a portion of the peri- toneum which contains large vessels; while the immediate development of peritonitis would indicate rupture of one of the hollow viscera. Pain in the right hypochondrium, with increased hepatic dullness, and, at a later period, bilious vomiting, clay-colored stools, and the presence of sugar in the urine, would afford evidence of laceration of the liver; haematuria would indicate lesion of the kidney, though its absence would, by no means, prove that this organ had escaped; heematemesis would be a symptom of ruptured stomach, and bloody stools of ruptured intestine— a lesion, the existence of which might also be suspected, if the abdominal wall were the seat of emphysema, the diagnosis of which from emphysema TRAUMATIC PERITONITIS. 367 due to thoracic injury, and from gaseous putrefaction, might be made by observing the history of the case, and the coincident symptoms. The history may also serve, sometimes, to distinguish between gastric and intestinal laceration, rupture of the stomach rarely occurring except when that organ is distended by a recent meal. Treatment__As these injuries are in the majority of instances neces- sarily fatal, their treatment must, of course, often be merely euthanasial. So far as any curative influence can be exerted by remedies, it must be (as Sir Thomas Watson puts it) in obviating the tendency to death. Hence the surgeon's first efforts must be directed to arresting the internal hemorrhage, which is the source of immediate danger, and at a later period to combating the peritonitis, which is the common cause of death in those cases which survive the early periods of the injury. The patient should be put to bed, and kept profoundly quiet; if the symptoms of shock be very prominent, cautious efforts may be made to induce reaction, preferably by the application of external warmth, for it must be remem- bered that internal stimulation might increase the risk of hemorrhage. Opium may be freely administered, both to relieve the sufferings of the patient, and as an anti-hemorrhagic remedy; to increase its efficiency in the latter respect, it may be advantageously combined with acetate of lead. The older writers recommended venesection in these cases, on the same principle on which it was employed in the treatment of penetrating wounds of the chest; but I imagine there are few surgeons at the present day, who would employ bleeding un'der these circumstances. The local treatment should consist (at this stage) in the application of cold to the abdomen—dry cold applied by means of an ice bag or box (see page 55), or if these be not at hand, cloths wrung out ofysold water and frequently renewed. The diet should be mild and unirritating, and if there be reason to suspect laceration of the stomach or bowel, the patient should be exclusively fed by means of nutritive enemata. If great suffering should be caused by gaseous distension, the surgeon would be justified in puncturing the bowel with a fine trocar, through the linea alba, as recommended by T. Smith. It does not appear that this little operation is in itself attended with any particular risk, and it would certainly be permissible as an euthanasial measure. Retention of urine should be obviated by the use of the catheter. Traumatic Peritonitis.—It is probable that slight and circum- scribed peritonitis occurs in almost every case of severe abdominal injury which recovers, but it is the existence of diffuse peritoneal inflam- mation, attended with the effusion of turbid serum, or with suppuration, that constitutes the chief danger to be apprehended in the later stages of these injuries. The symptoms of traumatic peritonitis do not differ from those of the idiopathic variety of the affection, and for their de- scription I would therefore refer the reader to works on the Practice of Medicine. The course of traumatic peritonitis is very rapid, death from this cause sometimes occurring in less than twenty-four hours from the time of reception of the injury. The treatment varies with the general condition of the patient, and the supposed nature of the internal lesion. NI have never had occasion to employ general bleeding in these cases, but I have applied leeches or cups (in cases occurring among those of robust health and vigorous constitution), and, I am sure, with advantage. The amount of blood drawn may vary from 8 to 12 ounces, and the imme- diate mechanical relief thus afforded to the inflamed peritoneum, is suf- ficient, I think, to compensate for the evils which inevitably attend all 368 INJURIES OF THE ABDOMEN AND PELVIS. forms of bloodletting. In an old or feeble person, however, or in a young child, I should consider even local bleeding highly improper. The ap- plication of a large blister is usually recommended in these cases, and I have myself employed it. I am disposed to think, however, that a jacket-poultice, enveloping the whole abdomen, would often be equally efficient, as it would be certainly more agreeable to the patient. I have found advantage from the use of the veratrum viride, in doses of 3 or 4 drops of the tincture, every three hours, simply as a means of reducing the rapidity of the heart's action, and the force of the circulation; the remedy is, however, a dangerous one, and its effects should be carefully watched, its administration being suspended as soon as the pulse falls to the normal average. Opium is an invaluable remedy in cases of trau- matic peritonitis, and may be freely given in every instance. Unless laceration of some part of the alimentary canal be suspected, this drug may be suitably combined with calomel; but in cases of intestinal rup- ture, the effect of the latter substance would be to increase the risk of fecal extravasation, and in such a case, if mercury is used at all, it should be employed by inunction. Milk diet is that which is best adapted to cases of traumatic peritonitis, wine or brandy being added if necessary. If the stomach or bowel be lacerated, nutritive enemata, of beef-tea, egg-nogg, etc., must be substituted. If serous effusion per- sist after the subsidence of acute symptoms, an attempt may be made to promote absorption, by the use of blisters, and by the administration of iodide of potassium. N v Retro-peritoneal Suppuration, resulting from rupture of the intes- tine between the layers of the mesentery, might possibly require inci- sions to evacuate the pus ; and similar treatment would be indicated in the event of Urinary Extravasation occurring from laceration of the kidney or ureter. Wounds of the Abdomen. Non-Penetrating Wounds of the abdominal parietes present few peculiarities requiring special mention. Foreign bodies are to be re- moved, and the wound cleansed, as in other localities. Hemorrhage in these cases cannot safely be controlled by pressure, simply because there is no surface to furnish counter-pressure, while closure of the external wound will not suffice, because it would allow interstitial bleeding to con- tinue, and thus dissect up the inter-muscular spaces ; therefore, if, in any case, the hemorrhage be greater than mere oozing, the part must be freely exposed (the wound, if necessary, being enlarged for this pur- pose), and the bleeding vessel secured by ligature, torsion, or acupres- sure. These wounds are apt to gape, and, hence, if extensive, require the use of sutures, muscular relaxation being secured by position. Ventral Hernia may occur after cicatrization, and would require the ap- plication of a truss or bandage. Penetrating Wounds.—These may be divided into—1. Those with- out protrusion or wound of the abdominal viscera; 2. Those without pro- trusion, but with wound of such viscera; 3. Those with protrusion of unwounded viscera; and 4. Those with protrusion and wound of viscera. 1. Penetrating Wounds of the Abdomen, without Protrusion or Wound of the Contained Viscera, may result from stabs, bayonet thrusts, or gunshot injuries. The diagnosis from non-penetrating wounds is often PENETRATING WOUNDS. 369 difficult, and any exploration with a probe would be manifestly improper. The escape of bloody serum may be taken to indicate penetration of the peritoneum, and the diagnosis will be confirmed should peritonitis sub- sequently occur. The treatment, in such a case, would be the same as in one of non-penetrating wound, visceral complications being managed on the principles already laid down, in speaking of visceral rupture without external wound. 2. Penetrating Wounds, with Wound of the Abdominal Viscera, but vnthout Protrusion.—The diagnosis of these cases from those of the last category, could only be made by observing the flow of the visceral contents through the external wound, or by noting a very rapid development of peri- tonitis, which, when resulting from extravasation of the visceral contents, occurs more quickly than under other circumstances. The treatment of a case of this kind would consist in placing the patient in such a posi- tion as to allow any matter that might be extravasated to escape exter- nally, in the free administration of opium, and in the adoption of such measures generally as would tend to moderate the peritonitis, which would almost inevitably ensue. It has been proposed in such a case to enlarge the external opening, search for the source of extravasation, and apply sutures to the wounded viscus, but the prospective benefits of such a proceeding would be extremely questionable, while the additional risks that it would entail are manifest. When the patient recovers, after an injury of this kind, it is usually with a gastric, biliary, or fecal fistula, according to the part which has been wounded. 3. Penetrating Wounds, with Protrusion of Unwounded Viscera.—Por- tions of almost any of the abdominal organs may protrude, if the wound be a large one, and instances are not wanting in which recovery has fol- lowed the protrusion, under such circumstances, of parts of the stomach, liver, spleen, or other viscera. In these cases, the wound being large, there is commonly not much difficulty in reduction, which should always be practised in the case of such organs as have been mentioned. If the bladder protrude, reduction may be much facilitated by the use of the catheter. The parts which are liable to protrude through small wounds are the bowels, mesentery, and omentum. The treatment of such cases would depend upon the condition of the extruded viscera. If Bowel protrude, and be found healthy, or only moderately congested, it should be at once returned. This may sometimes be effected by drawing down a further portion of the gut, and gently pressing upwards the fecal contents, so as to diminish the tension of the protruded mass. In other cases it may be necessary to enlarge the wound—just as in the analogous case of operation for strangulated hernia. This debridement, as it is called, should be made in an upward direction, and should be confined, if possible, to the skin and muscular tissues, the peritoneal aperture usually yielding without incision. If reduction be rendered impossi- ble by gaseous distension of the protruded bowel, the surgeon would be justified in puncturing the part with a grooved needle, as has been successfully done by Mr. Tatum and others. Reduction should be aided by placing the patient in such a position as will insure relaxation of the abdominal walls, and the portion of bowel which has last de- scended must be first returned. The surgeon must take care that reduc- tion is really accomplished, and that the protruding part is not merely thrust up between the planes of the abdominal parietes. If the pro- truded bowel be gangrenous, it would not be safe to attempt reduction, and, in such a case, the part should be freely incised, and the patient 24 370 INJURIES OF THE ABDOMEN AND PELVIS. allowed to recover, if possible, with a fecal fistula. What course should be adopted, if the bowel, though not absolutely gangrenous, be intensely inflamed? It is usually advised, under these circumstances, to effect reduction and close the wound, but I am not sure that it might not sometimes be better to allow the part to remain in situ, after dividing any constricting bands that might threaten strangulation. The risk of peritonitis would, at least, not be increased by this plan, while, if the bowel should subsequently give way, there would be less danger of fecal extravasation. The course to be pursued in case of Omental Protrusion likewise depends upon the state of the part; if this be healthy, it should be at once returned, but if violently inflamed, or if gangrenous, it should be excised—the part immediately above being first transfixed, and tied with a double ligature, to prevent hemorrhage, and the stump being secured in the deeper portion of the wound, by fastening the ligatures, with adhesive strips, to the abdominal wall. The treatment to be pursued after reduction, consists in accurately closing the wound with numerous sutures (which should embrace the whole thickness of the abdominal wall, except the peritoneum), and in adopting means to moderate the peritonitis, which may be expected to occur. If omentum have been excised, the cutaneous wound should be closed over the ligated stump, the ligatures being brought out between the points of suture. If bowel have been left in the wound, with the anticipation that a fecal fistula will follow, the part should be lightly dressed, with oiled lint or some similar substance, so as to exclude the air, and keep the wound from dust. 4. Penetrating Wounds, with Protrusion and Wound of Viscera.—If a solid viscus be affected, the treatment would consist in reduction, or (in the case of the omentum) perhaps in partial excision, according to the rules above laid down. Hemorrhage from a mesenteric artery, should be arrested by torsion or ligature. Wounds of the stomach or bowel, require the application of sutures, the part being subsequently returned into the abdominal cavity, and the after-treatment conducted as in cases of the previous category. The suture employed should, in case of a large wound, be the continued or Fig. 179. Fig. 180. glover's suture (Fig. 67), applied through all the coats except the mucous, or, which is pre- ferable, if the wound be transverse, Lembert's, or Gely's modification, each of which has for its object the inversion of the edges of the wound, and the consequent coaptation of the serous surfaces (Figs. 179, 180). The suture being applied, both ends are to be cut short, and the whole replaced in the abdominal cavity. The suture (which should be of silk Lembert's suture. Geiy's suture, or thread) gradually finds its way into the interior of the bowel, and is eventually dis- charged per anum. For small longitudinal wounds the common inter- rupted suture may suffice, while a mere puncture may be closed by simply throwing around it a ligature, the wounded point being raised for the purpose with tenaculum or artery forceps. If, on the other hand, a transverse wound involve the whole calibre of the bowel, it is probably better to secure the edges* of each extremity of the gut to the external wound, and allow the formation of a fecal fistula. This course would, I think, be safer, under such circumstances, than an attempt to restore the continuity of the bowel by means of sutures. FECAL OR INTESTINAL FISTULA. 371 In the after-treatment of all these cases the free administration of opium is of the highest importance. The patient must be kept perfectly quiet, purgatives strictly interdicted, and food given as much as possible in the form of nutritive enemata. Gastric Fistula is a condition by no means incompatible with long life and comfort. If small, an attempt may be made to promote con- traction and cicatrization, by occasional cauterization of the edges; but if large, the surgeon should content himself with applying a suitable compress or obturator. Attempts have been made to remedy gastric fistulae by plastic operations, but not with very encouraging results. The most promising plan would be to use two flaps, inverting one, with its cutaneous surface towards the orifice, as in Wood's operation for ex- strophy of the bladder. • Biliary Fistula scarcely admits of any treatment, except keeping the parts clean, and removing any gall-stones that may become impacted. Fecal or Intestinal Fistula (usually called Artificial Anus) is more frequently met with after strangulated hernia, than after a wound, but the treatment in either case is the same, and I shall, therefore, con- sider it here. If the opening into the bowel be but small, the greater portion of the fecal mass being evacuated in the natural way, it may be sufficient to keep the parts clean, and to apply a firm compress, which, with occasion- ally touching the edges with nitrate of silver, will sometimes effect a cure. If, however, the opening be larger, and still more if the whole calibre of the gut be involved, the condition is different. In such a case the ends of the bowel adhere by their serous surfaces, their position at the bottom of the external wound having been not inaptly compared to that of the tubes of a double-barrelled gun. The lower end of the bowel, being unused, undergoes contraction, while the upper extremity is frequently abnormally dilated. The mesenteric portion becomes pro- longed between the ends of the gut into a kind of spur, which acts as a valve in further occluding the lower opening. In some cases, the junc- tion of the two ends of bowel is at a considerable depth from the surface, the fecal contents finding their way to the external wound through a long and perhaps sinuous canal. The treatment consists in dividing the " Speron," or spur-like projec- tion between the intestinal extremities, so as to restore the continuity of the bowel, and in subsequently freshening the edges of the external wound, which is then closed with harelip pins—or in performing a plastic operation, if the simpler procedure fail. The division of the spur may be accomplished in several ways, the best probably being by means of the enterotome devised by Dupuytren. The enterotome consists of two serrated blades (Fig. 181, a, b), which are introduced, one into each end of the bowel, and which are then approximated, and fixed by means of a screw. This screw is tightened day by day, so as to cause the adhesion of the adjoining surfaces of bowel, and the removal of the septum by sloughing; if this be done too quickly, the peritoneal sac will be opened, and death will probably occur from fecal extravasation. Another risk is the possibility of pinching a knuckle of healthy intestine between the blades. The tightening of the screw must be very gradually effected, the time required for safe division of the septum being at least a week. To avoid the risk of premature perforation, Dr. David Prince has recently 372 INJURIES OF THE ABDOMEN AND PELVIS. suggested the use of a wire loop and pin, by which the sides of the sep- tum are invaginated, while the necessary pressure is afforded by an elastic cord which connects the pin and loop outside of the body. Perforation being effected, the little instrument is made to cut its way out through Fig. 181. Fig. 182. Dupuytren's enterotome. "3a*f. Enterotome applied. the septum, by means of another elastic cord, attached to a miniature " derrick" which is fixed upon the surface of the abdomen. Other plans are Physick's, which consists in bringing together the sides of the sep- tum with a ligature, and in subsequently dividing the part below, and Schmakhalden's, which consists in transfixing the septum with a ligature, which is then forcibly tied, and allowed to cut its way out. Various modi- fications of Dupuytren's method have been proposed by Liotard, Del- pech, Gross, and others. During the application of the enterotome, the patient should be kept pretty fully under the influence of opium. As soon as the continuity of the bowel has been restored, the edges of the external wound may be pared, and brought together with the twisted suture; or, if this fail, an attempt may be made to close the opening by means of a plastic operation. Foreign Bodies, such as coins, pins, buttons, or artificial teeth, are not unfrequently swallowed, and may lodge in the stomach ok bowels. The domestic treatment of such cases is usually the administration of a purgative—a remedy which is, however, really unsuitable, as the object should rather be to delay peristaltic action, and to allow the foreign body to become enveloped in a mass of fecal matter, so that it may pro- duce less irritation in its onward passage. If the foreign body cannot be extracted through the mouth, as has been successfully done in one instance by L. S. Little, and is of such a nature (as a table knife, or fork) that it cannot probably be either dissolved by the gastric and intestinal juices, or naturally evacuated, the surgeon would, I think, be justi- ■ fied, provided its position could be ascertained by external palpation, in attempting its removal by operation. Gastrotomy has, according to Durham, been successfully performed under these circumstances in seven, and according to Adelmann, in'eight cases; and as death would be, sooner or later, almost inevitable without operation, the attempt INJURIES OF THE PELVIC ORGANS. 373 would be at least permissible.1 The incisions, in such a case, should be regulated by the size and shape of the body to be removed, and the after- treatment should be the same as for an incised wound accidentally inflicted. Enterotomy might be similarly resorted to, if the foreign body, having reached the bowel, should cause complete intestinal obstruction. (See Chap. XLII.) Injuries of the Pelvic Organs. Injuries of the Bladder.—The bladder may be ruptured (without external wound), by violence, as a kick, applied to the abdomen. This accident is only likely to happen if the organ be distended with urine, as when empty it sinks beneath the pubic arch, and is thus measurably protected from external injury. The rupture usually occurs in the pos- terior wall of the bladder, involving the peritoneal, as well as the other coats of the organ, and allowing urinary extravasation into the peritoneal cavity, an event which is almost inevitably fatal. More rarely the rent is confined to the anterior wall of the bladder, urine then escaping into the pelvic areolar tissue, and inducing a condition which, though very grave, is not so uniformly fatal as the one previously referred to. The symptoms, in the former case, consist of intense epigastric pain, collapse, urgent but fruitless efforts to urinate, and in a short time the ordinary signs of peritonitis; the introduction of the catheter serves to evacuate either none or a very small quantity of bloody urine. If the perito- neum be not involved, the symptoms are less urgent, the patient being, in these cases, gradually worn out, by diffuse inflammation and sloughing of the areolar tissue. The treatment consists in the introduction of a large flexible catheter, which (as a general rule) should be secured in place, the urine being allowed, to run off constantly, by means of an attached India-rubber tube, into any convenient receptacle. The patient should be got as soon as possible under the influence of opium, a warm poultice may be placed over his epigastrium, and concentrated food or stimulants administered, if indicated by his general condition. Dia- phoresis should be encouraged by external applications, it being an •obvious indication to promote the vicarious action of the skin, and thus diminish the amount of urine secreted. It has been suggested to perform cystotomy (as in the median or lateral operation for stone), in these cases, and if it were found impossible to keep the bladder empty by means of a "catheter, the proposition might be reasonably entertained. Free incisions should be made on the first outward manifestation of urinary infiltration having occurred. A few instances are on record, in which the bladder has been ruptured by the accumulation of its own secretion; such an accident, however, is very rare, the urethra usually giving way, in such cases, rather than the bladder. Wounds of the Bladder are amongst the most serious complications of fractures of the pelvis. The bladder may also be wounded by gunshot projectiles, by pointed instruments, by the horns of infuriated animals, etc. When the wound is in that part of the organ which is covered with peritoneum, these injuries are usually fatal, but there are numerous in- stances of recovery from wounds of the bladder inflicted in the perineal region. The treatment of these cases is essentially that which has been described in the preceding paragraph; any foreign body that may have 1 See, however, this question discussed by Poland (who considers the operation unnecessary) in Guy's Hosp. Reports, 3d s., vol. ix. 374 INJURIES OF THE ABDOMEN AND PELVIS. lodged in the bladder should be removed, as its continued presence would produce great irritation, and probably cause the formation of a calculus. If the wound be through the rectum or vagina, a troublesome fistula may result, requiring, perhaps, the performance of a plastic ope- ration. Foreign Bodies, such as slate-pencils, pins, etc., may be introduced into the bladder, through the urethra, through an external wound, or, more rarely (by the process of ulceration), from another viscus—as in a remarkable case recorded by Dr. Kingdon, in which a pin, having been swallowed, lodged in the appendix vermiformis, from which it subse- quently made its way into the bladder, where it formed the nucleus of a calculus; the ulceration by which this process was attended, gave rise to the formation of an intestino-vesical fistula, through which no less than six round worms entered the bladder, and were at different times dis- charged from the urethra. Foreign bodies may occasionally be spon- taneously expelled from the bladder—or may be extracted with urethral forceps, or a small lithotrite, if the surgeon succeed in catching them in - the direction of their long axis. In the male, however, it is usually necessaiy to resort to lithotrity (if the nature of the body admit of its being crushed), or to lithotomy, the median being in such a case the preferable operation. From the female bladder, foreign bodies may be conveniently removed, in most cases, by dilating the urethra with two or three bladed forceps, or with graduated bougies, until the forefinger can be introduced, when it is very easy with forceps to seize and extract the foreign body, the finger serving to adjust it into a favorable position for removal. It occasionally happens that in using the female catheter, the instrument slips from the fingers, and is sucked into the bladder. In the event of such an unfortunate occurrence, the surgeon should at once dilate the urethra and remove the foreign body. I have known fatal ulceration to result under these circumstances, from the delay of only a few days. Injuries of the Rectum.— Wounds of the rectum, provided they are uncomplicated, usually heal without much difficulty, as is seen after the operation for fistula, or when the bowel is accidentally wounded in lithotomy. If the lesion involve the bladder or vagina, recto-vesical, or recto-vaginal fistula will probably result, and require the performance of a plastic operation. Death may follow perforation of the rectum (from the peritoneum being opened), as has occasionally happened from the incautious use of syringes, or of rectal bougies. Foreign Bodies are occasionally found in the rectum, and must be removed with scoop or forceps, as the ingenuity of the sunreon, and the exigencies of each particular case, may suggest. The removal of masses of impacted feces, of seeds or fruit-stones, etc., may often be accom- plished simply by the repeated use of warm enemata. A fish-bone, or similar article, may be caught in one of the pouches of the rectum, and, by the resulting ulceration, give rise to a fistula in ano. Injuries of the Penis and Male Urethra.— Wounds of the Penis, if limited to the skin, are not attended with any particular risk; they always require the use of sutures, on account of the retractile tendency of the part. In deeper wounds there may be profuse hemorrhage, which may require a ligature, if it proceed from any recognizable artery, but which, if of the nature of general oozing, may be checked by cold and pres- sure, the latter being best applied by introducing a full-sized catheter and INJURIES OF THE SCROTUM AND TESTES. 375 then compressing the organ upon this with adhesive strips. Contusion, or Partial Rupture, of the corpora cavernosa, is followed by interstitial extravasation of blood, attended by marked induration, and sometimes by priapism, which may persist for several days. Such an injury is best treated by the continued application of evaporating lotions. Strangu- lation of a portion of the penis, is sometimes produced in children, by tying a string around the part, or, in adults, by the introduction of the organ into a metallic ring, the neck of a bottle, etc. If gangrene has not been induced, the symptoms will usually quickly subside, upon the removal of the source of constriction. The Urethra may be Wounded by cutting instruments, or gunshot projectiles, or may be Lacerated by falls or blows, upon the perineum or penis, by injuries received during coitus, or even by violent straining efforts at micturition, in cases of stricture. It may also be wounded in rude attempts at catheterization, giving rise to the formation of "false passages." The symptoms of laceration of the urethra are pain, consid- erable swelling from interstitial bleeding, hemorrhage from the meatus, and inability to urinate. If the patient, by straining, succeed in passing water, Urinary Extravasation will usually occur, giving rise to extensive destruction of tissue, and the formation of perineal fistulae. This is less likely to happen in cases of "false passage" than in those of other varie- ties of urethral laceration, because in the former the direction of the pas- sage is away from the course of the urine. The treatment consists in the immediate introduction of a full-sized catheter (flexible, if possible), which must be retained for several days, until the subsidence of pain and swelling renders it probable that the laceration has healed; the catheter should not be plugged, lest the accumulating urine find its way by the side of the instrument. If it be impossible to introduce a catheter, the surgeon must at once open the urethra in the perineum, when, if the instrument still cannot be passed, a flexible tube may be introduced through the wound into the bladder. This I believe to be safer, in these cases, than puncture through the rectum or prostate. If extravasation of urine have occurred, free incisions must be made in the perineum, scrotum, and inside of the thighs, or wherever the urine may have reached, to permit the escape of the irritating fluid, and facilitate the separation of sloughs. Laceration of the urethra, according to its extent, will prob- ably result in an intractable form of stricture, or even in complete oblite- ration of a portion of the tube, with the persistence of an incurable perineal fistula. Foreign Bodies ift the urethra may be extracted through the meatus, with urethral scoop or forceps, or through an incision in the median line. If this incision be in the perineum, the wound may be allowed to heal by granulation, a full-sized catheter, or bougie, being passed every other day; but if in the penile portion of the urethra, sutures will be required, and in this case a flexible catheter should be retained until union has occurred. Injuries of the Scrotum and Testes.— Wounds of the Scrotum require the application of sutures; if the wound be extensive, the testis may be extruded, owing to the great contractility of the dartos muscle. In order to effect relaxation of the part, Mr. Birkett advises the use of warm fomentations, before the application of stitches, cold lotions being afterwards substituted, to produce contraction and prevent bagging. Contusion of these parts is followed by great swelling and ecchymosis, and often results in the formation of a hydrocele, or haematocele. 376 INJURIES OF THE ABDOMEN AND PELVIS. Wounds of the Testis usually heal readily, the tunica vaginalis, in such cases, commonly becoming obliterated by inflammation. Atrophy of the organ is said to occasionally follow these injuries. Injuries of the Prostate.—Incised wounds of the prostate heal without trouble, as is seen in cases of lithotomy. The prostate is some- times wounded in rude attempts at catheterization, causing retention of urine,and urethral hemorrhage; the treatment consists in introducing a large flexible catheter, or, if this be impossible, in tapping the bladder through the rectum or above the pubes. Injuries of the Spermatic Cord and Vas Deferens.— Wounds of the Spermatic Cord require the use of the ligature, or other means of checking hemorrhage, and the divided segments of the cord should be brought together with a stitch, in hope of procuring union. Mr. Hilton has met with several cases of Rupture of the Vas Deferens, marked by arterial hemorrhage from the urethra, with great pain and fever, and followed by atrophy of the corresponding testis. The treatment is that which is appropriate for ordinary deep-seated inflammation. Injuries of the Uterus.—Injuries of the Unimpregnated Uterus are very rare, and could scarcely occur except in combination with other more serious lesions. Injuries of the Pregnant Uterus, beside the risks of hemorrhage and peritonitis, are extremely apt to terminate in abortion. The treatment of such cases must be conducted upon the principles which have been laid down, for the management of cases of severe injury to the abdominal viscera, in general. If the foetus be partially or completely extruded from the womb, it must be removed, per vias naturales, or through the external wound, if there be one, ac- cording to the particular circumstances of the case. Rupture of the Womb, Occurring during Parturition, is not a subject properly within the scope of this work. Injuries of the Vulva and Vagina.— Contusions and Wounds of ^hese parts are to be treated on the principles which guide the surgeon in the management of similar injuries, in other regions of the body. Women are sometimes seriously wounded, while in the act of micturi- tion, by the breaking under them of chamber utensils, and fatal hemor- rhage has occasionally resulted, under these circumstances, from a wound of the internal pudic artery. The treatment would ponsist in plugging the wound with lint, dipped in a solution of the persulphate or per- chloride of iron, and in the application of a compress and firm bandage. Foreign Bodies occasionally become impacted in the vagina, or may be thrust through its walls into the bladder, rectum, or peritoneal cavity. The treatment consists in the removal of the offending substance, by such means as the ingenuity of the surgeon may suggest, and in the subsequent adoption of measures to combat the resulting inflammation. Injuries of the Perineum.—Wounds of the Male Perineum, not involving the urethra, commonly heal without much difficulty. Lacerations of the Female Perineum occasionally occur durino- labor, and, if at all extensive, usually require an operation for their cure. If the case be seen within twelve hours after the occurrence of the lacera- tion, it will probably be sufficient to approximate the parts with deep and superficial sutures, maintaining the thighs in apposition until union has occurred, and insuring cleanliness by frequent syringing with a INJURIES OF THE FEMALE PERINEUM. 377 solution of permanganate of potassa. At a later period, it will be neces- sary, after emptying the bowel by means of an enema, to draw away the anterior wall of the vagina with a duck-billed speculum, and freshen the edges of the opening (making a raw surface at least an inch in depth, and extending the whole length of the fissure), then accurately adjusting the parts with the quilled suture, as recommended by Brown, or simply with the interrupted suture as done by Sims and Agnew. In either operation, two sets of sutures may be properly employed; a deep set—entering an inch from the cut edge, passing as deep as the denuda- tion extends, and coming out an inch from the cut edge on the opposite side—and a superficial set to insure more accurate adjustment of the Fig. 183. Brown's operation for ruptured perineum; shows the denuded surfaces and the insertion of the quilled suture, before the parts are brought together, and also the division of the sphincter on each side of the coccyx. cutaneous surfaces. If the whole recto-vaginal septum be involved, it will be necessary to close this, by numerous interrupted sutures passed from the vaginal surface, and, in these cases, it may be desirable to divide the sphincter ani on either side, as recommended by Brown. If there be great tension upon the deep sutures, a curved incision may be made on either side of the perineum, as recommended by Dieffenbach. If the quilled suture be employed, either strong whip-cord, or flexible wire may be used. The best material for the interrupted sutures, both super- ficial and deep, is strong silver wire. The deep sutures are most con- veniently introduced by means of a needle fixed in a handle. In the after-treatment, constipation should be maintained by the administration of opium, for about two weeks, and the catheter should be used at regular intervals. Sims and Emmet advise the employment of a short rectal tube, to allow the escape of flatus. The deep sutures may be removed from the fourth to the sixth day, and the superficial set about four days later. 378 DISEASES RESULTING FROM INFLAMMATION. CHAP TEE XX. DISEASES RESULTING FROM INFLAMMATION. Abscess. An abscess is a collection of pus, surrounded by a wall or layer of lymph. Pus, existing in a serous cavity (as in empyema), or in a joint, does not strictly constitute an abscess (though often so called), any more than pus widely diffused through the cellular tissue, or covering the granulations of an ulcerated surface. Several varieties of abscess are described by surgical writers, as the acute or phlegmonous; the chronic; the cold, lymphatic, congestive, or scrofulous; the diffused (a contradiction in terms); the emphysematous; the metastatic or pyaemic; and the residual. The division which I shall adopt, and which seems to me to be the simplest, is into (1) the acute or phlegmonous abscess, which may be considered the typical form; (2) the chronic or cold abscess; and (3) the residual abscess. Diffused Suppuration (which, according to the definition above given, does not constitute an abscess) will be described in a separate place, and the so-called Metastatic Abscess in the chapter on Pyaemia. The presence of gas in an abscess (consti- tuting the Emphysematous variety) is a mere coincidence, depending on the locality of the affection, or on the occurrence of putrefaction. Acute or Phlegmonous Abscess.—When a part that has been inflamed becomes more swollen, the dull pain changing to one of a throbbing or pulsatile character, the skin assuming a deeper hue, and presenting a shining and glazed appearance, the surgeon knows that suppuration is impending, and that an abscess will probably be formed. If the seat of pus-formation be deep-seated, the superincumbent tissues become brawny and oedematous, from infiltration of lymph and effusion of serum, and, as the pus gradually approaches the surface (which it has an almost invariable tendency to do), the overlying tissue becomes soft- ened, the thinnest part bulges forwards, the cuticle often desquamates, fluctuation, which was at first obscure, becomes manifest, and pointing of the abscess is said to have occurred. A small circular slough is then formed at the thinnest part, and detached by the outward pressure of the pus, when the abscess discharges its contents, its walls contract by their own elasticity, the cavity is filled by the process of granulation, the remaining superficial ulcer cicatrizes, and the part returns gradu- ally to its normal condition—the scar and loss of substance, however, sometimes persisting for a very long time. The mechanism of pointing has never been explained in a perfectly satisfactory manner. The tissue which intervenes between the abscess and the surface upon which it is to break, is usually said to yield by a combined process of absorption and disintegration: it seems more probable, however, that under the influence of the inflammatory process, rapid cell-proliferation occurs in the abscess wall, with liquefaction of the intercellular substance, thus forming fresh pus cells, the number of which is probably still further ACUTE OR PHLEGMONOUS ABSCESS. 379 increased, by the direct transit of white blood corpuscles through the parietes of the capillary vessels. The final step consists, as has been mentioned, in a small disc of skin becoming deprived of its vitality, and being then thrown off as a minute circular slough. Though an abscess usually tends towards the cutaneous surface, it may, under other circumstances, break into a mucous canal, into a joint, or even into one of the large serous cavities of the body. A happy provision of nature in the case of abscesses of internal organs (as of the liver), pointing ex- ternally, is that localized inflammation and adhesion may open the way for the escape of the pus upon the cutaneous surface, without the inter- vening serous cavity becoming involved. Diagnosis.—The diagnosis of phlegmonous or acute abscess, can usually be made without difficulty, by attending to the history of the case, by observing the disposition to point, by noting the presence of fluctuation and the other local signs above described, and, lastly, if necessary, by using the exploring needle or trocar. Fluctuation, which is the sensation communicated to the surgeon's hands by a wave of fluid, can best be recognized by placing one or two fingers of each hand on the suspected swelling, and making alternate pressure, first with one hand, and then with the other. The fingers should be placed longitudinally as regards the direction of the muscular fibres of the part, and it must be observed that in any region in which the muscular and connective tissue is abundant, as in the thigh or nates, or bound down by dense fascia? or ligaments, as in the temporal region or the back of the hand, a very slight increase of tension from inflammation or effusion will give a deceptive feeling closely analogous to fluctuation. , Again, certain tumors, as the cystic, fatty, glandular, or encephaloid, are often attended with fluctuation, and have been frequently mistaken for abscesses. Finally, a partially consolidated aneurism may give the sensation of deep-seated fluctuation, and thus lead the surgeon into error. Hence, in any case of doubt, more especially if the suspected swelling be in the neighborhood of a large artery or other important part, the surgeon should, by all means, confirm his diagnosis by using the ex- Fig. 184. :£====== Suction-trocar. ploring-needle, before making a free incision. A better instrdment, in some cases, than the ordinary exploring-needle, is the suction-trocar (Fig. 184), or the common hypodermic syringe. Prognosis.—An acute abscess, unless very large, is usually a com- paratively trivial affection. In certain situations, however, even a small abscess may not only, by pressure on nerves or other important structures, cause great pain and discomfort, but may even seriously endanger life. An abscess of the prostate or perineum, may cause retention of urine; one of the fauces or throat, dyspnoea and even death; or one of the parotid or a cervical gland, fatal bleeding from the carotid artery or internal jugular vein. The drain from a very large abscess, or from numerous 380 DISEASES RESULTING FROM INFLAMMATION. abscesses, may cause death by exhaustion, with or without the develop- ment of hectic fever, or by inducing the peculiar form of visceral disease which has received the name of amyloid or albuminoid degeneration. Treatment.—This may be divided into the Prophylactic, and the Cura- tive treatment. The formation of pus, in acute phlegmonous inflamma- tion, may be prevented; more than this, pus after formation may be absorbed. I have myself seen this in several instances, and a number of cases were collected in the Medical Times and Gazette, for 1858, which proved the possibility, at least, of this occurrence. Nor can this be con- sidered at all unreasonable, if we accept the views of Cohnheim and his followers, who have pretty much proved the identity of the pus cell with the white blood corpuscle, and have actually seen the latter migrating through the capillary walls. Be this as it may, abscesses unquestionably disappear under treatment, though in many cases it is probably the fluid matter only which is absorbed, the solid remaining as a caseous residue, or undergoing cretaceous degeneration. The old humoralistic doctrine looked upon suppuration and abscess as efforts of nature to rid the system of some peccant matter, and hence taught the propriety of pro- moting and hastening, rather than of endeavoring to prevent suppura- tion. I suppose, however, that there are few surgeons at the present day, who would not consider the prophylactic treatment of abscess at least permissible. The remedies to be employed for this purpose, have been already referred to, in the chapter on the Treatment of Inflammation: they are such as tend to promote resolution. Sedative and anodyne ap- plications, are usually most appropriate; dry cold, or evaporating lotions, are often useful, the former, especially, in cases in which the integrity of a joint is threatened. Warm and emollient fomentations, on the other hand, sometimes answer a better purpose than cold applications; gentle friction with laudanum and olive oil, and the use of cataplasms, will be found most efficient in the prevention of mammary abscess. Finally, it is sometimes possible, as it were, to stimulate away an abscess: I have more than once succeeded in dispersing a bubo, by the use of a blister, even after pointing had occurred. Curative Treatment—The length of time during which abortive mea- sures, if not rapidly successful, may be persevered in, should depend a good deal upon the feelings of the patient. If the pain and febrile dis- turbance which accompany the formation of an abscess be very great, it will usually be wise to desist from such measures, and strive merely to relieve the patient's sufferings. I am not quite sure that we can often materially hasten the pointing of an abscess by treatment, but we can certainly make the patient more comfortable while the pus is approach- ing the surface, and the best application for this purpose, in the immense majority of cases, is an emollient poultice. Though an abscess will eventually burst of itself, it is usually better to evacuate its contents artificially—this little operation giving great relief to the patient, and rendering the resulting scar less conspicuous. The time at which an abscess should be opened depends on the circumstances of the case; if the pus be deep-seated and bound down by tense fasciae, the pain being great, an early incision, at the most dependent point, should be prac- tised, and will be found to afford the greatest comfort to the patient; if, on the other hand, the abscess be comparatively superficial, and the pain and constitutional disturbance not very intense, it is, I think, better to wait until decided pointing has occurred. The reason for this is, that if the incision be made prematurely in another locality, pointing and spontaneous opening may still take place, the surgeon's interference in CHRONIC OR COLD ABSCESS. 381 such a case being afterwards thought by the patient, and not unreason- ably, to have been uncalled for. An acute abscess should only be opened by incision, and this is best accomplished, I think, with a straight, narrow, sharp-pointed bistoury. The surgeon, holding the knife in his right hand as a pen, but almost per- pendicularly to the surface, with the edge towards himself, fixes the ab- scess with the thumb and fingers of the left hand, and resting the ring and little finger of the right hand upon the skin, quickly plunges the point of the knife into the cavity of the abscess, and rapidly drawing the blade towards himself, enlarges the puncture to the requisite extent as he withdraws the instrument. The depth to which the knife is to penetrate should be mentally determined beforehand, and the instrument is pre- vented from going too far by the pressure of the fourth and fifth fingers on the cutaneous surface. Local anaesthesia has been sometimes used in these cases, but the freezing process is in itself not devoid of pain, while it renders the skin much more difficult of penetration. If the abscess be situated very deeply, there might be some risk of wounding a large vessel, in making the opening as above directed, and in such a case it would be better to adopt Hilton's plan, incising the skin and fascia, and then pushing a grooved director through the overlying muscles into the abscess, the opening being dilated by separating the blades of a pair of forceps introduced along the groove of the instrument. A free aper- ture having been made, the abscess may be allowed to evacuate its con- tents by the elastic contraction of its own walls ; the surgeon may, if necessary, make very gentle pressure with soft sponges on either side of the incision, but all rude handling or squeezing should be strictly avoided. Hemorrhage into the cavity of an opened abscess may occur from a vessel accidentally divided, or which subsequently gives way from the relief of pressure upon its walls. The treatment consists in exposure to the air, cold, pressure, or ligation, as in other cases of hem- orrhage. After the evacuation of an abscess, poultices may be con- tinued for a few days, until the surrounding inflammation has subsided, when cerate or other simple dressing should be applied to the wound, and the walls of the cavity compressed by means of a bandage or adhe- sive strips. If, from the size or situation of the abscess, or from any other circumstance, there be a tendency to bagging of matter, a drainage-tube may be employed, being either Fig. 185. simply introduced into the incision by means of a forked probe (Fig. 185), or carried seton-like through the cavity, and brought out by a counter-opening. Instead of the ordinary drainage-tube, a flexible me- tallic probe may be substituted (the pus escaping by its side), or a coil of wire, as recently recommended by Mr. R. Ellis. The hygienic and constitutional treatment of abscess, and of suppuration generally, has already been considered in the chapter on the Treatment of Inflammation. Chronic or Cold Abscess.—The term chronic abscess is open to objection, as referring etymologi- cally only to time, and being of course merely com- DrainIge.tube and parative. A phlegmonous abscess, if deeply seated, forked probe. may be of slower development than a chronic or cold abscess, which is superficial. The term cold abscess is borrowed from the Germans, and is significant, as referring to a prominent symptom 382 DISEASES RESULTING FROM INFLAMMATION. in these cases, viz., the absence, in greater or less degree, of the increased temperature and other common signs of inflammation. These abscesses are chiefly met with in connection with diseases of the bones or joints, or of the lymphatic system. They are not attended with much pain, have little or no disposition to point, and sometimes extend widely be- neath the skin, or among the planes of muscular tissue. Their develop- ment is sometimes very slow, resembling that of phlegmonous abscesses, only with less local and constitutional disturbance, the investing layer of lymph being occasionally so dense as to obscure fluctuation, and give the appearance of a solid tumor; at other times, the patient suddenly discovers in the groin or axilla a large fluctuating swelling, no symp- tom having been previously manifested to call attention to the part. These abscesses may persist, without undergoing any marked change, for months or even years. The diagnosis must be made with the precautions already pointed out, and often requires the use of the exploring-needle. The pus in these abscesses is usually thin and ill-formed, containing a larger proportion of granules and oil globules, and fewer pus corpuscles, than ordinary " laudable" pus. The treatment of these cases is somewhat different from that appro- priate to those of the phlegmonous variety. If the abscess be quite small, it may be simply opened, healing of the cavity being subse- quently promoted by the use of some stimulating application, such as the diluted tincture of iodine. In dealing with a larger abscess, it is better to wait until the skin threatens to give way, unless, from the situ- ation of the abscess, it be necessary to relieve adjacent organs from pressure. With regard to very large abscesses, particularly those which are connected with disease of the spine or bony pelvis, I am decidedly of opinion that it is better, as a rule, to leave them unopened; a patient may carry a psoas or iliac abscess for years, with comparatively little annoyance, and maintaining very tolerable health, and yet sink in a very short time after such an abscess has been imprudently evacuated. Be- sides, there is always the hope that complete or partial absorption may occur, when the patient may remain well, if not permanently, at least for a very long period. If it be determined to open a large chronic or cold abscess, it may be done with a trocar and canula; or, probably bet- ter, by means of a valvular incision made under a veil of lint dipped in carbolic oil, as recommended by Prof. Lister. If an abscess have been freely opened and will not heal, stimulating injections of iodine may be tried, or a seton of oakum or tarred rope may be used (as recommended by Dr. Sayre, in cases of caries), a method which has the additional ad- vantage of insuring drainage of the suppurating cavity. In all cases of chronic abscess, it is necessary to pay great attention to the state of the general health, maintaining the patient's strength by the administra- tion of nutritious food and tonics. Residual Abscess.—This term has been recently introduced by Mr. Paget, who proposes to include under it "all abscesses formed in or about the residues of former inflammations." They may occur in the site of previous abscesses which have been partially absorbed, or in the indurations and adhesions left by old inflammation, which had not reached the suppurative stage. Residual abscesses are chiefly met with in connection with diseases of the spine, of the bones and joints and of the lymphatic glands. The prognosis is more favorable than that of ordinary chronic abscess, the healing after evacuation being, according to Paget, quicker, and attended with less constitutional disturbance than ULCERS. 383 that of a primary abscess, of the same size, and in a similar situation. The treatment is that already described as appropriate to chronic abscess arising under other circumstances. Sinus and Fistula.—These are narrow and often tortuous suppu- rating canals or tubes, left by the incomplete healing of abscesses, or resulting from wounds which have united imperfectly. The term fis- tula is also applied to abnormal communications between external and internal parts (as gastric, aerial, or urethral fistula), or between adjacent mucous canals or cavities (as recto-vesical, or vesico-vaginal fistula). When applied to the condition resulting from an abscess, or ordinary wound, the term fistula should be reserved for those cases where there are two openings, as in a fistula in ano, the more general term, sinus, em- bracing all those tortuous suppurating tracks, which have but one orifice. Sinuses may be kept from healing by the presence of a foreign body or a spicula of bone, by the passage of secretions, as of saliva or urine, or by the action of adjacent muscles. The treatment consists in remov- ing all irritating substances, and in placing the part at rest, by position, bandaging, etc. In a recent case, healing may be promoted by keeping the walls of the sinus in contact by means of compression, while, if the walls of the sinus be callous and indurated, they may be stimulated to greater activity, by means of irritating or caustic injections, the tarred seton, or the galvanic cautery. Finally, it may be necessary to freely lay open the sinus through its entire length, by introducing a grooved direc- tor and slitting up the superincumbent tissues; the sinus may then be dressed as an open ulcer, and made to heal from the bottom. This mode of treatment is specially indicated when healing is prevented by the action of neighboring muscles, as in cases of fistula in ano, or in the troublesome sinuses which are met with in the groin, in connection with suppurating buboes. It is often a good plan, after laying open a sinus, to wipe its whole track out with the solid stick of nitrate of silver, thus making a superficial slough, and preventing premature reunion of the cut edges. Diffused Suppuration, though ordinarily occurring in that form of diffuse inflammation of the areolar tissue which is closely analogous to, if not identical with, erysipelas, may, I believe, occur as a sequel of ordi- nary inflammation, in persons in a low state of health, and whose vital powers have beenfrom any circumstance much reduced. It may result from an accidental or other wound, or from the irritation of extravasated urine, but may also occur without any apparent exciting cause. The surface in these cases is but slightly red, the swelling is ill-defined, and rapidly spreads in various directions, there is a feeling of bogginess, rather than of fluctuation, and there is sometimes emphysematous crepitation, caused by the gases developed by the putrefactive process; the patient does not suffer very great pain, but is in a profoundly typhoid condition. The treatment consists in making numerous punctures, or small or even large incisions (to relieve tension, and facilitate the exit of pus and sloughs), and in the free administration of stimulants and quinia. Ulcers. The process of ulceration, and the mode in which ulcers heal, by granulation and cicatrization, have been considered in a previous chapter, and need not be again referred to. Ulcers have been variously classified by systematic writers, either according to the appearance of 384 DISEASES RESULTING FROM INFLAMMATION. the ulcer itself, or according to the constitutional condition of the patient. Thus, we read of healthy, irritable, indolent, weak, inflamed, exuberant, sloughing, varicose, and hemorrhagic ulcers; and, again, of eczematous, cold, senile, strumous, scorbutic, gouty, syphilitic, lupous, and cancerous ulcers. It is easy to understand that in a person disposed to eczema, an ulcer may be seriously complicated by an attack of that disease, and that any treatment, to be successful, must have regard to the eczematous condition, as well as to the ulcer itself. So in a strumous subject, such remedies as iodine and cod-liver oil may be more important than any local treatment. Scorbutic and gouty ulcers require medicines adapted to the scorbutic and gouty diatheses; while it would be idle to attempt to heal the ulcerated surface of a cancer, so long as the cancer- ous mass itself is allowed to remain. For practical purposes, the classi- fication usually adopted (which has reference to the appearances of the ulcers themselves, when occurring in persons of ordinary good health, and not the subjects of any special morbid diathesis), is convenient and sufficiently satisfactory, it being remembered that there is no specific or essential difference between these various forms of ulcer, but that the ulcerative process is identical in nature, under all circumstances. Simple or Healthy Ulcer.—This may be considered the type of all the other varieties, and that to which they must be brought, in order to effect a cure: it is such an ulcer as is seen in a healing burn, or in a superficial wound which is closing by the second intention. The natural tendency of such an ulcer being towards a cure, the only treatment necessaiy is to keep the part from being injured. Water dressing, or a greased rag, with an elevated position of the part, is all that is usu- ally required: if the granulations become exuberant, they should be touched with bluestone or lunar caustic; while if too small and closely set, the resin, or carbolic acid cerate may be substituted for the milder applications commonly employed. This variety of ulcer may be met with in any part of the body; those to be next described are most fre- quently seen in the leg. Inflamed or Phlegmonous Ulcer.—This variety is usually met with in those of full habit, and may arise from accidental irritation of a simple ulcer. One of the worst cases of this kind that I have ever seen, was in a gentleman who, having a slight excoriation of the tibial region, rode for several hours on horseback, with the stirrup-leather con- stantly rubbing and chafing the injured part; as a consequence, the whole leg was attacked with phlegmonous inflammation, which obliged the patient to stay in the house, with the foot elevated, for a considerable period. The treatment of an inflamed ulcer consists in enforcing rest, with elevation of the part, in the use of soothing applications, either cold or warm, as most agreeable to the patient, and in the administra- tion of laxatives, diaphoretics, etc., as may be indicated by his general condition. Sloughing Ulcer.—This may be considered as an aggravated form of the last variety, and is usually met with in cachectic or ill-nourished individuals. The treatment consists in the administration of opium and of concentrated nutriment, with stimulus if required, and in the local application of anodyne fomentations, such as diluted laudanum. If there be much tendency to spread, the ulcer should be treated as a case of sloughing phagedama, or hospital gangrene. INDOLENT OR CALLOUS ULCER. 385 Weak or (Edematous Ulcer.—In this variety the granulations are large, pale, flabby, and apparently distended with serum. They are not unfrequently detached in large masses by sloughing. This form of ulcer may be induced by long-continued application of poultices, or of water dressing. I have frequently seen it in cases of neglected gunshot wound. The treatment consists in improving the general tone of the patient, and in the local use of stimulating and astringent dressings, such as a solution of sulphate of zinc, or of sulphate of copper, zinc cerate, etc., with moderate support by means of a bandage. Neuralgic or Irritable Ulcer.—This variety is characterized by the intense pain and hyperaesthesia which accompany it. It usually occurs about the malleoli, or anterior edge of the tibia, and is most fre- quent in women past the middle age, and who are in a depressed state of health, though I have seen it in young, and otherwise healthy, laboring men. The treatment consists in the use of anodyne fomentations, with the occasional application of a solution of nitrate of silver (gr. iv-x ad f^j), as recommended by Skey for painful burns. The general health must at the same time be improved by the administration of tonics, especially quinia, nux vomica, etc. If the pain can be traced to any special nerve, this may be resected, as advised by Mr. Hilton. Indolent or Callous Ulcer.—This is by far the most common form of ulcer: it occurs usually in those of middle life, and is situated in the lower half of the leg, and more often on the fibular than on the tibial surface. The floor of the ulcer is somewhat concave, with flattened granu- lations, furnishing a thin and scanty pus. The ulcer is surrounded by an elevated ring of very dense and indurated tissue, which seems to be a provision of nature to prevent the spread of the disease, acting, indeed, as a kind of natural splint to keep the ulcerated surface at rest. As long as this hard ring remains, however, healing will not occur, and, hence, to depress the edges, is the first step in the treatment of an indolent ulcer. If the patient can remain in bed, with the foot elevated, a poultice may be applied for two or three days, to soften and relax the tissues, pressure being then applied by means of a few adhesive strips, the positions of which are varied at each dressing, while the edges of the ulcer are stimulated with the solid stick of nitrate of silver. A very good plan of hastening the disappearance of the indurated ring, is to make across it numerous radiating incisions, extending about a quarter of an inch into sound tissue, as recommended by Mr. Gay. Sappey's and Syme's method, which consists in the application of a blister, to the whole ulcerated sur- face and a zone of the surrounding healthy skin, is occasionally very efficient. Finally, the indurated edges may be trimmed away with the knife, a proceeding which, though apparently heroic, is almost painless, on account of the indolent nature of the sore. As soon as the ulcer has by these means lost its peculiar excavated appearance, it may be dressed with resin cerate, or some similar article, cicatrization being assisted by moderate compression with adhesive strips and bandage. In case the skin is very irritable, the disease approaching in character to what is called the eczematous ulcer, wet strips of bandage may be advantage- ously substituted for those of adhesive plaster. It often happens that patients with indolent ulcers find it impossible to lie by, as above re- commended, and, under such circumstances, I know of no better mode of treatment than that introduced by Baynton and Critchett, which consists in closely strapping the part, or even the whole limb, with strips of adhe- 25 386 DISEASES RESULTING FROM INFLAMMATION. sive plaster laid on in an imbricated manner, a firm bandage being then applied over all (Fig. 186). The only constitutional treatment usually required in these cases, is such Fig. 186. as may be indicated by the patient's general condition. Mr. Skey recommends the ad- ministration of opium, which may be given in doses of one grain, night and morning. In the eczematous cases, I have derived advantage from the persistent use of small doses of Fowler's solution. In some cases an ulcer will heal readily up to a certain point, and there will stop, in spite of the most careful dress- ing—the tension upon the part appearing to be so great that further contraction cannot take place. Under such circum- stances a longitudinal incision may be made through the healthy skin, on each side of the ulcer, the gaping of the incisions per- mitting the resumption of the healing process. Plastic operations have been occasionally practised for the cure of obstinate ulcers of the leg, but, in my experience, have not proved very successful. It has been recently suggested by a French surgeon, M. Reverdin, to treat ulcers by the Transplantation of Cuticle. The operation consists in applying shavings of the epidermis, or of this with a thin layer of the cutis—the latter plan has been most commonly adopted—to various points of the granulating surface, binding these grafts in position by means of adhesive strips. The grafts may at first seem to disappear, but in a few days become converted into isolated cicatrices, from which, as from centres, the healing process rapidly spreads. It is essential for the success of the experiment, that the granulations should be in a healthy condition, that no fat should be transplanted with the skin, and that the graft should be closely and accurately applied to the granu- lating surface. This mode of treating ulcers has excited a good deal of attention, and has been tried with more or less successful results at numerous English and American hospitals. In some situations, as on the back, between the shoulder-blades, it is very difficult to apply equable pressure by the methods ordinarily em- ployed. Here the application of a zinc plate, or disc of sheet-lead, cut to fit the ulcer, will often be attended by the happiest results—not, I believe, by the development of any galvanic current, as has been sup- posed, but simply by acting as an efficient means of applying mechani- cal compression. Hemorrhagic and Varicose Ulcers.—Other varieties of ulcer, described by systematic writers, are the hemorrhagic and the varicose. The Hemorrhagic Ulcer is one that bleeds from time to time, occasion- ally existing in connection with the hemorrhagic diathesis, but more often serving as a channel for vicarious menstruation. The treatment, in the latter case, consists in endeavoring to restore the normal flow, by GANGRENE AND GANGRENOUS DISEASES. 387 means of the remedies ordinarily used for amenorrhoea. The Varicose Ulcer is merely an ulcer coexisting with varicose veins. It is commonly taught that the varicose disease precedes and causes the ulcer, and ob- literation of the veins is accordingly proposed as the only rational mode of cure. It has been shown, however, I think, by Mr. Gay's researches, that the varicose condition is rather a consequence, than a cause of the ulceration, and that hence less active measures will commonly suffice. The treatment should vary according to the condition of the ulcer, whe- ther inflamed, irritable, or indolent. Hemorrhage from the bursting of a vein, may be checked, by position and pressure, or may occasionally require obliteration of the vessel, by the method which will be described when we come to speak of varicose veins in general. After the cicatrization of an ulcer is completed, a great deal may be done by care and attention to prevent the scar from again giving way. The part should be kept scrupulously clean, and should be protected as much as possible from external injury. If the ulcer be situated on the leg, the patient may advantageously wear an elastic bandage or stock- ing, to counteract the tendency to gravitation of blood, which necessarily exists in that part. Amputation for Ulcer.—It sometimes happens that an ulcer proves utterly incurable, either from extending completely around the limb, or from deeply involving a subjacent bone or. neighboring joint (as_ in the perforating ulcer which sometimes follows a bunion). In such cases the question of amputation may arise, and the operation under such circumstances would be occasionally justifiable. It must be remem- bered, however, that amputation, in the lower extremity, is in itself at- tended with very great risk to life, and that the disease, in the instances mentioned, is often more a source of discomfort than of danger or even positive suffering. Hence the surgeon should hesitate before proposing an operation which is not imperatively required, and which may be fol- lowed by the gravest consequences. When amputation is resorted to, it should be done at such a height as to insure the possibility of forming the flaps from perfectly healthy tissue. Ulcers occurring on Mucous Membranes present the ordinary characters of healthy, weak, or irritable ulcers, as met with in the cuta- neous structures. They usually require the free use of stimulating or caustic applications, the best being, probably, the nitrate of silver, which may be employed either in substance or in solution. Gangrene and Gangrenous Diseases. The nature and treatment of the ordinary forms of gangrene have already been considered in the chapters on Inflammation, on Wounds in General, on Injuries of Bloodvessels, and on Amputation. There re- main to be described, certain forms of Spontaneous Gangrene, and those affections which are commonly classed together as Gangrenous Diseases. Spontaneous Gangrene may occur at any age, and is due to arrest of the circulation, caused either by disease of the arteries themselves, or by a morbid condition of the circulating fluid. Inflammation of the arterial coats may cause gangrene, as may arterial thrombosis without inflammation, or embolism from the detachment of fibrinous concretions from the valves of the heart; the latter is, I believe, a more frequent occur- 388 DISEASES RESULTING FROM INFLAMMATION. rence than is usually supposed. Finally, the use of certain articles of food, as of spurred rye, has been followed by spontaneous gangrene. This form of gangrene is usually of the dry variety, though moist gangrene may occur after embolism, when the main trunks which furnish blood to the part are suddenly occluded—the difference probably depending, as remarked by Coote, upon the rapidity with which the death of the part takes place. Senile Gangrene (which, as ordinarily seen, may be con- sidered the type of the dry variety of the affection, or mummification) is dependent upon calcification of the arterial coats, together with the general loss of tone and enfeebled nutrition which accompany old age. In certain cases, the exciting cause of the disease is some slight irrita- tion, such as the chafing of a shoe, and, under such circumstances, the gangrene approaches somewhat to the ordinary inflammatory form of mortification. More often the disease begins, without apparent cause, as a dark purple or blackish spot, surrounded by a dusky red areola, which spreads with the gangrene and is the seat of intense burning pain, the latter, however, subsiding when the gangrene is complete. The seat of the gangrene is commonly the inner side of the foot, and especially of the great toe, though I have seen a precisely similar condition of affairs in the scrotum, in a patient worn out by a low fever; the fact that this form of gangrene occurs, under such circumstances, among compara- tively young persons, shows that the term senile gangrene, though sig- ■ nificant, is not strictly accurate. Warning is sometimes given of the approach of this form of gangrene, by the existence of signs of defec- tive circulation, such as numbness, coldness, tingling, and cramps in the calves of the legs. The course of senile gangrene is usually chronic, lasting sometimes for more than a year, and recovery occasionally fol- lows after the separation of the affected part. Treatment.—This consists in maintaining the general health of the patient, by the use of tonics, and by the judicious administration of food and stimulants. Among drugs, opium is particularly useful, and may be given in grain doses three or four times in the twenty-four hours. Antispasmodics also may be advantageously used in these cases, espe- cially chloroform (internally) and camphor. The local treatment con- sists chiefly in keeping the part warm, by wrapping it in cotton-wadding or wool; if there be much fetor, charcoal poultices may be substituted, or cloths wet with a solution of permanganate of potassa. The ques- tion of amputation in senile gangrene has already been referred to, at page 92. Bed-sores.—These may occur in any case in which a patient is con- fined to bed for a considerable period, simply from the long-continued pressure—just as similar excoriations and sloughs may result from the use of a badly-padded splint. The worst forms of bed-sore are, however, seen in patients whose general powers of nutrition are impaired by pre- vious illness (as in typhoid fever), or who, from spinal injury, are totally unable to vary their position. In such cases, it is not infrequent for the slough to extend so deeply as to involve the sacrum, or any other bone that is exposed to pressure, or even, in some instances, to lay open the vertebral canal. The pain attending bed-sores is usually very o-reat, though, in cases of spinal injuiy, the patient may be unaware oAheir existence. The formation of bed-sores may commonly be prevented by the use of a water-mattress, or of soft pillows, the parts being kept scrupulously clean, frequently bathed with stimulating and astringent lotions, and protected by the application of collodion, soap-plaster or HOSPITAL GANGRENE. 389 adhesive plaster; Prof. Brown-Se'quard recommends the alternate appli- cation of ice and hot poultices. If a bed-sore have actually formed, the separation of the slough may be hastened by the use of yeast or porter poultices, the ulcer which is left being subsequently dressed with resin cerate, or some similar application; the part must be entirely freed from pressure, and the patient's general health improved by the administra- tion of concentrated food, tonics, and stimulants. In obstinate cases, healing may sometimes be promoted by the application of the galvanic current. Bed-sores may occasionally prove fatal, by involving important structures (as the membranes of the spinal cord), by leading to hemor- rhage, by gradually exhausting the patient, or by the induction of py- aemia. Gangrenous Stomatitis, also called Gangraena Oris, Cancrum Oris, and Noma, is an affection of childhood, coming on after the various eruptive fevers, especially measles—a somewhat similar affection some- times occurring in adults after typhus. Gangrenous stomatitis has been attributed to the abuse of mercury, and this drug, if improperly exhibited, may of course be one source of depression, in addition to the debilitating effects of illness, deprivation of food, etc. That there is, however, any direct causal connection between the use of mercury and this disease, is, I think, at least not proved. The first symptom of gangrenous stomatitis is usually a dusky red swelling of the cheek, which becomes stiff and shining. Careful examination will now show a slough- ing ulcer on the inside of the cheek, extending to the adjacent gum, and discharging fetid, ill-formed pus, which, mingled with saliva, constantly dribbles from the mouth. As the disease progresses, a gangrenous spot appears on the cheek, the whole thickness of the part being finally involved, and perforation of the cheek, with denudation and perhaps necrosis of the alveoli, resulting. The constitutional symptoms are of a typhoid character, coma sometimes supervening before death, which may occur at almost any period of the disease. The treatment consists in everting the cheek (the patient being anaesthetized), and thoroughly cauterizing the whole ulcerated surface with strong nitric acid. One thorough cauterization is usually sufficient, though the case must be watched, and a second or third application made if necessary. The mouth should be frequently syringed with detergent and disinfectant washes, such as a solution of the permanganate or chlorate of potassa, or of borax, and the general health sustained by the frequent adminis- tration of concentrated food and stimulus. The deformity left after cicatrization may subsequently require a plastic operation for its cure. Noma Pudendi.—This grave affection, which seems to be confined to female children, is very analogous to the preceding, and usually attacks the mucous or submucous tissues of the generative organs, though, according to Holmes, it sometimes begins in the fold of the groin. The treatment consists in early and thorough cauterization, and in the adoption of measures to sustain the patient's strength. Death sometimes occurs very suddenly, after the apparent establishment of convalescence. Hospital Gangrene.—This affection, which has received a great variety of names, such as Sloughing Phagedasna, Pulpy Gangrene, Putrid Degeneration, Traumatic Typhus, Pourriture d'Hopital, etc., is occasion- ally met with as a sporadic disease, but has attracted most attention when 390 DISEASES RESULTING FROM INFLAMMATION. prevailing epidemically or endemically in hospitals, especially where large numbers of wounded meu are crowded together, as in military hospitals in the neighborhood of a battle-field. It has been studied by a great many writers, among whom may be particularly mentioned, Pouteau, La Motte, Ollivier, Delpech, Legouest, Rollo, Blackadder, Boggie, Hennen, Ballingall, Thomson, Guthrie, and Macleod. It has also been ably investigated by many American surgeons, who had ample opportunities for its study during the late war, and an elaborate mono- graph on the subject has been contributed by Prof. Joseph Jones, of New Orleans, to the Memoirs of the U. S. Sanitary Commission. The characters of hospital gangrene vary in different epidemics. The ma- jority of observers have found the local to precede the constitutional symptoms, and hence have regarded the disease as a strictly local affec- tion; while in other instances, equally careful observers have found con- stitutional disturbance, headache, furred tongue, etc., to precede the local changes in the wound by an interval of from one to three days. Hospital gangrene is undoubtedly contagious,1 having been developed by direct inoculation, as well as through the medium of instruments and sponges; the exceptional cases, in which one of two contiguous wounds, in the same patient, suffered from the disease, while the other escaped, merely prove that in those instances the affection was not auto- inoculable. While, however, hospital gangrene is usually transmitted by contagion, it may probably also originate de novo, as the result of overcrowding, bad ventilation, etc. Two forms of hospital gangrene maybe recognized, but the difference between them is one of degree rather than of kind. For the develop- ment of either, the presence of a wound is probably necessary, though this wound may be of the most trivial character, as the sting of an insect, the prick of a lancet, or even the scratch of a finger-nail. A depressed or depraved state of the system does not appear to be at all essential for the development of the disease, though it may very probably aggra- vate the intensity of the affection when it occurs. The following de- scription, taken from Guthrie, gives a vivid picture of the worst form of hospital gangrene. The wound thus attacked "presents a horrible as- pect after the first forty-eight hours. The whole surface has become of a dark-red color, of a ragged appearance, with blood partly coagulated, and apparently half putrid, adhering at every point. The edges are everted, the cuticle separating from half to three-quarters of an inch around, with a concentric circle of inflammation extending an inch or i Dr. W. Thomson examined microscopically the discharges, in several cases of hospital gangrene which occurred at Douglas Hospital during the late war, with a view of determining the presence or absence of funsci, which it was supposed might be the source of contagion. " No fungi were found. The discharge consisted of fluid, granular matter, and debris. The connective tissue seemed to have been broken down into unrecognizable granular material. The fibrous tissue was softened and easily teased out, and in the muscular tissue the striated appearance was lost before the fibrous. No evidence of textural growth was found in the discharges, although the 'piled-up' and thickened margins of the ulcers would probably reveal, on exami- nation, a multiplication of the connective tissue corpuscles, as reported in a similar group of cases at Annapolis, Md., by Assistant Surgeon Woodward, U S V " {Am. Journ. of Med. Sciences, April, 1864, p. 393.) By microscopic examination Prof. Joseph Jones has discovered numerous animalcules, as well as vegetable organisms, in the gangrenous matter of hospital gangrene, but has been unable to establish any relation between the cause of the disease and the nature and character of these organisms, which have been absent in the most extensive gangrene when excluded from the atmosphere by sound skin. [See U. S. Sanitary Commission Memoirs (Surgical), vol. ii. p. 266.] HOSPITAL GANGRENE. 391 two beyond it; the limb is usually swollen for some distance, of a shining white color, and not peculiarly sensible except in spots, the whole of it being perhaps oedematous or pasty. The pain is burning, and unbearable in the part itself, while the extension of the disease, generally in a circular direction, may be marked from hour to hour ; so that in from another twenty-four to forty-eight hours, nearly the whole of the calf of the leg, or the muscles of the buttock, or even of the wall of the abdomen, may disappear, leaving a deep, great hollow, or hiatus, of the most destructive character, exhaling a peculiar stench, which can never be mistaken, and spreading with a rapidity quite awful to contemplate. The great nerves and arteries appear to resist its influence longer than the muscular structures, but these at last yield; the largest nerves are destroyed, and the arteries give way, frequently closing the scene, after repeated hemorrhages, by one which proves the last solace of the unfortunate sufferer. . . . The extension of this dis- ease is, in the first instance, through the medium of the cellular structure of the body. The skin is undermined and falls in; or a painful red, and soon black, patch, or spot, is perceived at some distance from the original mischief, preparatory to the whole becoming one mass of putri- dity, while the sufferings of the patient are extreme." This, worst form of hospital gangrene is, happily, comparatively rare at the present day. In the milder form, the whole course of the affection is more chronic, causing less destruction of tissue, and accompanied with comparatively little constitutional disturbance. The general characters of the wound are the same, especially the circular shape, and cup-like excavation or scooped-out appearance of the ulcer. There is less eversion and under- mining of the skin, less oedema and pain, and the surface of the wound is covered with a pulpy, ash-colored slough, instead of the putrid clots described in Guthrie's vivid account. The constitutional symptoms of hospital gangrene may at first present a somewhat sthenic type, but rapidly change into those of a profoundly typhoid and adynamic condi- tion, the patient indeed presenting much the appearance of one suffering from typhus fever. The mortality from hospital gangrene has varied in different epidemics. During the Peninsular campaign, the death-rate, according to Guthrie, was 20 to 40 per cent., the general average being about 1 death in 3 cases attacked. In the Crimean war, the mortality in uncomplicated cases was much less, while in the experience of our own surgeons, during the late war, the number of deaths was comparatively very small. The causes of death, according to Prof. Jones, may be classified as (1) progressive exhaustion, (2) hemorrhage, (3) entrance of air into veins, (4) opening of large joints, (5) formation of bed-sores which subsequently become gangrenous, (6) diarrhoea, (7) subcutaneous disorganization of tissues around the original wound, (8) mortification of internal organs, (9) direct implication of vital parts, (10) pyaemia, (11) phlebitis, (12) profuse suppuration, necrosis, etc. In the treatment of hospital gangrene, it is very important to secure good ventilation and to enforce the utmost cleanliness. Affected pa- tients should be at once segregated (if possible) from others, and, if it were practicable, it would be better that each person attacked should be placed in a separate apartment or tent. It is, indeed, probable that a certain number of the milder cases would get well under simple hygienic treatment, and the risks of exposure are much less than those of over- crowding; as a German surgeon (Prof. Jungken) has somewhat quaintly put it, "It is, after all, better that the^patient should shiver a little in a 392 DISEASES RESULTING FROM INFLAMMATION. cold but pure air, than that he should die in a warm but poisoned atmosphere." As it is certain that the disease may be communicated by means of sponges, etc., the greatest precautions should be taken in washing and in dressing wounds. The ward carriage (Fig. 10), or some similar contrivance for using a stream of running water, will, in these cases, be found of great service. The Local Treatment of hospital gangrene, is now, I believe, almost universally regarded as of the highest importance; many different appli- cations have been employed, varying in severity from the actual cautery down to simple syrup, or buttermilk, and each remedy has proved occasionally successful. The oil of turpentine is highly recommended by Prof. Bartholow. Most surgeons are now agreed as to the propriety of thoroughly cauterizing the entire surface of the wound once, or oftener if necessary; and to insure thorough cauterization, it is necessary first to remove all the adherent slough with forceps and scissors, fol- lowed by rough sponging. The varieties of caustic most to be relied upon are, I think, nitric acid, bromine, and a strong solution of the per- manganate of potassa. The latter article is that which I have myself employed, in the proportion of 3j to f£j of water, and I have never, as yet, been disappointed in its effect; it is but just, however, to say that I have not had occasion to try it in any cases of the worst form, such as are described by Guthrie. The permanganate has been favorably reported upon by Prof. Jackson, Dr. Hinkle, Dr. Leavitt, and others. Nitric acid seems to be generally preferred by British surgeons, and is recom- mended by Prof. Jones, and by the authors of the "Manual of Military Surgery, prepared for the use of the Confederate States Army," while the hot iron seems to be preferred by the French; the latter application would probably be the best in cases attended with hemorrhage. Bromine, the merits of which were first announced, during our war, by Dr. Gold- smith, has been most favorably reported upon by Drs. Post, Moses, W. Thomson, Herr, and many others, and seems, from the published testi- mony in its favor, to be, upon the whole, the best caustic which has yet been proposed for these cases. The wound having been previously cleansed, the bromine may be applied undiluted, or in solution with bro- mide of potassium, by means of a camel's-hair brush, or a sponge, or mop, attached to a stick, or by means of a glass pipette or syringe; as the application is very painful, the patient should be first brought under the influence of ether or chloroform. Bromine has also been used in the form of vapor (the surface to be acted upon being protected with dry lint, upon which is placed a cloth dipped in pure bromine, and the whole covered with oiled silk), and by means of hypodermic injection at the circum- ference of the sore. (See Dr. Brinton's Report to Surgeon-General in Am. Journ. of Med. Sciences, July, 1863, p. 279.) The bromine acts by pro- ducing an eschar, upon the separation of which the wound will usually be found healthy and disposed to heal. Until the slough separates, the wound may be dressed with dilute liq. sodae chlorinatis, with the per- manganate of potassa (3j-Oj),or simply with water dressing; the result- ing ulcer is, of course, to be treated on general principles. The Constitutional Treatment, if less important than the local, is still not to be neglected. Almost all surgeons, with the exception of Boggie, have agreed in recommending a tonic and stimulant, rather than a depletory course of treatment. The milder cases require scarcely any medication, attention to the state of the secretions being all that is neces- sary in many instances. When the typhous condition is more marked, the mineral acids may be used with advantage; the muriatic acid of the FURUNCLE OR BOIL. 393 U. S. Pharmacopoeia, maybe given in five-drop doses, with opium and oil of turpentine, every three or four hours, as is done in cases of typhoid and typhus fever. Opium is, of all single remedies, the most useful in this affection: it may be given quite freely, and a case is reported by Pick, in which gradually increasing quantities of laudanum were administered for fifteen days, the patient taking at the last nearly half an ounce in the twenty-four hours. Quinia and iron (especially in the form of the muriated tincture), are particularly valuable in the later, though they may be required in the earlier, stages of the disease. The diet should consist of nutritious but easily digestible articles of food, such as milk and beef-essence, and on the first manifestation of adynamic symptoms, alcoholic stimulants should be freely administered. Amputation maybe occasionally rendered necessary by the occurrence of uncontrollable hemorrhage, from a wound which has been attacked by hospital gangrene, or the same measure may be required at a later period, on account- of the extensive destruction of tissue, involving, perhaps, bones and joints, as well as the more superficial structures of the part. It is said that hospital gangrene may occur as an idiopathic affection, upon an unbroken surface, the disease then beginning as a vesicle sur- rounded by a dusky areola, the vesicle ultimately breaking, and leaving a slough, upon the separation of which the characteristic appearances of the affection are manifested: these idiopathic cases are, however, at least, extremely rare, and in those which have been reported, it may be fairly doubted whether some excoriation may not in fact have existed, though so slight as to have escaped observation. Furuncle or Boil.—This very common affection consists of a local- ized inflammation of the skin and subcutaneous areolar tissue, almost invariably running on to suppuration, and attended by the formation of a small central slough, which is popularly called the core. Boils may occur at any age, and in any part of the body; they are, however, most common in youth, and are generally seen on the nucha, back, or gluteal region. They are often multiple, frequently come out in succes- sive crops, and occasionally occur epidemically—those who are affected being usually in a depressed state of health. The affection, though very painful and annoying, is not commonly attended with danger. The treat- ment consists in improving the general health by attention to the state of the secretions, and by the administration of tonics, especially quinia, if the patient be debilitated. Yeast is a favorite domestic remedy. Ar- senic is sometimes of benefit, given in small doses, and continued for a considerable period. The liq. potassae has been similarly used with advan- tage, and the celebrated John Hunter, who suffered much from boils, declared that he had cured himself by taking the carbonate of soda. The local treatment should vary with the circumstances of the case. If the boil be not very painful, it should be left to open of itself, being poulticed, or simply protected by means of the ceratum saponis, spread upon a piece of soft buckskin or wash-leather. There is some reason to believe that boils are less apt to recur if left to themselves, than if too actively treated. If, however, the patient be in great pain, with much constitutional disturbance, the surgeon should not hesitate to make a free single or crucial incision, the case being afterwards treated as one of abscess. It is sometimes, though very seldom, possible to abort a boil by purging, and by the application of tincture of iodine, or by touching the vesicle which usually marks the point of central slough, 391 DISEASES RESULTING FROM INFLAMMATION. with lunar caustic, a solution of corrosive sublimate, or the strong liquor ammoniae. Anthrax or Carbuncle.—A carbuncle may be regarded as an ag- gravated form of boil. It usually begins as a vesicle, surrounded by an indurated dusky areola. The subcutaneous tissue sloughs at an early period, giving the part a peculiar boggy feel, before the skin itself gives way. The skin may slough merely beneath the central vesicle, but, if the carbuncle be large, numerous apertures will be formed, ar- ranged in a cribriform manner. The carbuncle continues to spread, reaching its height in from three to eight days, and accompanied, while it is extending, with great pain and constitutional disturbance. The average diameter of carbuncles is two or three inches, though in some instances they attain a very much larger size. Mr. Paget mentions a case in a man aged eighty, in which the carbuncle measured fourteen by nine inches. Carbuncles are usually met with on the back of the neck or between the shoulders, but may occur in any portion of the body. They are most frequent in the male sex and in persons in advanced life. The causes of carbuncle are obscure. The affection is usually met with in those who are enfeebled by age, or worn down by overwork or priva- tion, and is sometimes associated with visceral disease, particularly affections of the kidneys, or diabetes. The prognosis should always be guarded; though the large majority of cases recover, the disease is always serious. Death may occur from the extension of inflammation to an important organ, as the brain or peritoneum, from visceral compli- cation, from simple exhaustion, or from the development of erysipelas 1 or pyaemia. Treatment.—If the surgeon be called at an early stage, it may be possible to abort the disease, by opening the central vesicle and applying some caustic agent, such as the nitrate of silver, the Vienna paste, or a strong solution of the permanganate of potassa; or, the plan proposed by Dr. Physick might be resorted to, and a blister applied over the whole inflamed surface. It usually happens, however, that the case is first seen when the bogginess and cribriform ulceration show that sloughing of the areolar tissue has already occurred. Under these circumstances, it is commonly advised to make crucial or radiating incisions, deep and free, so as to include the healthy tissue beyond the utmost limits of the dis- ease. Other surgeons make subcutaneous incisions; while others again rely upon the use of caustics, applying these either to the surface, to the incision wounds (when these are made), or around the circumference of the carbuncle, in the form of caustic arrows (cauterisation en fleches). It is not proved, however, that any of these methods are effective, either in limiting the extent of the carbuncle, or in shortening its duration. It is possible that incision may, in the early stage of the disease, give relief from pain, but it does so at the cost of considerable loss of blood; while the healing of the incision wounds themselves, imposes an additional tax upon the already overweighted powers of the patient. In most cases it will be found sufficient to cover the carbuncle with a piece of leather or thick kid, spread with lead plaster or soap cerate, a central aperture being left for the escape of the slough. Another plan, which I have found very useful, is to apply pressure, as suggested by O'Ferral, by means of strips of adhesive plaster, beginning at the circumference and laid on concentrically, until all except the central portion is covered. A poultice may be applied over all if there be much pain, or the ulcerated centre of the carbuncle may be simply dressed with wet lint. The MALIGNANT PUSTULE. 395 extrusion of the slough is much assisted by the concentric pressure (which is not at all painful), and may be further aided by the use of forceps and scissors. When the slough has come away, the resulting ulcer should be treated upon general principles. The constitutional treatment is equally simple. In the milder cases a little opium may be required as an anodyne, and, if there be constipa- tion, the bowels should be relieved by a mild laxative. Should the tongue be dry and covered with a brownish fur, muriatic acid, in combi- nation with laudanum and oil of turpentine, may be usefully adminis- tered. At a later period, quinia and the tinct. ferri chloridi will come into play, while at any stage, if there be delirium or other nervous com- plication, camphor and ammonia may be given with advantage. The diet should, as a rule, be mild, but nutritious, consisting of such articles as milk, beef-essence, soft-boiled eggs, etc. Alcoholic stimulus, though not necessary in every case, will usually prove a serviceable adjunct to treatment, and is often imperatively demanded, especially in the later stages of the affection. Facial Carbuncle.—Under this name is described, by British sur- geons, a malignant carbunculous affection, which attacks chiefly the lips, and which presents some analogous features to the disease known in France and in this country as malignant pustule.1 The affection is a very painful one, and frequently proves fatal, through the development of pyaemia. The treatment consists in the administration of stimulants, and of large doses of quinia. Local measures are of but secondary importance, but an incision may be required to relieve tension and allow the exit of sloughs. Malignant Pustule (Pustule Maligne, Charbon).—This affec- tion is usually communicated by inoculation, from direct contact with the blood or other fluids derived from diseased animals, as from horned cattle affected with the murrain, or from septic material conveyed by flies, and is said to have occasionally resulted from eating the flesh of such animals, or even to have been transmitted through the medium of the atmosphere. The affection begins a day or two after inoculation, as an itching red spot followed by a vesicle, which bursting leaves a dry brownish eschar. A fresh crop of vesicles next appears around the slough, and the subcutaneous tissue becomes involved, forming a hard swelling to which the French give the name of Bouton or Tumeur Char- bonneuse. The neighboring lymphatic glands often become secondarily inflamed. There is a good deal of fever, and of constitutional disturbance, the patient, in unfavorable cases, rapidly sinking into a typhoid state, and dying with the ordinary signs of blood-poisoning. The affection is said by Prof. Gross and other American writers, to be intensely painful, but Bourgeois (one of the latest French authorities on the subject) speaks of the absence of pain as a prominent characteristic. The dis- ease may be distinguished from carbuncle, by the fact of its beginning in the skin and only involving the subcutaneous tissues at a later period, and by the almost complete absence of suppuration. The treatment 1 M. Eeverdin maintains, in an elaborate memoir published in the Archives Gen- erates de Medecine for June, July, and August, 1870, that the gravity of carbuncles of the face, and particularly of the lips, is solely due to the frequent occurrence of phlebitis, which may cause death by the inflammation spreading to the sinuses of the dura mater, or by the development of pyaemia. He regards the affection as totally distinct from malignant pustule, and recommends early and free incisions. 396 ERYSIPELAS. consists in thorough cauterization with caustic potassa, either with or without previous scarification, according to the progress which the dis- ease has made when first seen ; Prof. Gross recommends total excision. The constitutional treatment consists in the administration of concen- trated food and stimulus, with tonics, especially quinia, and the mineral acids. Other Gangrenous Affections.—Various forms of gangrene are occasionally met with, which cannot be referred to any of the diseases above described. Under the name of White Gangrene of the Skin, is described by Quesnay, Brodie, and others, a form of dry gangrene, in which successive patches in various parts of the body, especially the neck, arms, and back, undergo mortification, preserving at first their white color, but becoming subsequently horny and straw-colored, and showing, in the form of red streaks, the capillaries filled with coagulated blood. After the separation of the sloughs, the ulcers heal without dif- ficulty. Quesnay states that this form of gangrene is due either to arte- rial obstruction, or to compression or paralysis of the nerves of the part. The treatment, according to Brodie, is rather unsatisfactory. In one case, in which the disease was associated with irregular menstruation, the sulphate of copper was given with advantage. Tonics would seem to be usually indicated, and when, as in one of Brodie's cases, and in one quoted by Quesnay from De La Peyronie, the disease succeeds an affection of the skin, arsenic might probably be advantageously em- ployed. A curious case came under my observation at Cuyler Hospital, in which a soldier, noticing a painful pimple or pustule on the back of his hand, applied to the "medical officer of the day," who ordered a flaxseed poultice; the next day the man came to me in great alarm, with a black dry slough upon his hand, exactly the size and the shape of the cata- plasm; the eschar, which was quite deep, separated in a few days, and the remaining ulcer healed rapidly under the use of the permanganate solution. CHAPTEE XXI. ERYSIPELAS. Erysipelas' is an acute febrile disease, attended by a peculiar form of inflammation, which affects the skin, areolar tissue, mucous, or serous membranes. It occurs as an idiopathic affection, or as a complication of a wound, being called in the latter case traumatic erysipelas. Ex- ternal erysipelas, or that which affects the skin and connective tissue, is much more common than the internal variety, or that which attacks the mucous and serous membranes. External erysipelas may be divided into the simple, or cutaneous, the phlegmonous, or cellulo-cutaneous, i The usual derivation given for this word is from the Greek iputf (I draw) and mxat (near); others, however, prefer to derive it from t?u6?»; (red) and wtWa, (skin). (See, upon this subject, a note to Mr. DeMorgau's paper in Holmes's Syst. of Sur- gery, vol. i., p. 207.) SYMPTOMS OF ERYSIPELAS. 397 and the cellular, or areolar, which is often spoken of as diffuse inflam- mation of the areolar tissue. t Causes of Erysipelas.—These may be divided into the predispos- ing and the exciting. Of the Predisposing Causes, some relate to the patient's own condition, and others to the circumstances by which he may be surrounded. Among the former may be enumerated a depressed or debilitated state of the system, resulting from any source, such as Ghronic visceral disease, especially of the kidneys or liver; diabetes; chronic diarrhoea or dysentery; deprivation of food; neglect of hygienic rules; intemperate habits; overwork, etc. Any sudden source of de- pression may act as a predisposing cause of erysipelas; thus, in military hospitals, the disease is often seen to follow in the wake of secondary hemorrhage. Among the surrounding circumstances which predispose to erysipelas may be mentioned overcrowding, bad ventilation and sew- erage, and the season of the year and state of the atmosphere; it is no- torious that erysipelas is most apt to occur during the cold, damp weather which often prevails about, and after the vernal and autumnal equinoxes. The principal Exciting Causes of erysipelas are epidemic influence, con- tagion, and the presence of a wound. Symptoms of Erysipelas.—1. Simple, or Cutaneous Erysipelas__ Constitutional disturbance, consisting of rigors, headache, nausea, and fever, may precede the local manifestations for one or two days, though in many instances the patient is not conscious of any marked indisposi-' tion, until the appearance of the rash or cutaneous inflammation. In traumatic erysipelas, the locality of the rash will be determined by the position of the wound; in the idiopathic variety, though the disease may appear on any part of the body, it is most frequently seen upon the face (especially about the nose, ears, and eyelids), next upon the legs, and more rarely upon the trunk. The eruption appears as a red spot, rapidly spreading into a large patch with pretty well defined margins; some- what elevated ; of a bright rosy hue, disappearing under pressure; with a smooth, glazed, shining surface, and attended with a tingling and burning sensation. Except in the mildest cases, vesicles appear on the affected part, containing serum, which at first is clear, but soon becomes turbid, these vesicles eventually drying into brownish scabs. The erup- tion of simple erysipelas lasts (as a rule) but four days in the same part: it may, however, spread to adjacent parts, or may break out in an entirely different region of the body, the affection in these cases con- stituting respectively the erysipelas ambulans, and the erysipelas errati- cum of the older writers. As the eruption fades, the swelling subsides, the margins lose their definition, and the skin assumes a dry and some- what wrinkled appearance. The constitutional symptoms are rather aggravated than diminished by the appearance of the eruption, the period of defervescence usually coinciding with that of the decline of the local phenomena. 2. Phlegmonous, or Cellulo-cutaneous Erysipelas.—In this form of the affection both the local and general symptoms are more marked. The inflammation involves the subcutaneous connective tissue as well as the skin, the swelling being greater, the color darker, the vesications larger, and the pain more intense than in the simple variety. These signs continue gradually increasing up to the sixth or eighth day, when reso- lution may commence, or, as is very apt to happen, suppuration and extensive sloughing of the areolar tissue take place; the part, from being 398 ERYSIPELAS. hard and tense, now becomes soft and boggy; the skin, at first deeply congested, becomes pale in spots, and then black, and quickly falls into a sfate of moist gangrene. The constitutional symptoms, which may appear in the beginning to be of a somewhat sthenic character, rapidly degenerate into those of a typhoid type, and death may occur from exhaustion, hectic, diarrhoea, or pyaemia. This form of erysipelas is that which most often occurs in connection with wounds, simply because in such cases the deeper planes of fascia are usually opened, and thus ex- posed to the influence of the disease. Under the name of oedematous erysipelas is described a modification of the phlegmonous form of the disease, which is chiefly met with in the legs, and about the genital organs of old or feeble persons. Both the local and general symptoms are less marked than in ordinary phlegmo- nous erysipelas, but there is a considerable effusion of lymph and serum, solid oedema sometimes persisting, and giving the part the appearance of Scleroderma, or Elephantiasis of the Arabs. 3. Cellular Erysipelas (Diffuse Inflammation of the Areolar Tissue).— The former name is preferable, as there may be a diffuse inflammation of the connective tissue unconnected with the erysipelatous influence (see page 383). In this variety of the affection there is great swelling, tension, and pain, but comparatively little redness. The disease extends rapidly and widely, sometimes from a wound, but at other times be- ginning at a distance from the point of injury. Suppuration, sometimes attended with emphysematous crackbng, occurs about the fourth day, or even earlier, and the skin quickly falls into a state of gangrene. This affection may also attack the deep planes of connective tissue, as in the pelvis or anterior mediastinum. The constitutional symptoms are of a profoundly typhoid type, death sometimes occurring on the second or third day of the disease. 4. Traumatic Erysipelas is attended with changes in the condition of the wound itself. The edges become flabby, and the neighboring tissues oedematous. A thin sanious fluid replaces the ordinary healthy pus, the granulations become pale and shining, and the healing process is arrested; recent adhesions may even be broken down and absorbed. A sensation of weight and heat, with great pain, may precede by several hours the development of the characteristic eruption. 5. Erysipelas of Mucous Membranes.—The parts most usually affected are the fauces, pharynx, and larynx. Beginning in the fauces, which are swollen and deeply red, the uvula being markedly oedematous, the disease may spread to the larynx, giving rise to a croupy cough, dyspnoea, aphonia, and sometimes death from oedema of the glottis. At a later period fatal consequences may result from extension of the disease to the bronchi or lungs, from sloughing of the part, or from the development of pyaemia. This variety of erysipelas is considered peculiarlv con- tagious. 6. Erysipelas of Serous Membranes—This is chiefly met with in the arachnoid and peritoneum, the former being secondarily affected in cases of erysipelas of the scalp, or of injuries in the cranial region, and the latter in cases of injuiy of the abdomen or pelvis, or after various ope- rations, such as herniotomy, ovariotomy, etc. The symptoms are those of inflammation of the affected parts, with the general evidences of a profoundly typhoid condition. Diagnosis of Erysipelas.—Simple erysipelas maybe distinguished from erythema, by the fact that the latter occurs in patches of various TREATMENT. 399 size, which have no particular tendency to spread, are not elevated, and are unaccompanied by the formation of vesicles. The marked con- stitutional disturbance also is absent in erythema. From scarlet fever the diagnosis may be made by observing the circumscribed character of the erysipelatous eruption, its well-defined margin, the tenseness and glazed appearance of the surface, and the presence of vesicles. There is a peculiar inflammation of the skin which results from contact with the poison sumach (Rhus radicans, Rhus toxicodendron), which is almost identical in appearance with erysipelas ; the diagnosis can only be made by the history, and by the invariably mild course of the former affection, which, moreover, is not, I believe, contagious. Phlegmonous erysipelas may be distinguished from ordinary inflammation, by the greater extent of surface involved, by the absence of any tendency to point, by the rapidity of its course, and by the asthenic type of the constitutional symptoms. From phlebitis, it may be distinguished by the hard, cord- like condition of the vein, and the absence of general redness in that affection; and from angeioleucitis, by the fact that in that disease the redness and pain are confined to the course of the lymphatics and their neighboring glands. Cellular erysipelas maybe distinguished from com- mon diffuse inflammation of the connective tissue, by the even greater rapidity of the course of the former disease, and by the more asthenic type of its general symptoms. Erysipelas of the fauces or larynx, may be distinguished from ordinary inflammation of those parts, by the dusky redness exhibited in the former affection, and by the generally typhoid condition of the patient. Moreover, the manifestation of erysipelas on the cutaneous surface will usually throw light upon the diagnosis. From diphtheria, erysipelas of the throat may be distinguished by the greater degree of constitutional disturbance, and by the absence of ex- udation. Erysipelas of the arachnoid or peritoneum, can only be dis- tinguished from common arachnitis or peritonitis, by the primarily typhoid character of the constitutional symptoms in the former affec- tions. The presence of delirium is a very frequent accompaniment of erysipelas of any form, which affects the scalp, and must not be considered as in itself any evidence of meningeal complication. Prognosis.—The prognosis, in any case of erysipelas, depends chiefly upon the form which the disease assumes, the locality of the part attacked, and the constitutional condition of the patient. Simple erysipelas is usually a mild affection, and, in the large majority of instances, termi- nates in recovery; if, however, it involve the scalp, or the abdominal wall, there is always a risk of transference to the arachnoid or peritoneum; if the face be affected, it may spread to the fauces or larynx; while, if there be serious visceral disease, especially of the kidney, the slightest attack of erysipelas is likely to prove fatal. Phlegmonous and cellular ery- sipelas are always very serious affections. In the head, abdomen, and lower extremities they are particularly apt to prove fatal, extensive sloughing in the latter situation sometimes laying bare the bones and opening the articulations. Faucial and laryngeal erysipelas sometimes prevail in an epidemic form, and have occasionally, under the name of "black tongue," produced frightful ravages in certain regions of our country. Finally, erysipelas in any form is a serious disease in new- born children, in very old persons, and in women in the puerperal state. Treatment.—A great deal may be done to prevent the development and spread of erysipelas. For this purpose, hospital wards, or the apart- 400 ERYSIPELAS. ments occupied by sick or wounded persons, should be well ventilated and scrupulously clean. All excreta and soiled clothing should be promptly removed, and particular attention should be given to the sewerage; the presence of a foul drain has not seldom proved the starting-point of a local epidemic of erysipelas. As the disease can be unquestionably propagated by direct inoculation, precautions should be taken against the transference of morbid material from one patient to another. The washing of wounds should, if possible, be effected with a stream of running water; if this be impracticable, each patient should, at least, be provided with his own basin and sponge; the dressings should be of such a nature that they can be frequently renewed; they should, therefore, be as simple and as inexpensive as possible. Disin- fectants, such as the chlorine preparations, the permanganate of potassa, carbolic acid, or bromine, may be placed in various portions of the room, or may be employed in the dressings. Personal cleanliness on the part of nurses and dressers should be rigidly enforced, and the latter should not be allowed to come directly from the post-mortem or dissection rooms to engage in their ward duties. The surgeon himself should ex- ercise similar precautions, and, as there is an undoubted connection be- tween erysipelas and certain forms of puerperal fever, should, while at- tending cases of the former affection, if possible, temporarily decline engaging in obstetric practice. On the first appearance of a case of erysipelas in a surgical ward, the affected patient should be isolated, and disinfectant measures resorted to, in order to prevent the further spread of the disease. The Curative Treatment of erysipelas may be divided into the consti- tutional and the local treatment. Constitutional Treatment.—In simple, or cutaneous erysipelas, very little medication is, as a rule, required. If the patient, as is usually the case, be constipated, with a furred tongue, a mercurial purge may be administered. Emetics are often recommended, but, unless it be known that the stomach contains some irritating material, they are, I believe, as unnecessary as they are disagreeable; their reputation is probably derived fr.om their known efficiency in those cases of erythema which result directly from the use of certain articles of food. Asa cathartic, two or three grains of blue mass may be given, to be followed, in the course of twenty-four hours, by a dose of castor oil or a Seidlitz powder. If there be much heat of skin, neutral mixture may be given, combined with camphor-water, if the nervous symptoms are at all prominent. Anorexia will usually indicate the propriety of abandoning solid food, for which milk with lime-water, and beef-essence may be substituted, in small quantities, and at frequent intervals. In most cases, at least as met with in hospitals, a small quantity of alcoholic stimulus may be ser- viceably directed, but there is seldom occasion to give large quantities, four or five fluidounces of wine, or two or three of brandy, in the course of the day, being usually quite sufficient. Most cases of cutaneous erysipelas will run a satisfactory course under the above simple mode of treatment. If, however, the surgeon wish to do more, there can be no objection to giving the muriated tincture of iron, which is a remedy of undoubted value in the phlegmonous form of the disease. The sul- phites and hyposulphites have been rather extensively used in erysipelas, and have, with some surgeons, acquired a reputation, which is, 1 believe, due more to the natural tendency of this form of the disease to sponta- neous recovery, than to any curative virtue of the remedies themselves. In phlegmonous, and in cellular erysipelas, the patient maybe put at TREATMENT. 401 once, after attention to the state of his bowels, upon the use of the muri- ated tincture of iron, which must be believed, from published experience, to exercise a controlling influence over the course of the disease. This remedy, which was first brought prominently to the notice of the profession in 1851, by Dr. G. Hamilton Bell, of Edinburgh, may be given in large doses—as much as twenty or thirty minims—every three or four hours, or even every hour if the urgency of the case require it. Quinia is another drug which may be usefully employed, particularly in the later stages of the disease. Free stimulation may be employed in these cases from the very outset, and as the symptoms assume more and more a typhoid aspect, carbonate of ammonia and oil of turpentine may be properly added to the remedies previously employed. The complications which demand special attention, are the supervention of arachnitis, of perito- nitis, or of erysipelatous laryngitis. In the case of arachnitis, benefit may be expected from free purgation and the use of turpentine enemata. If coma occur under these circumstances, Dr. Copland recommends a full dose of calomel and camphor, followed by an electuary of castor oil and oil of turpentine, placed upon the back of the tongue, and repeated from time to time until purging is begun. Enemata may then be used as adjuvants, and blisters applied to the nucha and thighs, as deriva- tives. In erysipelatous peritonitis opium is the remedy most to be relied upon. If the disease attack the air-passages, the greatest risk is from oedema of the glottis; here (beside the local measures which will be presently alluded to) a cautious trial may be given to antimony in com- bination with opium, the latter remedy serving to counteract the spas- modic tendency, which almost always exists in laryngeal affections. If the dyspnoea, however, should increase, no time should be lost in resort- ing to laryngotomy; the oedema does not extend below the vocal cords in these cases, and hence this operation is preferable to that of opening the trachea. 2. Local Treatment.—The local treatment of erysipelas is almost as important as the constitutional. Very various applications have been used in these cases, and each, at least in simple erysipelas, often with apparent success. It must not be forgotten, however, that, as pointed out by Velpeau, the duration of the eruption in one spot is limited to four days, and that in many instances no other part may become affected. In this, as in many other diseases, a knowledge of the natural history of the affection may tend to shake our faith in the curative power of the remedies employed. With regard to local applications in erysipelas, a good general rule is given by Dr. Reynolds, viz., to avoid anything which shall expose the skin to variations of temperature, or which shall interrupt its natural function. Hence cold applications and oily or unctuous substances should not be employed. In simple or cutaneous erysipelas, if the affected patch be small, it may be sufficient to keep it well dusted with rice flour, toilet powder, oxide of zinc, or even common wheat flour. If the patch be large, particularly if a limb be the part affected, and generally in hospital practice, it will be better to cover the whole seat of eruption with carded cotton, loosely applied; the cotton excludes the atmosphere and keeps the part in a kind of con- tinuous vapor bath. In cases in which the tension of the part is very great, and which approach, in character, to the phlegmonous form of the disease, warm fomentations, such as chamomile or hop poultices, may be substituted for the simpler applications. Various other articles are recom- mended by surgical writers, particularly collodion, sulphate of iron, tinc- ture of iodine, and nitrate of silver. Bromine in the form of vapor,applied 26 402 ERYSIPELAS. as described in speaking of hospital gangrene, was somewhat extensively used during our late war, and with alleged advantage. The nitrate of silver, which was first recommended in this affection by Higginbot- tom, is used in the form of a very strong solution (one part to three), and is applied, after thoroughly cleansing the part, " two or three times on the inflamed surface and beyond it, on the healthy skin, to the extent of two or three inches." Another plan, if an extremity is affected, is to apply the caustic in a broad band, entirely around the limb, a few inches above the seat of inflammation. The spread of the eruption certainly seems, in some cases, to be arrested by the caustic application thus made, but perhaps not oftener than it would have been spontaneously arrested at the same point, had the treatment not been employed. In phlegmo- nous erysipelas more active measures are required. In the early stages benefit may be derived from making numerous punctures with the point of a sharp lancet, as advised by Sir R. Dobson ; these may be frequently repeated, and act by relieving tension and promoting resolution. If these fail, or if the case be first seen at a later stage, when the brawny feelingof the surface indicates impending suppuration of the subcutaneous areolar tissue, incisions, from one to two inches long, and two or three inches apart, should be made over the inflamed surface, in the general direction of the subjacent muscular fibres. These incisions, which should extend through the superficial fascia, were first popularized by Dr. Copland Hutchinson. They gape pretty widely, owing to the great distension and swelling of the part, their edges presenting a gelatinous appearance from the infiltration of serum and lymph, and soon breaking down into pus mingled with shreds of disintegrated tissue. If the hemorrhage from these incisions be troublesome, they should be stuffed with scraped lint until the bleeding has ceased. South advises that the incisions should be arranged in the form of a lozenge, thus II, the greatest relief from tension being thus obtained with the least destruc- tion of tissue. At a still later stage, when brawniness has given place to bogginess, showing that sloughing of the subcutaneous tissues has already occurred, free and deep incisions, three or four inches long, may be required, in order to prevent gangrene of the skin, and to afford an exit for sloughs, the separation of which may be hastened by means of forceps and scissors. Warm fomentations should be constantly applied, and antiseptics may be freely used, not only in the dressings, but in- jected among the tissues by syringing. When the suppuration is very profuse, the fomentation may be omitted, the part being simply covered with lint and charpie, tow, oakum, or carded cotton, the now relaxed tissues being supported by the gentle pressure of a bandage. The ab- scesses, sinuses, and ulcers which are left after phlegmonous erysipelas, are to be treated on the principles laid down in the last chapter. Cel- lular erysipelas requires the same local treatment as the phlegmonous form of the disease; the incisions should be made even earlier and more freely than in that variety, on account of the greater rapidity with which sloughing of the connective tissue occurs under these circumstances. In certain localities, as in the orbit, the scalp, and the scrotum, early incisions are particularly imperative. In the orbit, the incisions are to be made by everting the lids, and pushing the blade of a lancet or bistoury, held flatwise, through the conjunctiva, between the eyeball and orbital walls ; in the scalp, crucial incisions are the most effective ; while in the scrotum, a single free incision on either side of the raphe will usually be all that is necessaiy. PYAEMIA. 403 Erysipelatous arachnitis should be met by the application of cold to the scalp—the only form of erysipelas, I believe, in which the use of cold is desirable. In erysipelatous peritonitis, the whole abdomen should be covered with a warm hop poultice. If erysipelas attack the fauces, a strong solution of nitrate of silver, or the muriated tincture of iron, maybe freely applied with a sponge, or camel's-hair brush; while in erysipelatous laryngitis, before resorting to laryngotomy, a trial should be given to free scarification of the glottis, and of as much of the larynx as can be reached, followed by the inhalation of steam, and the free application of the solution of nitrate of silver (5j-f3j)- The scarifica- tion may be effected with a probe-pointed curved bistoury wrapped with adhesive plaster, or, more conveniently, with an ordinary hernia-knife. Should the patient survive the first risks of the disease, the inevitable sloughing will require the use of detergent gargles (especially such as contain chlorine or bromine), to obviate the fetor and diminish the risk of secondary blood-poisoning. In a case of traumatic erysipelas, if the disease appear to originate directly from the wound, it would be proper to apply to the latter some disinfectant, such as a solution of bromine with bromide of potassium, in hope that the disease might thereby be, if not arrested, at least favor- ably modified in its course. CHAPTEK XXII. PYEMIA. Pyaemia (in the sense in which the term is used in this work) is a peculiar morbid condition resulting from the absorption of septic mate- rial, and usually accompanied by the formation of puriform collections in various tissues and organs of the body. Virchow, to whose labors we are greatly indebted for our knowledge of the pathology of this disease, distinguishes several forms of blood- poisoning, which are usually classed together as pyaemia, and proposes the names Ichorrhaemia, Septhaemia, and Septicaemia, for that variety which results from the absorption of putrid material from wounds, and is not accompanied by the development of those puriform collections which the older surgeons called "metastatic abscesses," and the forma- tion of which he believes to be invariably due to plugging of the capil- lary vessels by fragments of disintegrated venous coagula. A similar distinction is made by many of the most eminent French surgeons, who differentiate between what they call purulent and putrid infection, and Dr. Lidell, one of the more recent American authors on the subject, is disposed to limit the term Pyaemia to those cases which are connected with pre-existing suppuration, and to apply the term Septhaemia to the forms of blood-poisoning which occur in connection with traumatic and hospital gangrene, dissection wounds, etc. While it is quite possible that further experience and more accurate investigation may, at some future time, enable us to separate and classify different varieties of septic poisoning, to recognize their several sources, and to distinguish the courses which they severally pursue, I cannot but think, with Verneuil, that in the present state of science, it is more practically 404 PYiEMIA. useful, as it is certainly more convenient, not to aim at these theoretical refinements, but to use the word pyaemia (as has been done in the defini- tion given above) as a generic term, embracing one or more morbid systemic conditions—and to study such condition or conditions as parts of one disease, considering successively its pathological, clinical, and therapeutical relations, with the light afforded by observation and ex- perience. Nomenclature.—The fact has long been known that patients who have received injuries (especially of the head, or of the long bones), or who have undergone operations, may die from inflammation or suppuration in widely different parts of the body j1 and various names have been sug- gested by surgeons, expressive of the theories adopted to account for these phenomena. Pyaemia or Pyohemia (meaning literally purulent blood) was the name proposed by Piorry, in the early part of this cen- tury, and has been used by the large majority of surgical writers; though a misnomer, as far as any pathological significance is concerned, it is perhaps no more objectionable than any other term, and is adopted in this work simply from motives of convenience. Among the other names that have been employed may be specially mentioned, Phlebitis, Puru- lent Infection, Purulent Absorption, Purulent or Pyogenic Diathesis, Multiple or Metastatic Abscess, Thrombosis, Surgical Fever, Pyogenic Fever, Suppurative Fever, and Surgical Typhus. These are all more or less objectionable, either as implying an untenable theory, or as refer- ring to some mere incident of the disease. Surgical Fever (the name used by the late Sir James Y. Simpson), is perhaps the least objection- able name—even less so than Pyaemia—but is not adopted here because it is usually recognized as a synonym for Inflammatory Fever, which is quite a different condition. Pathology.—Various pathological theories have been advanced upon the subject of pyaemia, which, though affording an interesting field for study, cannot be entered into within the limits of this work. I shall merely refer very briefly to the views which have most advocates at the present day, and which are—1. The theoiy which makes pyaemia dependent upon the existence of pus in the blood; 2. That which makes it dependent upon thrombosis (the formation of venous clots or thrombi), and subse- quent embolism,"1 or plugging of the capillary vessels with fragments broken off from these clots and called embola; and 3. That which makes it dependent on the introduction of a septic material into the blood, and which looks upon the processes of thrombosis and embolism as subsidiary and not absolutely necessary. This seems to me in the present state of our knowledge to be the most plausible theory, and it is that which is here adopted. The theory which accounts for the phenomena of pyae- mia by assuming the existence of a morbid diathesis, merely puts the difficulty one step further back; it is as hard to account for the diathe- sis, as for the disease which it is supposed to produce. The theory which 1 See ?£ William Thomson's "Historical Notices of the Occurrence of Inflam- matory Affections of the Internal Organs after External Injuries and Surgical Ope- rations" (reprinted from Edinburgh Med. ,n,d Surg. Journal), Philada 1840- T Rose's "Observations, etc.," in Med.-Chir. Transactions, vol xiv • Dr G W Norris's edition of Fergusson's Surgery ; Braidwood, " On Pyemia, 'etc '" chap' i., London, 1868; and Blum's Memoir, in Archives Generates de Medecine Nov 1869, pp. 534-554. ' 2 From two Greek words, sv (in) and 5axx« (I throw or cast) PATHOLOGY. 405 looks upon the symptoms of pyaemia as reflex phenomena brought about through the agency of the nervous system, is somewhat plausible, but must be rejected as ignoring the facts which have been obtained by clinical ob- servation and dissection, as well as by experiments upon the lower animals. 1. Pus in the Blood.—The existence of pus, in the blood of pyaemic patients, has been affirmed by a very large number of observers, but strenuously denied by Virchow and others, who declare the supposed pus cells to be merely the white corpuscles of the blood, in increased numbers, and the condition of the blood in these cases to be one of leu- cocytosis, as in the disease called by Virchow, Leukaemia, and by Ben- nett, Leucocythemia. Sedillot indeed pointed out certain diagnostic marks as to size, color, etc., by which he believed that the pus cell could be distinguished from the white blood corpuscle, but it is now generally conceded that they are undistinguishable. It may be added that, if Cohn- heim's observations are correct—if the white corpuscles and pus cells are really identical, and capable, by means of their amcebaform movements, of wandering through the unbroken capillary walls—the whole question of pus in the blood will have lost much of its significance. The entrance of pus into the blood has been accounted for in two ways, viz., by the previous existence of suppurative phlebitis, and by the occurrence of direct absorption.1 Phlebitis was supposed to be the cause of pyaemia by Hunter, Aber- nethy, Guthrie, Arnott, Cruveilhier, and Liston, and this view has been and perhaps still is adopted by the majority of practical surgeons. The pus is supposed to be formed from the lining membrane of the vein, and thus to enter the circulation, either directly, or by the breaking down of the limiting clot. The objection to this view is that in many cases of pyaemia the veins are not inflamed at all, and that when inflammation does exist, it is secondary and does not involve the lining membrane of the vessel, being what is called by Virchow a meso-phlebitis or peri-phle- bitis. Even when the inner coat is involved in phlebitis, the entrance of inflammatory products into the general circulation would be prevented by the coagulum which in these cases fills the vein. The theoiy of absorption of pus, has received support from the well- attested fact that pyaemia is particularly apt to occur after injuries or operations in parts in which open veins are, from mechanical causes, unable to collapse when cut, or to contract at a subsequent period, as veins ordinarily do, upon the shrinking of their contained clots. On the other hand, it has been repeatedly shown by experiment that (1) the effect of applying healthy pus to blood is simply to induce coagulation ; (2) that injection of pus into the blood of healthy animals is not usually followed by fatal results, though repeated injections may produce death; (3) that the injection of the fluid part of pus is of itself followed by no evil result; (4) that injections of small quantities of pus act just as injections of various other substances, such as mercury, oil, powdered oxide of zinc, etc., by producing local obstructions (infarctus) in the first set of capillaries; and that (5) these obstructions may, in healthy animals, spontaneously disappear, the subjects of the experiments eventu- 1 Piorry's idea that the blood itself could become the seat of inflammation and suppuration, may, in the present state of science, be looked upon as purely chimeri- cal ; while the theory which supposes pus to enter the circulation by absorption through the lymphatic system, must be .rejected on anatomical grounds, the lymphatic glands acting as filters to prevent the passage of solid particles much smaller than the pus corpuscles. [See Virchow'1 s Cellular Pathology ( Chance's edit.), pp. 184-185.] 406 PYJSMIA. ally recovering. Hence it is shown that if pus be absorbed into the blood, its action can be only mechanical, and it is very reasonably argued that the pus corpuscle, being at least no larger than the white corpuscle of the blood, is no more likely to produce the obstruction which results in the formation of the " pyaemic patch" or " metastatic abscess," than the white corpuscle itself.1 Finally, as already remarked, if Cohnheim's views be correct, this whole question will have lost much of its importance. 2. Thrombosis and Embolism.—Thrombosis, or the coagulation of blood in the vessels during life, may depend upon a variety of causes, as (1) quiescence or simple retardation of the circulation, (2) the con- tact of a rough surface, and (3) an alteration of the blood itself, consist- ing probably in an increase in the proportion of fibrine.2 Thrombi form in the veins in almost every case of injury, or of inflammation of the surrounding tissues, as well as in cases of phlebitis. These venous thrombi or clots increase by aggregation, until they reach the points at which the veins in which they are seated anastomose with their parent trunk; if the force of the circulation in this be sufficiently strong, it may prevent the further increase of the thrombi, but if not, these will continue to enlarge till they project into the main trunk, as shown in the annexed diagram taken from Callender (Fig. 187). A fragment of the projecting part of a thrombus may be broken off and swept into the circulation, passing through the heart, and plugging an artery, produc- ing embolism, and, if the vessel be of sufficient size, perhaps leading to gangrene ; just as we have seen in a previous chapter that gangrene may be induced by embolism, from the breaking up of a clot formed in the heart. Under certain circumstances, probably owing to an un- healthy condition of the fibrine, a venous coagulum or thrombus softens and undergoes general disinte- gration ; a large number of small fragments are thus carried into the circulation, and, passing through the heart, plug the first set of capillaries (which, if the seat of thrombosis be in the systemic circulation, will of course be the pulmonary), causing thus capillary embolism. A few embola may slip through the first, to plug other sets of capillaries, or each point of ob- struction may cause fresh thrombosis, and a repeti- tion of the whole process. In the same way capil- lary embolism may be due to disintegration of car- diac coagula, and to cases of this kind Dr. Wilks has applied the name "Arterial Pyaemia." The sec- ondary effects of capillary embolism consist essen- tially in the development of congestion and inflam- mation in the part deprived of its vascular supply, which often, though not always, goes on to the occur- rence of suppuration and gangrene—the embola them- selves, in the latter case, breaking down and mingling their debris with the products resulting from the disintegration of surrounding tissue. It is probably to this process of thrombosis and capillary embolism, Diagram illustrating processes of thrombosis and embolism: a, clot projecting into venous trunk and increasing by aggregation ; 5, clot un- dergoing disintegration and allowing fragments to enter the circulation {embola). (After Cal- ender.) ' It is, however, possible, as remarked by Bristowe, that aggregated masses of pus cells may enter the circulation as pellets or flakes, and prove a mechanical source of embolism. See Moxon, in Guy's Hosp. Reports, 3d s., vol. xiv. p. 101. MORBID ANATOMY. 407 that is due the formation of the large majority of secondary depo- sits, or "metastatic abscesses," in cases of pyaemia; but that this pro- cess is not necessarily present in every case, is shown by the facts that (1) precisely the same set of changes may result from capillary stagnation, produced by the introduction into the circulation of putrid fluids,1 (2) that the secondary deposits are sometimes absent from the lungs, though present in other viscera (which would be unaccount- able on the supposition that they were due solely to mechanical ob- struction by solid particles, as in that case these particles, or embola, would necessarily block the first set of capillaries), and (3) that in cases of capillary embolism from cardiac disease (arterial pyaemia2), the course of the affection is very much less acute than is seen in the im- mense majority of cases of ordinary venous pyaemia, as met with in sur- gical practice, showing that in the latter there must be something more than the simple processes of thrombosis and embolism. Indeed, Virchow and his followers acknowledge that certain of the phenomena of pyaemia (as ordinarily seen) are not accounted for by these processes, and de- clare, therefore, that in many cases there is in addition a state of ichor- rhaemia, due to the absorption of septic material. 3. Absorption of Septic Material.—We are thus brought to the con- clusion that the only theory which is capable of accounting for all the phenomena of pyaemia, is that which supposes the pyaemic condition to be induced by the absorption of septic material (usually in a liquid, but possibly sometimes in a gaseous state), which unfits the blood for the processes of healthy nutrition, induces capillary stagnation and its con- sequences, low forms of inflammation, or serous and synovial effusions, and may, and probably does in most cases, cause venous thrombosis, giving rise to the occurrence of loose and ill-formed coagula, which, rapidly undergoing disintegration, cause capillary embolism, and thus produce the secondary deposits, or metastatic abscesses, which are so common in this affection. Morbid Anatomy.—Under this head I shall describe very briefly the chief post-mortem appearances observed in fatal cases of pyaemia. In cases which prove very rapidly fatal (the septicemic foudroyante of Ver- neuil and his followers), time is not afforded for these changes, and, under such circumstances, the post-mortem appearances are almost negative. The characteristic lesions of this affection consist in local congestion, extravasation, and inflammation, with gangrene, and occa- sionally true suppuration. Small fibrinous plugs (embola) can some- times be detected in the smaller vessels leading to the affected part, but more often the microscope reveals only a mass of granular matter, lymph and blood cells, fibrils, oil globules, and debris of tissue. If true pus exist, it is the result of suppuration occurring secondarily around, and not in the pyaemic patch. Lungs.—Pyaemic patches, or, as they were formerly called, metastatic abscesses, are most often seen in the lungs, and (according to Callender) in the left, more frequently than in the right. They vary in size from that of a small pea to an inch or more in diameter. They may occupy any portion of the lung, but are most frequent at the posterior part, and are usually present in considerable numbers. They are hard and resisting to the touch, and when cut open present varying appearances, 1 See Savory, in St. Bartholomew's Hosp. Reports, vol. i. pp. 118-126. 2 See Wilks, in Guy's Hosp. Reports, 3d s., vol. xv. pp. 29-35. 408 PYJSMIA. according to the stage which has been reached, their color being reddish- black, brown, pale buff, or yellowish-gray. They are always surrounded by a well-marked vascular zone. When near the pleural surface, they often cause pleurisy, marked by the formation of lymph, in patches, and by the effusion of turbid serum. Beside presenting these pyaemic patches, the lungs are often diffusely congested, or even inflamed. Liver___The liver is most often affected, next to the lungs. The pro- gress of pyaemic patches in this organ seems to be more rapid than in the pulmonary tissues, so that the puriform appearance is very quickly developed; a circumstance which accounts for the fact that " metastatic abscesses" are often observed in the liver, when the morbid changes in the lung have escaped attention. Other Viscera.—The Kidneys, Sjyleen, Heart, Brain, Bowels, Testes, Prostate, Eye, etc., may all be similarly affected, and probably in the order named, as regards frequency. Dr. Bristowe, indeed, considers that the kidneys are more often affected in pyaemia than the liver. The Perito- neum is not unfrequently locally inflamed, as the result of pyaemic de- posits in the various abdominal viscera. Joints.—The articulations are often swollen and inflamed, containing a turbid puriform fluid (sometimes, probably, true pus), the synovial structures being deeply congested, and the cartilages eroded. Bones.—The bones are probably occasionally, but very rarely, the seat of secondary pyaemic changes. On the other hand, pyaemia very often originates in inflammatory affections of bone, especially (as we shall see hereafter) in osteo-myelitis. Muscles and Areolar Tissue—Pyaemic deposits are not unfrequently met with among the muscular layers of the thoracic or abdominal walls, or in the neighborhood of joints, and, according to Bristowe, occasion- ally in the tongue. True suppuration may occur under these circum- stances, resulting in the rapid formation of abscesses of large size. External Surface—The skin presents a yellowish appearance, and is sometimes absolutely jaundiced. Open wounds are found dry, the gran- ulations having often completely disappeared, and the surface being pale and glazed, or occasionally covered with a grayish slough. Lymphatics—The lymphatics in the neighborhood of a wound are often inflamed, and abscesses form in the adjoining lymphatic glands. It is doubtless to the irritation of the lymphatic system, that is due the increased number of white corpuscles sometimes observed in the blood in pyaemic cases. It was this phenomenon (which Virchow calls leuco- cytosis) which first suggested to Piorry the name of Pyaemia. Bloodvessels—Phlebitis is a very frequent accompaniment of pyaemia. The veins are thickened and somewhat contracted, containing clots, which are usually firm and adherent above, but softened below, and dis- integrated into a puriform fluid, which was formerly supposed to be actually pus. The arteries are, I believe, not affected in cases of ordi- nary pyaemia, except that the smallest branches may be sometimes the seat of embolism. Dr. Wilks believes that in some cases of what he calls arterial pyaemia, the pathological condition is one of arterial throm- bosis in situ, rather than of embolism from softening cardiac clots. The capillaries in various parts of the body are occasionally seen to be plugged by embola; but, as already indicated, this condition is, in most instances, inferred rather than demonstrated. Blood.—The blood often presents no abnormal appearances, though in other cases it contains an unusually large proportion of white blood corpuscles (leucocytosis). Its coagulability is usually diminished, and CAUSES OF PYEMIA. 409 it is commonly found fluid or imperfectly clotted. This want of coagu- lability is one cause of the liability to capillary oozing or parenchyma- tous hemorrhage, which is often observed in cases of pyaemia, a ten- dency which is probably assisted, as pointed out by Stromeyer, by the venous obstruction due to thrombosis, and which is still further aided by the complication of leucocytosis, when present—capillary bleeding being, as is well known, a frequent occurrence in cases of leukaemia or leucocythemia. Causes of Pyaemia.—As Predisposing Causes of pyaemia may be mentioned previous illness, visceral disease (especially of the kidneys or liver), exhaustion, loss of blood, prolonged shock, over-crowding (especially of suppurating cases), a scorbutic condition, the puerperal state, certain diseases—such as erysipelas, hospital gangrene, carbuncle, osteomyelitis, etc__and, finally, the presence of an open wound. The Exciting Cause, according to the pathological view adopted in this chapter, is the absorption of a septic material, usually in the form of a liquid, from a wound or ulcer, but, in some cases, from the alimentary or other mucous membrane; or, possibly, in the form of a gas, by the medium of the lungs. It is asserted by many writers, that pyaemia never occurs except in connection with the existence of an open wound. There are, however, cases on record, in which pyaemic symptoms have not appeared until after the cicatrization of a wound, and Savory de- clares that pyaemia not only occurs without the previous existence of any wound, "but sometimes, so far as the most careful and complete examination can show, without any previous suppuration or any other local mischief whatever."1 Dr. Savreux-Lachappelle2 has collected a number of cases of so-called idiopathic or essential pyaemia, and has shown that in most of these instances exposure to cold has been the apparent cause of the affection. There is, moreover, reason to believe that, in some cases, the pyaemic poison is generated in the secretion which lubricates mucous membranes. Hence, while in the immense ma- jority of cases, we may safely, assume that the materies morbi of pyaemia is developed in the fluids of a wound or ulcer, we are forced to believe it possible that the septic material which gives rise to the disease, may origi- nate de novo in the system, as the result of extraneous influences. With regard to the question of the contagiousness of pyaemia, we must speak with a certain degree of hesitation; in the ordinary sense of the term it is certainly not contagious—not in the same sense, that is, as typhus fever or measles. Pyaemia may, undoubtedly, be inoculated by careless use of sponges, etc., or may possibly be transmitted by proximity alone; but in either case the septic material must be generated in the fluids of the wound or ulcer of the person about to be affected, before infection can take place. Even in the rare cases, in which the peculiar septic matter of pyaemia is supposed to have been absorbed in a gaseous form through the lungs, it is possible that the sole office of the morbid sub- stance derived from without has been to produce a change in the fluids of the part, the true pyaemic poison being there developed, and causing infection as a secondary consequence; just as in other instances, it is probable that the pyaemic poison is generated in the secretions of the alimentary, or genito-urinary mucous membranes. 1 St. Bartholomew's Hosp. Reports, vol. iii. p. 77. 2 See notice in Archives Gen. de Medecine, October, 1869, pp. 488-491. 410 PYEMIA. Symptoms of Pyaemia.—The first symptom of pyaemia, at least in surgical cases, is almost always a sensation of cold, with usually a decided rigor or chill. These chills are subsequently repeated, at irre- gular intervals, and are commonly followed by profuse and exhausting diaphoresis, the hot stage which is generally observed after malarial chills being, in cases of pyaemia, absent, or but slightly marked. The greatest elevation of temperature coincides with the period of rigor, the thermometer not often going above 104°, though occasionally, if the chill be very severe, reaching 106° or 107°, or, according to Billroth, even 108°, Fahr. During the sweating stage the temperature rapidly falls. According to Ringer and Le Gros Clark, the elevation of tem- perature begins before the development of the chill, and the former author believes that the occurrence of the rigor may be predicted by thermometrical observation. The pulse rate is rarely below 90, usually ranging from 100 to 130, and (according to Bristowe) occasionally reaching 200. The respiration is usually hurried and anxious, ranging from 40 to 50 in the minute, and sometimes even more. The breath is said to have a hay-like odor, though I cannot say that I have myself observed this symptom. There is commonly cough, with expectoration of viscid or of blood-stained sputa, and physical examination reveals the signs of pulmonary congestion, with pneumonia (lobular or lobar) and pleurisy. Pericarditis may be present, but its signs are often masked by the respiratory sounds. The countenance is flushed, the skin presents a dusky, sallow, somewhat jaundiced hue, and is often marked with sudamina, which, being surrounded by a zone of congestion, have been mistaken for the spots of typhus, or of typhoid fever. At a later stage, a pustular eruption, resembling that of smallpox, has been ob- served. Petechiae, ecchymoses, and localized gangrene occur in some cases. The tongue is usually furred; there is commonly complete ano- rexia; often nausea and vomiting; and usually diarrhoea. The urine is frequently albuminous. The patient is often delirious, particularly at night, or may be profoundly soporose, though rousing up and answer- ing intelligently when addressed. Intense pain often accompanies the formation of the secondary deposits or inflammations, particularly when these are superficial, as in connection with the joints. If there be an open wound, it will probably become dry and glazed, all reparative action ceasing; occasionally, however, healthy granulations continue to be formed almost to the end of the case, or, on the other hand, absolute sloughing may occur. Profuse capillary hemorrhage may tend still further to weaken the patient. Before death the symptoms assume a profoundly typhoid character: sordes accumulate upon the lips and gums; the tongue becomes dry and brown, and sometimes cracked and bleeding; subsultus tendinum and carphologia, with low-muttering de- lirium, mark the profound implication of the nervous system, and the patient may die comatose, or apparently from pure exhaustion. Diagnosis.—The diagnosis of pyaemia can usually be made by care- fully observing the history and the symptoms of the case. From In- flammatory Fever, from Hectic, and from Typhoid Fever, pyaemia can usually be distinguished by its greater fluctuations of temperature and higher thermometrical range, and by its repeated rigors, occurring at irregular intervals. From inflammatory fever it further differs, in that the former affection commonly yields on the occurrence of suppuration. The irregularity of the chills, together with the absence, or at least the want of prominence of the hot stage, will prove of diagnostic value, as PROGNOSIS AND TREATMENT. 411 regards Intermittent and Remittent Fevers. From Rheumatism,1 and es- pecially from what is called Rheumatoid Arthritis, the diagnosis is often extremely difficult, particularly if the pyaemia assume a chronic form. Under such circumstances, the surgeon must rely chiefly upon the history of the case, the condition of the wound (if there be one), the degree of prostration, and the tendency to suppuration—which occurs as a rule in pyaemic joint affections, and only exceptionally in those of a rheumatic character. The secondary local manifestations of pyaemia may be readily confounded with other diseases. Thus an idiopathic pneumonia, occur- ring after an amputation, might be mistaken for the lung complication of pyaemia, and a similar error might be made with regard to other organs. I was once asked to see a patient in whom marked brain symptoms, with general febrile disturbance, had followed traumatic erysipelas, super- vening upon an excision of the elbow. The case had been supposed to be one of pyaemia, but I diagnosticated tuberculous meningitis, chiefly from observing the intense headache, with screaming, the absence of prostration, and the existence of the tache cerebrate, or red mark pro- duced by lightly drawing the finger-nail over the surface of the chest or abdomen. The correctness of this opinion was subsequently demon- strated by an autopsy. Prognosis.—The prognosis of pyaemia is always unfavorable, and in an acute form the disease is almost invariably fatal. The subacute and chronic varieties, however, are less hopeless, and, in any case, the longer the patient can be kept alive, the better is the prospect of ultimate reco- very. I have myself seen three cases of pyaemia terminate favorably— two after partial excision of the radius, and one after partial amputation of the hand:—but in none of them did the affection assume a very acute form. The duration of the disease varies greatly in different cases. Occasionally, in what the French call the foudroyante form of pyaemia, death may occur within a day or two of the first rigor. From four or five days to a week is the usual duration of acute cases, though life may be prolonged for ten days, a fortnight, or even longer. In cases-which recover, the patient usually goes through a long illness, and may be left permanently crippled by secondary implication of the articulations. The occurrence of abscesses in superficial parts, where they can be evac- uated, is looked upon as rather a favorable omen; and I have some- times thought that the diarrhoea, in these cases, appeared to act as a derivative in relieving the internal viscera. Treatment. — As Prophylactic Measures, all those precautions should be adopted, which were discussed in speaking of operations in general, and of erysipelas, hospital gangrene, etc., diseases which are often followed by pyaemia. As every patient with a suppurating wound is liable to this affection, the surgeon should use every effort to obtain primary union, or at least cicatrization without any unnecessary delay: at the same time he must take care to secure free drainage from the wound, lest, in his zeal for early healing, he cause purulent and other fluids to be pent up and confined, thus defeating the very object which he is seeking to promote. 1 There is reason to believe that the affections known as Gonorrheal Rheumatism, Urethral Rheumatism, Urethral, or Genital Fever, etc., are actually mild forms of pyaemia, resulting from the developme.nt of septic material in the secretion of the genito-urinary mucous membrane. 412 PYEMIA. The various predisposing causes of pyaemia should as far as possible be obviated, for we know of no way by which the development of the poison can be certainly prevented, nor by which it can be hindered from produc- ing its deleterious effects. The administration of various drugs has been proposed, with the idea that they would exercise a prophylactic influence: the permanganate of potassa, and more particularly the sulphites and hyposulphites, the latter agents on the recommendation of Polli, of Milan, have been somewhat extensively employed, but have not, I believe, fulfilled the expectations of those who have used them, and the same may be said of carbolic acid and the carbolates. Labat, of Bordeaux, has advised the internal exhibition of ergotine, which he believes acts by increasing the plasticity of the blood; the evidence adduced in its favor, is, however, but negative, as is that in favor of the tincture of aconite, recommended as a prophylactic in these cases by Chassaignac. Curative Treatment.—The treatment of this disease must be conducted on those principles which guide the surgeon in the management of other affections of a typhoid character: there is no specific for pyaemia. If the patient be at first constipated, with a deeply furred tongue, it may be proper to give a small dose of blue mass, followed by magnesia or other mild cathartic. Under such treatment the tongue will often clean off, to become, however, again furred in a short time, as the case progresses. Quinia is, I believe, more valuable than any other single drug, in the treatment of pyaemia: it may be given in doses of four or five grains, every three or four hours. Guerin, who has great confidence in this medicine, uses very large doses—giving as much as a drachm in twenty- four hours. Legouest and Bouillaud think the cinchona bark itself a preferable agent to quinia. Iron may be combined with the quinia in the form of the muriated tincture, or, which Braidwood .prefers, the citrate of iron and quinia may be substituted. The oil of turpentine is, I think, a useful stimulant in these cases; it may be given with muri- atic acid, in an emulsion, a few drops of laudanum being added to each dose, if there be a tendency to undue purging. As diarrhoea, however, appears in some cases to be a means adopted by nature to eliminate the poison, it should not be hastily checked, unless so profuse as to be in itself a cause of exhaustion. Opium may be required to relieve pain or restlessness, and in such cases may be given in any form that conve- nience may indicate. Carbonate of ammonia may often be employed with advantage ; if the pulmonary complications be prominent, it may be properly combined with syrup of senega, as a stimulating expecto- rant. In all cases the patient should be supplied with abundance of light but nutritious food,given in small quantities, and at short intervals: alcohol, in the form of wine or spirit, must be likewise administered very freely. In the worst case of pyaemia in which I have ever known re- covery to follow, the patient got every hour, day and night, a table- spoonful of whiskey, with six of milk, and four of lime-water, for more than a week: his anorexia was complete, with constant nausea, and retching at the very idea of food, and it was only by his taking this combination regularly, as medicine, that life was sustained. With regard to Local Measures, beyond care as to the cleanliness of wounds, and the use of disinfectants, I do not know of any plan worthy of much confidence. The application of the actual cautery in the course of the superficial veins (if these be inflamed), or to the wound itself, has been highly recommended by several writers. Legouest advises that the wound should be washed with the perchloride of iron. Nitric acid and various other caustic agents have been likewise employed, but the STRUMA. 413 evidence is not very satisfactory as to any benefit derived from their use. Probably the most rational plan is to be satisfied with keeping the wound clean and lightly dressed; and diluted alcohol, or a weak solution of the permanganate of potassa, or of carbolic acid, are probably better appli- cations, in these cases, than poultices or other more cumbrous forms of dressing. Free drainage from the wound should be secured by position or otherwise, and if abscesses form in accessible situations, they should be opened at an early period, and their cavities afterwards frequently washed out with disinfectant fluids. Under the course of treatment above described, a certain number of the milder cases of pyaemia may be conducted to a favorable termina- tion, and, occasionally, a patient more severely attacked, may be snatched as it were from the very jaws of death; but there is reason to fear that the large majority of pyaemic cases will prove fatal in spite of all our care and attention, and that this frightful affection will continue to deserve the name which has been not inaptly bestowed upon it, of the " Bane of Operative Surgery." CHAPTEE XXIII. DIATHETIC DISEASES. Struma (including Tubercle and Scrofula) ; Rickets. Beside the affections to the consideration of which this chapter is devoted, there are two diseases which have claims to be regarded as of a diathetic or constitutional nature, viz., Cancer, and Hereditary Syphilis. The former will be described when we come to speak of malignant tumors, and the. latter, under the head of Venereal Diseases. Struma. The terms Struma, Scrofula, and Tubercle have been very variously applied by pathologists. Some look upon them as identical, while others use struma as a general term embracing both the others ; some subdivide scrofula into two varieties, the sanguine and phlegmatic, and ignore the independent nature of tubercle, while others recognize the two forms of scrofula, and consider tubercle as a distinct affection; some, again, recognize but one form of scrofula (the phlegmatic), and apply the term tubercle to the sanguine variety, while still others are disposed to doubt the existence of any form of scrofula, apart from a syphilitic taint. It will thus be seen that the use of these words is necessarily attended with a good deal of confusion, and it would be well if we could dispense with them all, and adopt others which might be universally adopted as having a definite signification. Under the general term of struma, surgeons (whatever be their theo- retical views) practically recognize, as justly remarked by Holmes, three classes of cases, viz., (1) those in which there is evidence of the exist- ence of tubercle, (2) those in which there is no tubercle, but in which the ordinary processes of inflammation, etc., present modifications which 414 DIATHETIC DISEASES. can only be accounted for, on the supposition of the antecedent existence of some morbid condition or diathesis, and (3) cases which present, in reality, nothing more than the constitutional effects of long-continued local disease. Under the latter head come a large proportion of cases of chronic bone and joint disease, which are commonly though incor- rectly called strumous. Rejecting then entirely the third class, we have the cases in which tubercle exists, and which may be properly called tuberculous, and those in which there is evidently a morbid dia- thesis (not tuberculous), to which we may conveniently, if not very scientifically, apply the term scrofulous. Tubercle or Tuberculosis.—I shall not enter into any discussion as to the nature and origin of tubercle, a question which belongs more properly to the domain of general pathology than to that of practical surgery, and upon which the leading authorities of the present day are still not agreed.1 It is usually said that tubercle occurs under two forms, the gray or miliary tubercle, and the yellow tubercle. The latter is probably in many instances not tubercle at all, but the result of case- ous or cheesy degeneration (tyrosis) of pus, cancerous deposits, or other pathological formations; in other cases, however, the yellow is the result of caseous degeneration of the miliary tubercle. Gray or miliary tubercles occur as small granular masses, about the size of millet-seeds, rather hard, semi-translucent, and presenting a glis- tening cartilaginous appearance. Under the microscope, these masses show a homogeneous or slightly fibrous stroma, containing cells with one or more nuclei, free nuclei, granules, etc. In the so-called yellow tuber- cle, which usually occurs in larger masses, the cells have a withered appearance, and the granular matter is in larger proportion, and mixed with oil globules. The following scale of the frequency of tubercle, in various textures and organs, is taken from Rokitansky: lungs, intestinal canal, lym- phatic glands (particularly the abdominal and bronchial), larynx, serous membranes (especially the peritoneum and pleura), pia mater, brain, spleen, kidneys, liver, bones and periosteum, uterus and* tubes, testicles with prostate and seminal vesicles, spinal cord, and striated muscles. The favorite primary seats of tubercle, after the lungs and lymphatic glands, are the urinary and sexual organs, and the bones. Tubercles are only met with in vascular parts (hence not in cartilage), and are often deposited in the external coats (adventitia) of the smaller vessels, a cir- cumstance which may account for their frequent appearance in the choroid coat of the eye, where they have been recognized during life, by means of the ophthalmoscope (see Waldenburg, and Reeve, loc. cit., p. 148). Tubercle may become indurated and calcified (obsolete), but usually tends to softening, disintegration, and liquefaction; the fact of its absorption is not established, though its possibility is admitted by both Rokitansky and Virchow. The causes, symptoms, course, and general treatment of tuberculosis are described in every work on the Practice of Medicine, and need not therefore be referred to here: it may be stated, however, that there are strong grounds for believing that, among the sources of depression which act as predisposing causes of the development of tubercle, long-continued > See an elaborate and able review of Waldenburg's "Tuberculosis Pulmonary Consumption, and Scrofula," by Dr J. C. Reeve, of Dayton, Ohio, in Am. Journ. Med. Sciences, Jan. 1870, pp. 137-171. SCROFULA OR SCROFULOSIS. 415 suppuration is one which must not be ignored. Hence an additional reason in the treatment of surgical cases, for paying attention to the constitutional condition of the patient, and for preventing, if possible, deterioration of the general health. With regard to the question of operative interference in tuberculous cases, no general rule can be given. The prognosis of an amputation or excision for tuberculous disease, is undoubtedly less favorable than that of a similar operation for scrofu- lous, or simple chronic inflammation. If there be evidence of tubercu- losis of internal organs, any operation should as a rule be avoided; the only exceptions are—(1) when it appears that the visceral disease is caused by the external affection, and when therefore there would be reason to hope that by removing the latter the progress of the former might be checked, and (2) when the patient's suffering from the external disease is so great, that the operation is called for simply for the relief of pain. Scrofula or Scrofulosis, as the term is here used, denotes a con- stitutional condition or diathesis, which imparts a peculiar character to the processes of inflammation and ulceration, and which is particularly marked by a tendency to cheesy degeneration in the lymphatic glands, and to a low form of inflammation of the bones and joints. Many writers speak of a scrofulous temperament, and describe certain peculiarities of feature and complexion, as characteristic of the scrofu- lous diathesis. Mr. Erichsen describes two forms, the fair and the dark, and subdivides each of these into two varieties, the fine and the coarse: Sir Wm. Jenner, on the other hand, regards the fine varieties (which con- stitute what is usually called the sanguine temperament) as belonging to the tuberculous diathesis, and limits the term scrofulous to the tem- perament commonly recognized as the phlegmatic. Although, however, there are doubtless many cases of tuberculosis met with among persons of a sanguine temperament, with delicate features, clear complexions, and highly developed nervous systems, there are perhaps almost as many among those whose temperament would be unhesitatingly pronounced phlegmatic, so that, as Holmes justly remarks, the exceptions to the rule are almost as numerous as its exemplifications. It is indeed questionable whether there be any temperament, that can be positively declared to predispose to either scrofula or tubercle, or, on the other hand, any temperament, in which either or both of these diseases may not under favoring circumstances be developed. The scrofulous diathesis may be inherited, or maybe acquired by sub- jection to various sources of depression, such as bad or insufficient food, intemperance, bad ventilation, exposure, mental anxiety, etc. Even when not manifesting itself in the form of any particular malady, it is usually characterized by weakness and irritability of the digestive sys- tem, by a feeble circulation, and by a state of general anaemia. Manifestations of Scrofula.—The manifestations of scrofula which chiefly come under the notice of the surgeon, are scrofulous inflamma- tion and ulceration, affecting the skin and mucous membranes, scrofu- lous disease of the bones and joints, and cheesy degeneration of the lymphatic glands. 1. Skin.—Various cutaneous eruptions have been considered as scrofu- lous, but upon somewhat questionable grounds ; there can be no doubt, however, that cutaneous ulcers are modified in their appearance and course by the scrofulous diathesis, the tissues around the ulcers in these 416 DIATHETIC DISEASES. Fig. 188. cases being greatly thickened and infil- trated with serum, the granulations large and feeble, and the cicatrices, when formed, thin, weak, and liable to reulcerate (Fig. 188). 2. Mucous Membranes—The mucous membranes, under the influence of the scrofulous diathesis, become thickened and irritable. The secretions may be thin and acrid, or sometimes mixed with pus. In the eyes, there may be granular conjunctivitis, with perhaps haziness or ulceration of the cornea, and in the Schneiderian membrane, hypertrophy, giving rise to obstructed breathing and snuffling; the antrum may swell, discharging purulent mucus into scrofulous ulcer ofieg. the nostrils; the tonsils are not unfre- quently enlarged, and the voice rendered husky, by relaxation or thickening of the laryngeal mucous membrane; diarrhoea is frequent, and cystitis, urethritis, and leucorrhea may each in turn be due to the scrofulous diathesis. 3. Bones and Joints.—The scrofulous diathesis seems to render the bones and joints peculiarly disposed to unhealthy and destructive forms of inflammation. Thus an accident, which occurring to a healthy per- son would be quite trivial, may in one of a scrofulous diathesis be pro- ductive of the most serious consequences. I have known a fall on the ice, which would ordinarily have caused a mere bruise, to give rise, in a scrofulous child, to acute osteo-myelitis of the humerus, with pyarthrosis of both elbow and shoulder, amputation at the scapulo-humeral articula- tion being eventually required. Under the influence of scrofulosis, inflam- mation of bone is apt to assume the form of caries, or of caries with limited necrosis (caries necrotica), while in the joints are found the various affec- tions popularly called " white swellings," gelatiniform degeneration of the synovial membranes, ulceration of cartilages, etc. 4. Lymphatic Glands—Perhaps the most unequivocal manifestation of scrofula is the tendency which it induces to cheesy degeneration (tyrosis) of the lymphatic glands. Indeed, Waldenburg, as quoted by Reeve (loc. cit., p. 154), defines scrofula as " a constitutional anomaly in which the lymphatic glands have an abnormal tendency to disease, and possess a local disposition to undergo cheesy degeneration." Glandular enlargement, particularly in the cervical and submaxillary regions, is very frequently observed in cases of scrofulosis, and, under very slight irritation, suppuration is apt to occur in the neighboring areolar tissue, the glands themselves breaking down, and mingling the caseous products of their degeneration with the surrounding pus. The abscesses thus formed are extremely indolent, not healing permanently until all the affected glandular structure has been removed, and cicatrizing finally with depressed and disfiguring scars. 5. Other Organs are occasionally though less frequently affected by scrofula. Among those which are most important, from a surgical point of view, may be enumerated the mammary gland and the testis. Treatment of Scrofula—The treatment of scrofulosis should consist more in attention to hygienic rules than in the use of medicines. Good air, good food, habitual cleanliness, sufficiently warm clothing, and pro- tection from exposure or other sources of depression, are of the hio-hest RICKETS. 417 importance. Special attention should be given to the digestive func- tions, and either constipation or diarrhoea should be obviated, rather, however, by regulating the diet than by the use of drugs. Among medi- cines, certain tonics are particularly serviceable. Cod-liver oil probably deserves the first place, the most useful articles after it being iron, qui- nia, and the preparations of iodine. The syrup of the iodide of iron is a very good combination, particularly for administration to children. These tonics should not, however, be given indiscriminately, and, as a rule, not while there is evidence of marked intestinal derangement. Al- coholic stimulants must be used with great moderation, and the lighter wines, or malt liquors, such as lager beer, are commonly preferable to the stronger forms of stimulus. By local treatment, it is doubtful whether much can be accomplished. A most important rule, and one which should be constantly borne in mind, is to take care, lest by our treatment we convert this, which is essentially a chronic affection, into one which is acute. Hence in many instances the best thing for the surgeon to do is to let the part alone, merely protecting it from external injuiy. In other cases more active measures may be employed, though always with care and watchfulness. Scrofulous ulcers maybe dressed with slightly stimulating or astringent applications, and the livid unhealthy-looking edges may be touched with the actual cautery, or even removed with the knife. Lymphatic enlarge- ments should be protected by means of soap plasters, or, if very indo- lent, may be submitted to gentle frictions, with moderate pressure, and the use of mildly discutient lotions. Even if abscesses form, it is better, I think, to delay opening them, so long as there is the slightest chance of absorption and spontaneous disappearance. If an opening be inevita- ble, it is probably better made with the knife than left to nature, as the resulting scar will be less disfiguring. Any sinuses that are left may be encouraged to heal, by stimulating injections, or by means of a seton. Repeated tappings with the hypodermic syringe, are recommended by Lawson Tait, in the treatment of suppurating glands in the neck. With regard to operations in scrofulous cases, no rule of universal application can be laid down. I am decidedly of the opinion that, in the immense majority of instances, enlarged cervical glands should not be interfered with; apart from the fact that the disease in such a case com- monly extends much deeper than it appears to, these operations almost always come into the category of operations of expediency, and, as such, are only exceptionally justifiable. With regard to operations for scrofu- lous bone and joint disease, the question is more doubtful. As a rule, it may be stated that no operation should be performed, while a reasonable hope remains that a cure can be effected by expectant treatment; if, however, the powers of nature should be manifestly incompetent for the task, or if (as is often the case among patients of the poorer classes) the time which would probably be required for a natural cure be an important consideration, operative measures may be properly resorted to, and will often be followed by the most gratifying results. Excision is of course pre- ferable to amputation, when the circumstances of the case permit a choice. Rickets. Rickets or Rachitis is a constitutional disease, occurring almost exclusively in childhood, and characterized by a peculiar lesion of the osseous system, and by a tendency to the so-called amyloid or albumi- noid degeneration of certain viscera, especially the spleen aud liver. 27 418 DIATHETIC DISEASES. Causes.—Rickets may possibly in some cases be inherited, but is, at least, much more frequently acquired, and usually results from mal- nutrition, or from other sources of constitutional depression to which children may be exposed. Morbid Anatomy.—The most characteristic manifestation of rickets is seen in the skeleton, and affects the long bones as well as those of the head, chest, and pelvis. The bony changes consist essentially in in- creased cell-growth, with deficiency of earthy matter. The epiphyseal cartilages (cartilages of conjunetion) become enlarged, giving what is often called the "double-jointed" appearance observed in these cases. The periosteum is also greatly thickened, while the osseous shaft itself undergoes softening, its lacunae being much enlarged, and filled with red, pulpy granulations. Under the influence of muscular action, or other mechanical causes, the bones undergo modifications of shape, giving rise sometimes to great deformity; if the child has begun to walk before the development of rickets, these changes will probably be most marked in the lower extremities. The cranial bones are often much thickened, giving a massive appearance to the head; in other cases they are abnor- mally thin, or even perforated (craniotabes), the pericranium and dura mater seeming to be in contact; the anterior fontanelle remains open longer than in health. The ribs bend at their junction with the costal cartilages, allowing the sternum to project, and causing the so-called "pigeon-breasted" deformity. In some cases the enlargement of the sternal extremities of the ribs, gives the appearance of a deep gutter on either side of the breast-bone. The spine is occasionally the seat of lateral, but more often of antero-posterior curvature, the backward curve being in the dorsal, and the forward in the cervical and lumbar regions. The pelvis often becomes very oblique, in consequence of the deformity of the lower extremities, and of the "lordosis" or anterior curvature of the lumbar spine; and serious complications may thus arise in after-life, in the process of parturition, or in operations on the pelvic organs. Symptoms and Course.—In the earliest stages of rickets, there are disorder of the digestive system and other evidences of mal-nutrition, but nothing that can be considered distinctive. Teething is delayed, and often accomplished with difficulty. The child sleeps badly, and is rest- less ; sweats profusely about the head, and constantly kicks off the bed- clothes. The muscular system is weak, and the patient, if he has already begun to walk, soon loses both the power and the disposition to do so. The urine is abundant, and usually loaded with phosphates. As tbe disease advances, a curious state of muscular hyperesthesia is often ob- served, either voluntary motion or the touch of another being attended with acute pain, and the child, as a consequence, maintaining an almost fixed position, and appearing listless and indisposed to even the slightest exertion. There is a tendency to bronchial and pulmonary inflammation, laryngismus stridulus, and cerebral irritation with convulsions. Fever is often, but by no means always, present; the appetite is capricious or wanting, and the fecal evacuations (whether there be or be not diarrhoea) are ill-formed and offensive. The liver and spleen are often enlarged, and sometimes albuminous or amyloid, in the latter stages of the affec- tion, while the bony deformities, which have been described, frequently persist even after the entire restoration of the general health and streno-th. Intelligence is diminished during the existence of the disease, but "the mental powers are usually completely restored with bodily convalescence. TREATMENT OF RICKETS. 419 Diagnosis and Prognosis.—There are no symptoms by which, in its earliest stages, rickets can be distinguished from the other diathetic diseases which we have considered. In any case in which dentition is much delayed, or in which difficulty in walking is observed, the surgeon may suspect rachitis, and, by careful attention to the symptoms above described, may usually be able to recognize it if present. When the characteristic osseous changes have begun, the nature of the affection can scarcely be mistaken. The prognosis of rickets, if the disease be not too far advanced, is usually favorable; as justly observed by Hillier, however, mortuary records recognize the secondary affections which complicate rickets, while the primary condition which renders those complications fatal, is itself ignored. As a rule, it may be said that the earlier the disease appears, the less is the chance of recovery, while even in the most favorable cases the affection may last for several years. Treatment.—The hygienic management of rickets is of the greatest importance; if the disease occur during the first six or eight months of life, and the mother's milk be found either scanty or of bad quality, a healthy wet-nurse should be procured, or the natural food supple- mented or replaced by fresh cow's milk, diluted with lime-water (1 part to 4). After a time, beef-tea may be made to alternate with the milk, and wine or brandy may be given, in quantities adapted to the patient's age. The child should be warmly clothed, and kept as much as possible in the open air, and at night in a well-ventilated apartment. Warm or cold sponging, or sea-bathing, will often prove of great service. If the digestive system be much disordered, a few doses of mercury with chalk, or some similar combination, may be given, but the remedies of greatest importance are tonics, especially cod-liver oil, iron, quinia, and mix-vomica. The cod-liver oil is probably the most valuable, and may be given in gradually increasing doses as the child is able to assimilate it. Some difference of opinion exists as to whether mechanical appli- ances should be used to obviate deformity in these cases. In the most acute form of rachitis, when, in the vivid language of Sir William Jenner, the child " is indeed fighting the battle of life, . . . striving with all the energy it has to keep in constant action every one of its muscles of inspiration," the use of splints and bandages would be doubtless an unnecessary annoyance; again, after the stage of bony consolidation has come on, splints can be of no use, and would do harm by impeding the natural motions; but, while the bones are yet soft and yielding, a great deal may be often accomplished by the use of light apparatus, to prevent if not to remedy deformity. For the lower ex- tremities, simple wooden splints may be used, and may be made to pro- ject below the feet, so as to prevent the child from standing or walking; while for the spine, various forms of apparatus, such as will be described in speaking of spinal curvature, may be employed. When excessive deformity of the long bones persists in after-life, it may occasionally be proper to endeavor to remedy it by removing, subperiosteally, a wedge-shaped piece of bone—as has been successfully done by Mr. Little, who thus operated upon both tibiae, in an aggravated case of knock-knee. 420 VENEREAL DISEASES. CHAPTEE XXIY. VENEREAL DISEASES. Gonorrhoea and Chancroid. The term Venereal Disease is applied to certain affections which are usually acquired in sexual intercourse. There are three separate dis- eases which are properly described as venereal, which until within a comparatively recent period were all confused together, and the distinc- tion between two of which is even at the present time not recognized by a large number of surgeons. These diseases are Gonorrhoea, Chan- croid, and Syphilis. The first two are strictly local, while the latter is a constitutional affection. The non-identity of gonorrhcea with the other venereal diseases, though pointed out by Balfour, B. Bell, Hernandez, and others, was not clearly established until the publication of Ricord's treatise, in 1838, while the diversity of chancroid and syphilis—first clearly shown by Bassereau, in 1852—is even now denied by a good many surgeons, and is practically ignored by a still larger number. Gonorrhoea. Gonorrhcea, Blennorrhagia, or, as it is vulgarly called, Clap, is a virulent, contagious, muco-purulent inflammation, affecting the mucous membranes. It isc hiefly seen in the generative organs, being usually met with in the male urethra and in the vulvo-vaginal canal—the glans penis and lining membrane of the prepuce, the uterus, and the female urethra being less often involved. It also occurs in the conjunctiva, and is said to have been seen in the rectum, the nose, and the mouth. Causes.—The most frequent cause of gonorrhoea is unquestionably direct contact with the muco-pus derived from a person similarly affected. It may, however, arise from contact with the vaginal secretions in cases of leucorrhcea, from contact with the menstrual fluid, or even, possibly, from intercourse between healthy persons, if coitus be violent, prolonged, or attended with unusual excitement. In the immense majority of in- stances gonorrhoea is acquired in sexual congress, and hence is observed in the mucous membranes of the urino-genitaiy apparatus. Ophthalmic gonorrhoea—or, as it is usually called, gonorrhceal conjunctivitis—is caused by transference of the contagious secretion from the private parts to the eye, by the patient's hand, or possibly by means of dirty towels, etc., while the rarer forms of rectal, nasal, and buccal gonorrhcea may be similarly produced, or may be due to practices, the nature of which it is not necessary to specify. Gonorrhcea of Male Urethra.—I shall first describe, under this heading, the course, symptoms, and appropriate treatment of an ordi- nary gonorrhceal attack, considering subsequently the various complica- GONORRHCEA OF MALE URETHRA. 421 tions which may arise, and the modifications of treatment required by each. The first symptoms are usually manifested from one to five days after exposure to contagion, though the disease is occasionally not ob- served until a week, or even a fortnight after the infecting coitus. The patient first notices an uncomfortable stinging or tickling sensation (which the French call picotement) at the urinary meatus, and, on ex- amining the part, observes the lips of the urethra slightly swollen and reddened, and moistened with a small quantity of viscid secretion. This fluid gradually increases in amount, and from being, as at first, colorless, soon becomes milky or yellowish-white in appearance, and under the microscope is found to consist of mucus mingled with pus. In this— which is called the first, or incubative stage, the inflammation is confined to the anterior portion of the urethra, and especially the part known as the fossa navicularis, but in the course of two or three days spreads backwards, and becomes much more intense. The discharge is now quite profuse, of a greenish-yellow color, somewhat thicker than at first, and occasionally streaked with blood; the urethra is tense and painful, and the whole penis—but particularly the glans—red and turgid. Uri- nation is frequent, and attended with a good deal of irritation, or scald- ing (chaude-pisse), and the stream is lessened in size, on account of the swelling of the mucous membrane. If the bulbous portion of the ure- thra be affected, the perineum is tense and painful; while, if the pros- tatic portion be involved, the anus feels hot, and as if stuffed with a foreign body. If the inflammation run very high, there may be a good deal of general febrile disturbance. This, the second or acute stage of gonorrhcea, lasts from one to three weeks, and then gradually subsides into the third or chronic stage, which, when long persistent, receives the name of Gleet or Blennorrhcea. In the third stage, the discharge dimin- ishes in quantity and gradually loses its purulent character, while the intensity of all the symptoms, and especially of the scalding in urina- tion, becomes markedly lessened. The inflammation lasts longest in the posterior portion of the urethra, and matter can be sometimes made to flow by pressure from behind forwards applied to the perineum, when the anterior portion of the canal has apparently quite resumed its normal condition. Gonorrhoea, in most cases, tends to a spontaneous cure, lasting on an average from six to twelve weeks; but occasionally an intractable gleet may persist for many months, or even for years. Under the name of Dry Clap have been described cases of gonorrhoea, in which it is said that all the symptoms were well marked, with the single exception that at no time was there any discharge. I am disposed to think, with Bumstead, that in these cases closer observation, with per- haps examination of the urine, would have shown that some muco-pus was actually present. I do not believe that gonorrhcea can exist without discharge, though it is very possible that the amount of discharge may sometimes be so slight as readily to escape detection. Diagnosis.—I do not believe that it is possible to distinguish with abso- lute certainty, gonorrhoea caused by impure coitus, from other forms of muco-purulent urethritis. It is usually said that the diagnosis can be made by observing the greater virulence of the blennorrhagic affection, and, unquestionably, ordinary inflammation of the urethra rarely attains the intensity which is common in cases of gonorrhoea. Very intense muco-purulent urethritis may, however, be caused by the contact of the acrid vaginal secretions in cases of leucorrhcea, or by the contact of the menstrual fluid; and it is believed by many of the very highest authorities, that genuine gonorrhoea is thus not unfrequently produced. Whether 422 VENEREAL DISEASES. this be admitted or not; whether, that is, we believe in the existence of any special gonorrhceal virus, or consider, as has been done in the pre- ceding pages, that gonorrhcea is merely a peculiarly virulent form of ordinary inflammation, we must grant that it is often quite impossible to fix upon the exact source of the disease, in any particular instance; and hence the practical inference, that the surgeon should, in cases the history of which is not clear, exercise great caution in expressing an opinion, of the correctness of which he cannot be absolutely sure, and which may not only cause great unhappiness, but may perhaps involve some innocent person in unmerited disgrace and blame. Fortunately the question is one of theoretical rather than of practical interest, for the treatment of muco-purulent urethritis is the same, no matter whence its origin. In its chronic stage, the diagnosis of gonorrhcea presents still greater difficulty, for a thin, gleety urethral discharge may come from very various sources of irritation—being indeed a not unfrequent attendant upon the gouty, strumous, and scorbutic diatheses, or a mere secondary affection resulting from diseases of neighboring parts, such as the rectum or prostate gland. Prognosis.—Though in the large majority of instances, gonorrhoea proves a perfectly tractable affection, and passes off without any dis- agreeable consequences, cases are occasionally met with in which a trou- blesome gleet proves utterly rebellious to treatment, remaining as the starting-point for an acute attack of the disease, which may be provoked by any sexual excess, indulgence in intoxicating beverages, or even im- prudence of diet; in other cases gonorrhceal inflammation gives rise to organic stricture of the urethra, or may cause serious and even fatal disease of the bladder and kidneys. Treatment.—The treatment of gonorrhoea is principally of a local character. If the patient be seen in the first stage, before the inflamma- tion has reached its point of greatest intensity, what is called the abor- tive treatment may be properly employed. The plan which I am in the habit of following, is to direct urethral injections of a solution of nitrate of silver (gr. ^-f.fj). Of this preparation from two to four fluidrachms should be carefully injected into the urethra, three, four, or five times a day, the patient taking the precaution to wash out his urethra by urina- tion, ten or fifteen minutes before each injection. The injections are best made with a small hard-rubber syringe, which is in every way preferable to the common glass syringe usually sold for the purpose. In using the syringe, the patient should gently introduce its beak as far as it will go into the urethra, the lips of which are then closely pressed against the instrument with the thumb and fingers of the left hand, while the piston is slowly driven down by the forefinger of the right hand, which holds the syringe. By this method the escape of fluid is prevented, and the whole amount is introduced into the canal; there is no risk of the injec- tion entering the bladder, and even should it do so, no harm would result, for it would be instantly decomposed by the salts of the urine. Two syringefuls may be used on each occasion of injection, as the effect of the first is always to some extent neutralized by the mucus which lines the urethra. The first effect of these injections, is apparently to a•) With intra-cystic growths. (3.) Mucous. (10.) Cutaneous. (4.) Sanguineous. (11.) Dentigerous. (5.) Oily. (6.) Colloid. (7.) Seminal. 2. Solid Tumors and Outgrowths. (1.) Fatty, or adipose. (2.) Fibro-cellular, or connective tissue (including myxomatous and glioma- tous). (3.) Fibrous, fibro-muscular, fibro-cystic, etc. (4.) Cartilaginous, fibro-cartilaginous, and mixed. (5.) Myeloid. (10.) Recurrent. (6.) Osseous. (11.) Neuralgic. (7.) Glandular. (12.) Pulsating. (8.) Vascular. (13.) Floating. (9.) Papillary. (14.) Phantom. Malignant Tumors. 1. Cancer, or Carcinoma. (1.) Scirrhous, or hard cancer (Scirrhus). (2.) Medullary, or soft cancer (Encephaloid). ' (a) Melanoid. (d) Villous. (b) Hrematoid. (e) Colloid. Cc) Osteoid. (/) Fibrous. 2. Epithelioma. Non-Malignant Tumors, as a rule, displace, without involving, surround- ing tissues; they possess considerable vitality, and hence may persist for a long period, without undergoing either ulceration or interstitial degeneration; they are homogeneous, or at least do not commonly ex- hibit, in the same mass, any great diversity of structural elements; and if removed, they do not, usually, recur—even the recurrent tumors not unfrequently admitting of a permanent cure by repeated removals. Malignant Tumors, on the other hand, are commonly infiltrated among the surrounding tissues, which they gradually replace, or appropriate to themselves; they possess comparatively little vitality, and hence tend to ulceration and destructive degeneration; they exhibit, in the same mass, a considerable number of diverse structural elements; and though re- moved with the greatest care, almost invariably recur. These remarks, though generally, are not universally applicable. It occasionally happens that a tumor, which is undoubtedly cancerous, does not recur after removal, while, on the other hand, a growth which, struc- turally, is such as would be placed among the non-malignant tumors, may recur indefinitely, and eventually cause death. The special characters and appropriate treatment of each variety of tumor which comes under the observation of the surgeon, will now be briefly described. SIMPLE OR BARREN CYSTS. 461 Cystic Tumors, or Cysts. Cysts may originate in several ways. The most common, is from the distension and enlargement of ducts, or sacs, as is usually the case with the mucous, and ordinary cutaneous cysts. Another mode of origin is from the enlargement and coalition of the natural interspaces of the areolar and other tissues ; these interspaces being distended with fluid, the surrounding structures undergo condensation, until a cyst wall is formed. It is in this way that adventitious bursas are formed, as well as cystic developments in solid tumors. A third mode of origin is from the direct growth of newly-formed elementary structures, cells, or nuclei—the cysts thus formed being sometimes called primary or auto- genous, as distinguished from the other, or secondary cysts. Finally, a cyst may be formed by the protrusion and subsequent separation of a portion of a serous membrane, as happens in some cases of so-called " false spina bifida." A. Simple or Barren Cysts. Serous Cysts, or Hygromata, may occur in any part of the body, but are most usual in or near glandular structures. These cysts contain a liquid of variable consistency, and of a yellowish, reddish-brown, or olive hue; this liquid sometimes contains crystals of cholestearine, and in other cases is fibrinous and coagulates when removed. The cyst walls are of connective tissue, adherent to surrounding structures, not very vascular, and lined with a tessellated epithelium. These cysts may be single or multiple, and, in the latter case, may intercommunicate, or may be merely aggregated. When found in external parts, they may commonly be diagnosticated by observing that they have a smooth and rounded outline, are movable with, though adherent to the neighboring healthy structures, are painless, covered with normal skin, and some- times translucent,' and fluctuate, or, if very tense, are at least found to be elastic and resilient on pressure. The treatment may consist of punc- ture (which may also be used as an exploratory measure), the applica- tion of tincture of iodine, the injection of the same substance after tapping, the use of a seton, incision with or without cauterization, or partial or complete excision. Iodine injections or the seton, are particu- larly adapted for cysts found in the cervical region, and incision, with cauterization or simply stuffing the cavity with lint, for those met with in the gums or bones. Partial excision is usually sufficient if the cyst be solitary, any portion that is left subsequently granulating and under- going cicatrization. For multiple cysts, however, total excision may be required, and, if seated in the mammary gland, it may be necessary to remove the whole breast, in order to prevent any portion of the diseased structure from remaining. Serous cysts are occasionally connected with vascular nsevi, in which case the operation for removal may be attended with profuse bleeding. In the breast, it sometimes happens that a serous cyst coexists with a cancer. Synovial Cysts may consist simply in enlargement and distension of the normal synovial bursas; or may be adventitiously developed in abnormal situations, as the result of pressure; or may occur in the 1 When occurring in the neck, they constitute the so-called hydrocele of that part. 462 TUMORS. sheaths of tendons, constituting ganglia. The fluid of these cysts varies in consistency from that of serum to that of honey, and they not unfrequently contain small bodies, about the size and shape of melon- seeds, which may be loose, or attached to the cyst walls, and which are composed of a dense connective tissue substance. The treatment of synovial cysts, consists in the use of external irritation, in tapping, fol- lowed by stimulating injections, in the formation of a seton, in subcu- taneous division and scarification, or, finally, in excision. Mucous Cysts are chiefly seen in mucous membranes and in con- nection with the mucous glands, where they result from distension of obstructed ducts or follicles. They are met with in connection with Cowper's, or Duverney's glands, in the antrum, and beneath the tongue, where they constitute a form of ranula. Their general characters are those of the serous cysts, from which they differ chiefly in the nature of their contained fluid (which resembles mucus), and in their locality. The treatment consists in free incision, or in cutting awa}r a portion of the cyst wall, the cavity being allowed to heal by granulation. Sanguineous Cysts, or Haematomata, may result from accidental hemorrhage into the cavity of a serous cyst (just as hematocele from hemorrhage into the sac of a hydrocele), from transformation of a vas- cular naevus, from Occlusion and dilatation of a portion of a vein, or from effusion of blood, which subsequently becomes encysted by the con- densation of the surrounding areolar tissue. They are chiefly met with in the cervical and parotid regions (in the former locality constituting haematocele of the neck), though they also occur in other parts of the body. These cysts contain blood, which may be clotted and partially' decolorized, or which may be liquid. In the latter case it may have been fluid from the first, and will then coagulate when evacuated, or may have been clotted at first and subsequently re-liquefied. The walls of these cysts may be simply membranous, or may be deeply ribbed. These oysts occasionally resemble, in their outward appearances, ence- phaloid tumors, with which indeed they may coexist. The treatment ordinarily to be recommended for sanguineous cysts, is excision, with precaution against hemorrhage, if the cyst be connected with a naevus or bloodvessel; or, if the tumor be very large, it may be reduced in size by repeated tappings, and then laid open, as has been successfully done by Erichsen. Amputation may occasionally be required, as in a remarkable case reported by Moore, in which the cyst was developed in the course of the popliteal nerve, and in which loss of blood during an attempt at excision necessitated removal of the limb. Oily Cysts.—Cysts containing oil or fatty matter alone, are very rare, though fatty substances not unfrequently occur in cysts, as the result of degeneration of other materials, or as a curdy residue from milk. Oily cysts do, however, occasionally occur in the orbital and superciliary regions, and in the breast. The treatment should consist of excision. Colloid Cysts occur in the kidney and thyroid gland, in the latter situation constituting a variety of goitre. Their contents vary in con- sistency from that of serum to that of a firm jelly, being clear or turbid, and of very variable color. The treatment of cystic goitre consists in tapping and the injection of iodine. COMPOUND OR PROLIFEROUS CYSTS. 463 Seminal Cysts.—This is the name used by Paget for most examples of the affections usually known as Encysted Hydrocele, Hydrocele of the Cord, and Spermatocele. Seminal cysts probably arise from dilatation and subsequent isolation of a portion of a seminal tubule. They may be single or multiple, and may occur in any part of the spermatic cord, though usually just above the epididymis. Their walls are of areolar tissue, sometimes lined with tessellated epithelium, and they contain a milky fluid, in which spermatozoa are commonly found. The treatment consists in the injection of iodine, or in the use of a seton; or, if these fail, in free incision of the sac, which is then allowed to heal by granulation. B. Compound or Proliferous Cysts. These are such as have the power of producing vascular or other organized structures, which may be inclosed within the original cyst wall, or may project from its surface. It is sometimes very difficult to distinguish a true proliferous cyst from a mass of simple cysts closely aggregated together, the latter indeed constituting a considerable pro- portion of what are known as multilocular cysts. Complex Cystigerous Cysts are chiefly met with in the ovary, and in the chorion, in the disease of that membrane known as the hydatid mole, in which, however, the cysts are probably merely secondary forma- tions (see p. 468). Complex ovarian cysts present a parent cyst with numerous secondary cysts variously arranged, which project into its cavity (endogenous), or from its surface (exogenous growths). Dr. Wilson Fox has carefully investigated the mode of origin of these tumors, and believes that the parent cyst originates, like the simple ovarian - raay be elliptical (Fig. 227), or in the form of a double S (Fig. 228). If the tumor be encapsulated, it should be removed, if possible, by enucleation, the finger and handle of the knife being used in the deeper 494 SURGICAL DISEASES OF THE SKIN. parts, instead of the cutting edge of the instrument: when it is necessaiy to resort to dissection, the growth should be loosened first at the part at which its main vessels enter, so that if Fig. 228. these are cut, they may be secured once for all. In removing a non-malignant growth, the knife should be kept close to the tumor, so as to avoid wounding the important structures to which it may be attached, but if the growth be malignant, the surgeon should keep wide of it, in all his manipulations, so that no portion may be allowed to remain. If possible, a tumor should never be cut into until it is removed: neglect of this precaution may lead to hemorrhage (for the tumor itself may be very vascular), and if it be a malignant growth, particles may escape from it, which will act as germs in promoting the recurrence of the disease. If the tumor be of moderate size, the first incision should be made sufficiently free to allow removal of the whole mass : in the case, however, of a very large tumor, it is well to expose only a portion of it at first, enlarging the wound at a later stage of the operation when necessary; the loss of blood will thus be less, than if the whole incision had been made at the beginning. If, when a tumor is exposed, it be found that its deep attachment cannot be safely interfered with, the best thing left for the surgeon to do is to strangulate the base of the growth with strong ligatures, and cut off the remainder: no operation, however, should be undertaken, unless it appear that the whole tumor can be safely extirpated. After the excision of a tumor, the surgeon should carefully explore with his finger the whole surface of the wound, so as to make sure that no portion of the growth has been allowed to remain : this is particularly important in dealing with a malignant tumor, and, in such a case, any suspicious structures that cannot be removed, may be touched with the actual cautery, or with a solution of chloride of zinc. The lips of the wound may then be approximated with a few points of suture and adhe- sive strips, and lightly dressed with a strip of lint dipped in olive oil, or any other simple application that may seem appropriate. If the cavity left by the removal of the tumor be large, the whole should be supported with a compress and bandage, to prevent oozing, or accumu- lation of pus. CHAPTER XXVII. SURGICAL DISEASES OF THE SKIN, AREOLAR TISSUE, LYM- PHATICS, MUSCLES, TENDONS, AND BURS^E. Diseases of the Skin and its Appendages. The consideration of the ordinary cutaneous affections, which are commonly spoken of as "skin diseases," does not properly come within the scope of this work; but there are certain morbid conditions of the skin and its appendages, which require surgical manipulations in their treatment, and which may, therefore, be here appropriately referred to. VERRUCA OR WARTS. 495 Vermcae or Warts.—Warts consist of hypertrophied cutaneous papillae, which may project, each papilla by itself, or, as is more usual, ensheathed by a common investment of thickened scaly epithelium. Anatomically, they belong to the papillary variety of tumor. The sim- ple warts which appear upon the hands and face, come without any ap- parent cause, and often disappear spontaneously. In other cases, they remain permanently, becoming of a dark color, and occasionally form- ing a nidus for epitheliomatous formations. The treatment con- sists in the application of nitrate of silver in substance, nitric or chromic acid, or the muriated tincture of iron—or in ligation or excision, if the wart be peduncu- lated. Warts occasionally have a moist, muco-cutaneous cover- ing, and are irritable and dis- posed to bleed; the glycerate of tannic acid will often be found a useful application in this form of the disease. Warts not unfre- quently occur upon the muco- cutaneous surfaces of the anus, or of the genital organs in either sex, and in the latter situation are often spoken of as venereal warts or vegetations: they are not, however, necessarily of a venereal origin, but may be pro- duced simply by the irritation of frequent sexual intercourse, or may even result from the accu- mulation of smegma and want of personal cleanliness. They are particularly apt to occur in per- sons with congenital phimosis. The treatment consists in the application of nitric or chromic acid, or powdered calomel, or in paring or snipping off the growths with a sharp knife or scissors, and cauterizing the surface from which they spring. Warts of the genera- tive organs, and occasionally those of the hand, appear to be communi- cable by contact. Corns are local indurations and hypertrophies, usually confined to the cuticle, but occasionally involving the papillae of the true skin. Corns result from intermittent pressure, as from wearing badly-fitting boots, and are chiefly seen on the feet, but occasionally on the hands, knees, elbows, and, according to Hulke, even on the tongue. Hard Corns are such as form upon exposed surfaces, as on the edge of the foot, and are consequently dry and indurated, while Soft Corns are such as occur in situations where they are kept moist, as between the toes, where they assume a spongy, mucous appearance, not unlike the mucous patch of syphilis. Bursae are occasionally developed beneath both varieties of the affection. Soft corns are usually more irritable than the Warts around the anus. 496 surgical diseases of the skin. hard, but either may be very painful if inflamed, the Papillary Corn, which occurs principally on the sole of the foot, causing, probably, more acute suffering than any other variety. The treatment of hard corns consists in relieving the part from pres- sure by the use of suitable shoes or the application of a perforated plaster, in shaving off the surface of the corn and applying the solid stick of nitrate of silver to its base, or in excising the centre of the indurated part with a sharp knife or scissors, after the whole has been softened by the use of a warm water-dressing. Soft corns may be dusted with powdered oxide of zinc, or touched with nitrate of silver or glacial acetic acid, the toes being kept apart by the interposition of scraped lint or raw cotton. Suppuration occurring beneath a corn, requires poulticing and the evacuation of the pus, after shaving down the part with the point of a sharp lancet. Onychia is an affection of the matrix of the nails, of which we may recognize two varieties, the simple and the malignant. Simple Onychia, or, as it is vulgarly called, "run-around," consists in an inflamed condition of the matrix of the nail, usually resulting from slight injury, and attended with suppuration and loosening of the nail, which becomes shrivelled and discolored, and is eventually cast off—the new nail which forms, being commonly thickened and distorted. This affection occurs chiefly in the hand, and is almost exclusively con- fined to children. The treatment consists in the use of poultices, or water-dressing, until the nail has separated. The growth of the new nail may sometimes be advantageously regulated, as advised by Erichsen, by the application of a layer of wax. Malignant Onychia results from injuries occurring to persons in a depressed -constitutional condition, and is usually seen in the thumb or forefinger, or in the great toe, where it sometimes receives the name of toe-nail ulcer. It consists in an unhealthy form of ulceration in the matrix of the nail, which becomes brown or black, and is thrown off, its Fig. 230. Fig. 231. Malignant onychia. Toenail ulcer. place being occupied by fungous granulations. The disease has little or no tendency to a spontaneous cure, and sometimes leads to necrosis'of the ungual phalanx. The treatment consists in avulsion of any portion of the nail which remains, and thorough cauterization of the matrix with solid nitrate of silver—a simple dressing, such as lime-water, being after- wards applied. T. Smith, following Abernethy, recommends the appli- cation of dilute Fowler's solution. Syphilitic Onychia has already been referred to at page 446; it requires the application of black or keloid or cheloid. 497 yellow wash, with the use of suitable antisyphilitic remedies. Amputa- tion may be required, if necrosis occur in a neglected case of onychia maligna. Ingrowing Toe-Nail is an affection almost exclusively confined to the outer side of the great toe; it results from wearing narrow shoes, which compress the foot, and cause the soft part of the toe to overlap its nail, giving rise to an ulcer which is painful and persistent. A cure may be sometimes effected by dusting the ulcer with oxide of zinc, or interposing a little lint, or a strip of adhesive plaster, between the nail and the inflamed part of the toe; but in many cases it will be necessaiy to remove a portion, or the whole, of the nail. This may be done (the patient being etherized) by thrusting one blade of a pair of sharp- pointed scissors beneath the nail up to its root, when the whole nail may be divided at a single stroke; the segment to be removed is then grasped with forceps, and torn away from the matrix, this process being repeated on the other side, if necessary, and the part then simply dressed with wet lint. A new nail grows, which is usually straight and well formed. The shoe must, of course, be so arranged as to free the part "from pressure. Hypertrophy of a Toe-Nail, usually of that of the great toe, is occasionally met with, the lamina? of the nail becoming distorted, and constituting a horn-like protuberance, which may grow so large as to interfere with walking. The Fig. 232. treatment consists in avulsion of the nail, which operation usually effects a permanent cure. Keloid or Cheloid (of Alibert) is an affec- tion met with chiefly, if not exclusively, in the scars produced by burns or by wounds, and. especially in those produced by flogging, and is to be distin- guished from the disease known as Morphsea or the Keloid of Addison (true keloid), which occurs in healthy skins, where it produces a scar-like ap- pearance. The former appears in the shape of small Hypertrophy of toe-naii. and shining, indurated elevations, of a dusky red color, which extend, sending out, as it were, claw-like processes, and are attended during their growth by great itching and considerable pain. In their structure they correspond with the fibro-cellular outgrowths described in the last chapter. The Keloid of Addison begins as a "white patch or opacity" of the skin, surrounded by a zone of redness, gradually spreading and inducing contraction of fascia? and tendons, and giving a "hide-bound" character to the part affected.1 The treatment of either form of keloid is very unsatisfactory. Extirpation with the knife has been tried, but the disease almost invariably recurs. Dr. Addison de- rived advantage from the use of iodine, both internally and externally, in one case of the variety of the disease known by his name. Warty Tumors of Cicatrices.—Under the name of Warty Tumor, or Warty Ulcer of Cicatrices, an affection somewhat resembling the keloid 1 Addison, in Med.-Chir. Transactions, vol. xxxvii., pp. 27-47. According to J. Collins Warren, of Boston, the two forms of keloid cannot be distinguished by their anatomical features. 32 498 SURGICAL DISEASES OF THE SKIN. of Alibert, has been described by Caesar Hawkins.1 Some of these warty ulcers are non-malignant, being of a fibro-cellular character, but others are really epitheliomata of a papillary form. When occurring over the anterior surface of the tibia, as in the so-called " Warty Ulcer of Marjolin," they are very often complicated by a carious condition of the bone. The treatment consists in excision or am- Fiff. 233. putation, according to the size and locality of the affection; the opera- tion, even when the disease is epi- theliomatous, often resulting in an apparently permanent cure. Recov- ery may, according to Collis, be some- times obtained in the early stage, by the application of bismuth, or of ice. Malignant warty ulcer of the leg. Rodent Ulcer.—This affection, which is also known as Jacob's2 Ulcer, is most often seen in the eyelids, cheeks, upper lip, nose, or scalp, but may also occur in other parts of the body. It is a disease of late adult life, and commonly originates in some tubercle or mole, which may have existed for many years. It is usually single, at first rounded, but becoming irregular as it spreads, with indurated base and edge, and a somewhat abrupt, and but slightly elevated border; it very rarely assumes the character of a tumor. The ulcerated surface is smooth, glossy, and dry, and of a reddish-yellow color. The progress of the disease, though extremely indolent and chronic, is never spontaneously arrested, though partial cicatrization may sometimes occur. The rodent ulcer produces frightful ravages, exposing the orbit, nasal cavities, pharynx, or even the brain, and thus ultimately causing death—though the local character of the affection is strictly maintained to the last, the lymphatics and distant organs never becoming involved. The microscopic characters of the rodent ulcer are, according to Paget, simply those observed in ordinary granulations; Fig. 234. Collis classes the disease among myeloid or fibro-plas- tic growths, while Moore, on the other hand, looks upon it as a form of cancer. The treatment consists in complete extirpation, which is best accomplished, when possible, with the knife. If, however, excision be contra- indicated by the size or lo- cality of the ulcer, or the age of the patient, caustics Rodent uker. may be employed, the Vi- enna, or Canquoin's paste, or nitric acid, or acid nitrate of mercury, being respectively preferred, according to the deep or superficial character of the affection. Lupus.—Under this name are commonly included two affections, 1 Med.-Chir. Trans., vol. xix.,pp. 19-34. 2 See Dr. Jacob'* paper in Dublin Hosp. Reports, vol. iv., pp. 232-239. MALIGNANT DISEASES OF THE SKIN. 499 which may be described as Lupus Non-exedens, or Simple Lupus, and Lupus Exedens, or Ulcerating Lupus. Lupus Non-exedens appears as a red patch on the skin (usually of the face), attended with brawny desquamation, and sometimes accom- panied with indolent tubercles. It runs a very chronic course, and pro- duces inconvenience merely by the deformity and scar-like contraction to which it gives rise. It is usually seen in persons of a scrofulous dia- thesis. The treatment consists in the administration of tonics, especially of cod-liver oil, with arsenic, and in the local use of a solution of nitrate of silver, gr. x-xx to f^j. Lupus Exedens, Ulcerated Lupus, or Lupous Ulcer, is usually seated on the tip or alas of the nose, but sometimes on the upper lip, or in other situations, and is chiefly seen in young persons. It begins as one or more reddish papules, or tubercles, which soon ulcerate and coalesce. The lupous ulcer may be super- ficial, when it appears as a fungous, warty, ulcerated surface, with pro- minent nodular granulation s,which are often scabbed over by the dry- ing of the discharge, and are some- times irritable, though seldom dis- posed to bleed. The ulceration progresses under the scabs, and the affection is liable, at any mo- ment, to assume the deep, or pha- gedaenic form, which was known to the older writers as noli-me-tangere. The phagedenic lupous ulcer is a very painful affection, attended with great destruction of tissue, and accompanied with a fetid dis- charge. Under its influence, the greater part of the nose may melt away, as it were, in the course of a few weeks, and it is to be ob- served, that when the ulcer has reached the level of the rest of the face, it may become at least tempo- rarily arrested. The affection rarely proves fatal by itself, and cicatri- zation may occur, adding to the deformity caused by the disease,'by inducing contraction and distortion of neighboring parts. The treat- ment of the superficial form consists in the administration of arsenic and cod-liver oil, and in the local use of a solution of nitrate of silver, diluted tincture of iodine, or dilute citrine ointment. The phagedseriic variety requires the application of caustics, or of the actual or electric cautery, together with the constitutional treatment already recommended. Excision may be resorted to in certain situations, as the upper lip, the resulting gap being closed by a plastic operation, if necessaiy. Lupus, complicated with a syphilitic taint, requires the administration of the iodide of potassium. Malignant Diseases of the Skin.—Both cancer and epithelioma may occur primarily in the skin, as was mentioned in speaking of those affections. The treatment consists in excision, or amputation, according to the size and situation of the malignant growth. Fig. 235. Phagedenic lupous ulcer. 500 DISEASES OF AREOLAR TISSUE AND LYMPHATICS. Diseases of the Areolar Tissue. Cellulitis, or Inflammation of the Areolar Tissue, may be circum- scribed or diffused: in the former case it gives rise to an abscess, and in the latter to diffused sup- Fig. 236. puration. When depending upon an erysipelatous taint, it constitutes cellular ery- sipelas [see pp. 383,398]. Elephantiasis Ara- bum, or Arabian Elephanti- asis, may be described as a hypertrophy of the skin and subcutaneous areolar tissue. In its structure, it corre- sponds with the fibro-cellu- lar outgrowths described in Chapter XXYI. It is chiefly seen in the scrotum, and in the lower extremity, where it constitutes the affection known as Barbadoes leg. Its appearances are well shown in the annexed cut (Fig. 236), from a paper by Dr. Isaac Smith, Jr., of Fall River, Mass. This form Elephantiasis Arabum in the lower extremity; Barbadoes leg. Of elephantiasis is closely analogous to the affections known by modern pathologists as Sclerema or Scleroderma, as well as to the curious growth described by Mott as "Pachydermatocele." The treatment consists in the use of pressure, ligation of the main artery of the part, excision, or amputation, according to the circumstances of the particular case (see page 467). Diseases of the Lymphatic System. Angeioleucitis or Lymphangeitis (Inflammation of the Lym- phatic Vessels, or Absorbents) may occur as an idiopathic affection, as a complication of erysipelas, or as the result of the irritation produced by a wound, ulcer, or local inflammation, as in cases of gonorrhcea. Its occurrence is usually preceded or accompanied by marked constitutional disturbance, rigors, and febrile reaction. If the inflamed lymphatics be superficial, their course will be marked by a number of fine lines, which soon coalesce into a band about an inch wide, of a vivid red color, run- ning from the point at which the disease originates, to or beyond the nearest lymphatic glands, which are always themselves inflamed. The line of the absorbents is somewhat doughy, and not very tender, and the limb is usually swollen and often erythematous. If the inflamma- tion affect only the deep lymphatics, the affection of the glands may alone be perceptible. Resolution usually occurs in the course of a week or ten days, though suppuration often takes place in the glands, and sometimes in the lymphatics themselves; the prognosis is favorable, DISEASES OF MUSCLES AND TENDONS. 501 though death may occur from the supervention of erysipelas, pyaemia, or diffuse cellulitis. The only disease with which angeioleucitis is likely to be confounded is phlebitis, from which it may be distinguished by ob- serving that the red line in the latter affection has a dusky hue, and gives a peculiar, cord-like, and knotty sensation to the touch. The local treat- ment consists in the application of nitrate of silver along the line of inflamed lymphatics, so as to blacken without blistering the skin; the limb may then be wrapped in carded cotton. Should suppuration threaten, poultices may be employed, and pus evacuated by early inci- sions. The constitutional treatment consists in the use of saline diapho- retics and anodynes, with or without stimulants, according to the general condition of the patient. If erysipelas occur, the tinct. ferri chloridi may be given in combination with the liq. ainmoniae acetatis. Adenitis, or Inflammation of the Lymphatic Glands, always accom- panies angeioleucitis, but may also occur independently, as the result of transmitted irritation (as in sympathetic bubo),'or of the absorption of morbid matter (as after poisoned wounds, or in chancroidal bubo), or as the result of direct violence, or of over-exertion in walking or otherwise. The so-called bubon d'emblee is, as already mentioned (p. 435), an instance of this form of adenitis. The symptoms of adenitis are those of circumscribed, deep-seated inflammation in general, terminating some- times in resolution, but more often in suppuration, or in chronic indu- ration and hypertrophy. The treatment consists in the use of blisters, nitrate of silver, or tincture of iodine, applied around but not over the inflamed gland, with poultices and early incisions if suppuration ensue, together with the administration of anodyne diaphoretics during the acute stage, and tonics, such as cod-liver oil and iron, especially in the form of the iodide, when the affection assumes a chronic form. The lymphatic glands are affected in Tuberculosis, in Scrofula,'and in Syphilis, and are frequently the seat of various morbid growths, par- ticularly the adenoid, and those of a malignant nature. The treatment appropriate to these various conditions has already been described in the chapters on the several affections referred to. Varicose Lymphatics.—A dilated or varicose condition of the lymphatic vessels has been occasionally met with, and may form a troublesome complication in cases of Arabian Elephantiasis. By sponta- neous rupture, or accidental wound, a fistulous opening maybe formed, through which the lymphatic fluid escapes, constituting the disease known as Lymphorrhea. The treatment consists in the application of caustic, and in the use of pressure. Diseases of Muscles and Tendons. Myositis, or Inflammation of the Muscular Tissue, may occur as a primary affection, as the result of injuiy, etc., or may be secondary, depending upon various lesions of other structures, especially of the bones and joints. Its symptoms and treatment have already been suffi- ciently considered in the chapters on Inflammation in general. Fatty Degeneration of muscle, is a not infrequent sequence of inflammation of the muscular tissue, conjoined with long disuse, and may probably in some cases be dependent on the latter cause alone. In some cases, to which the name of interstitial fatty degeneration has been 502 DISEASES OF MUSCLES AND TENDONS. given, the striated character of the muscular fibre is still preserved, the connecting tissue alone being replaced by oily matter; in other cases the change is more complete^ the whole muscle being converted into a fatty and granular mass (necrobiotic, or intrinsic fatty degeneration). The latter condition appears to depend upon more complete disuse of the muscle than the interstitial form, and is probably incurable. The treat- ment of the milder cases consists in endeavoring to restore, or at least maintain, the nutrition of the part, by passive exercise, frictions, etc. Rigid Contraction of Muscles.—Another consequence of muscu- lar inflammation, especially in persons of a gouty or rheumatic tendency, is rigid contraction of the affected muscle, giving rise to deformity, and often attended with much pain. This is most often seen in the sterno- cleido-mastoid and splenius muscles, the rigid contraction of which causes the affection known as stiff- or wry-neck. The pelvic muscles also often become contracted as a consequence of hip disease. Rigid muscular contraction may likewise result from mere disuse, from long- continued spasm, and from paralysis of opposing muscles. Examples of the two latter conditions are seen in cases of club-foot. When rigid contraction persists for a long time, it is accompanied by atrophy and usually by fatty degeneration of the muscular tissue. The treatment of the inflammatory form of the affection consists in the use of stimulating embrocations, and the administration of anodynes, colchicum, iodide of potassium, etc.; while the more permanent cases require the use of elastic extension, or division of the contracted muscle or its tendon. (See Orthopaedic Surgery.) Ricord and others have described a peculiar form of muscular contraction which is dependent upon syphilis; it is chiefly seen in the biceps, and yields readily to the administration of iodide of potassium. Ossification of Muscle is a rare affection, of which cases have been recorded by Abernethy and Hawkins, and which apparently depends on the coincidence of muscular inflammation with a tendency to excessive bony deposit. The treatment consists in the repeated application of blisters, with the internal use of colchicum, iodide of potassium, etc. Tumors in Muscle.—Yarious forms of tumor occur in muscular tissue, the most important being of the cancerous, fibrous, cystic, and vascular varieties. Cartilaginous and osseous tumors are also met with, but are comparatively rare. Hydatids are occasionally found in muscle. The treatment of these various affections is to be conducted on ordinary surgical principles. Excision usually presents no particular difficulties, and, except in the cases of malignant tumor, may be expected to effect a permanent cure. For the cancerous tumors, unless the case be seen at a very early period,?amputation (if the tumor be suitably situated) offers a better chance than excision, and should in most instances be preferred. If, however, the case be seen at a very early stage, an attempt should be made to preserve the limb, by extirpating the tumor with a wide margin of healthy tissue. If practicable, the plan suggested by Teevan might be adopted, of dissecting out the entire muscle in which the malignant growth was seated. Tenosynovitis, or Inflammation of Tendons and their Sheaths or Thecae (Thecitis), not unfrequently occurs as the result of injury, as well as in cases of gout or rheumatism. The disease is characterized by PARONYCHIA OR WHITLOW. 503 the appearance of a tender, puffy swelling in the course of the affected ten- don, together with a peculiar sensation of fine crackling or dry crepitation, which is best marked when the disease has become chronic. The treatment consists in rest, with the use of stimulating embrocations or blisters. Paronychia or Whitlow (Panaris) consists in inflammation of the flexor tendons and sheaths of the fingers. In the mildest form of the disease, the theca is but slightly, if at all, involved, the inflammation being chiefly confined to the dense subcutaneous tissue of the pulp of the finger, being in fact a mere digital abscess. In the true paronychia, or tendinous whitlow, the theca is principally affected, suppuration often extending in the course of the tendon beneath the palmar fascia (giving rise to palmar abscess), or even to the forearm, involving, per- Fig. 237. haps, the remaining fingers, and causing extensive destruction of parts by sloughing. In the worst form of the disease, or felon, the phalangeal periosteum is involved, often leading to necrosis and exfoli- ation of considerable portions of bone, with destruction of neighbor- ing articulations. The disease com- monly originates from some slight puncture or other injuiy to the ex- Felon. tremity of the finger, and is usually, though not invariably, confined to the palmar surface. Paronychia occa- sionally occurs as an epidemic, without being traceable to any traumatic cause, and is believed by Erichsen to be uniformly of an erysipelatous na- ture. The symptoms are those of deep-seated inflammation, with intense throbbing pain and tenderness, much aggravated by the depending posi- tion, and with considerable constitutional disturbance. Though suppu- ration may occur pretty early in the disease, fluctuation is not very apparent, on account of the density of the intervening tissues. Gan- grene is occasionally, but rarely, met with. The treatment consists in the application of leeches, followed by poul- tices, or by soaking the hand in water as hot as can be borne, together with the internal administration of laxatives and anodyne diaphoretics. If relief do not follow in the course of twenty-four hours, a deep incision should be made on one or both sides of the affected phalanx, so as to relieve tension and evacuate any pus that may be present. The incision should not be made in the centre of the finger, lest the sheath be opened, when the tendon would almost certainly slough; nor too far towards the side, lest the digital artery be wounded. The incision should be made from above downwards, so that, if the patient withdraw his hand sud- denly, he may rather assist than hinder the completion of the operation. If suppuration extend along the sheath of the tendon towards the palm, the surgeon must follow it up with free incisions, repeated as often as necessary. The strength of the patient must be, at the same time, sustained by the administration of tonics, concentrated food, and stim- ulus. If necrosis occur, the sequestra must be extracted as soon as they are loosened—partial or complete amputation of a finger being occasionally required, though excision of the phalangeal articulations may sometimes be advantageously substituted. By unremitting care and attention on the part of the surgeon, a hand may often be preserved 504 DISEASES OF MUSCLES AND TENDONS. which will prove quite useful, though somewhat stiff and deformed; but occasionally the destructive process continues in spite of treatment, involving the wrist, and eventually requiring removal of the limb. During the whole after-treatment of a whitlow, the hand should be sup- ported on a broad splint, to keep the parts at rest and prevent contrac- tion of the fingers. Some surgeons endeavor to abort whitlow by the application of blis- ters, tincture of iodine, or nitrate of silver; the plan may occasionally succeed, but, if it fail, cannot but aggravate the affection. Ganglion.—A ganglion is a synovial cyst, developed in connection with the sheath of a tendon. Erichsen distinguishes two varieties, the simple ganglion, which is found on the tendinous sheath, and the com- pound ganglion, which consists of a dilatation of the sheath itself, and which often involves several adjacent tendons. Ganglia vary in size from a third of an inch to two or more inches in diameter, that of the simple ganglion rarely exceeding three-fourths of an inch. Their shape is round or oval, and they con- Fig. 238. tain a clear fluid, varying in consistence from that of se- rum to that of honey, mingled sometimes with irregularly- shaped, melon-seed-like bo- dies; these are formed of a compact connective sub- stance, and appear to have become separated from the lining wall of the sheath, which is itself often fringed and vascular. Ganglia occur chiefly in connection with the extensor tendons on the back of the hand or wrist, or on the dorsum of the foot, though they are also seen in the palm, extending beneath the annular ligament, or on the side or sole of the foot. ■ They occasion, in some cases, compound ganglion. a good deal of pain by press- ing on adjacent nerves, and sometimes interfere considerably with the motion of the tendons on which they are seated. The presence of the melon-seed-like bodies may be recognized by the occurrence of a peculiar grating or creaking sound on manipulation. The treatment of the smaller ganglia may consist in rupture by forcible compression with the thumbs; or by a sudden blow, as with a book; or in puncture, and subsequent compression. If these means fail, the interior of the cyst may be scarified, after puncture, with the point of a knife; or iodine may be injected; or a seton established. Excision is attended with a good deal of risk—diffuse inflammation sometimes ensuing—and should therefore be employed with hesitation. For the larger ganglia, and especially those beneath the annular ligament of the wrist, repeated blisters may be employed, in hope of inducing con- solidation; or recourse may be had to iodine injection, or to the seton. If suppuration occur, the cyst must be opened, the melon-seed-like bodies DISEASES OF BUESJ1. 505 evacuated, if there be any present, and the wound allowed to heal bv granulation. Excision may be required if the ganglion be of large size and with semi-solid contents. Diseases of Bursae. Synovial bursse exist normally in certain situations, and may be ad- ventitiously developed by continued friction or pressure in other lo- calities. The most important bursas, in a surgical point of view, are that between the hyoid bone and thyroid cartilage, and those over the acro- mion, the condyles of the humerus, the olecranon, the styloid processes of the radius and ulna, the tuber ischii, the trochanter major, the anterior superior spinous process of the ilium, the patella, the femoral condyles, the tuberosity of the tibia, the malleoli, the heel, and the heads of the first and last metatarsal bones. Bursse are also met with beneath the deltoid and gluteus maxim us, between the point of the scapula and the edge of the latissimus dorsi, and in the popliteal space. Bursitis, or Acute Inflammation of a Synovial Bursa, is most fre- quently seen in the bursa patellae, constituting a variety of the disease ordinarily known as "Housemaid's Knee," from the fact that women who constantly kneel in scrubbing are peculiarly exposed to the affection. Similarly the enlargement of the bursa over the olecranon is known as ^Miner's Elbow." Acute inflammation of a bursa is attended with much pain and considerable constitutional disturbance. The swelling is superfi- cial, and in the case of the bursa patellse above the bone—a diagnostic point of some importance, as in inflammation of the joint the patella is floated up by the articular effusion. The treatment consists in the enforcement of rest, with the application of a,suitable splint, a few leeches perhaps, evaporating lotions—or poultices and warm fomentations, if more agree- able to the patient—together with the administration of anodyne and sedative diaphoretics. If suppuration occur, a free and early opening must be made, and the case treated as one of abscess. If the incision be delayed, the pus Fig. 239. may diffuse itself somewhat widely around the part, necessitating numerous counter-openings. Caries of the patella is an occasional sequence of housemaid's knee, requiring the use of the gouge to remove the diseased bone. Sloughing of the bursa may likewise sometimes occur, leav- ing a large ulcer, which slowly heals by granu- lation. Simple Enlargement or Dropsy of a Bursa (Hygroma) may result from subacute inflammation, or simply from long-continued pressure. This condition in the bursa patellse constitutes the true housemaid's knee, and some- times causes considerable inconvenience by the bulk of the swelling. The fluid in these enlarged bursse maybe of the ordinary synovial character, or may be of a darker hue, containing chole- stearine and disintegrated blood, when it is not unfrequently mixed with numerous rice-like or melon-seed-shaped bodies such as have been Enlarged bursa over the pa. tella, the result of pressure; housemaid's knee. 506 DISEASES OF BURSAE. described as occurring in compound ganglia, and which appear to con- sist of imperfectly developed connective tissue, formed originally upon the lining wall of the bursa, and subsequently separated by the friction and constant motion to which the part is subjected. The treatment con- sists in the application of discutients, such as iodine or blisters; or in tapping, followed by the injection of iodine; or by the establishment of Fig. 240. Formation of seton with trocar and canula. a seton—the thread being passed through the canula as in Fig. 240. If the bursa contains the rice-like bodies above referred to, they must be evacuated through a tolerably free incision, when the seton may be passed as before. Solid Enlargement of a Bursa is caused by the gradual deposit of organized lymph in the interior of the sac, previously filled with fluid, until the whole or nearly the whole of the cavity is obliterated. A bursa, when cut open under these circumstances, presents a laminated appearance, such as is seen in a partially consolidated aneurism. In some cases, according to Erichsen, the tumor is solid from the first, fibroid matter being primarily deposited in the bursa. The treatment consists in the use of sorbefacient remedies, or, if these fail, in excision—taking care not to injure any neighboring articulation, and, in the case of the bursa patellse, not to open the deep fascia which is attached to that bone, lest the structures of the ham should become involved in suppuration. Bunion.—The term bunion is applied to an enlarged bursa occurring in any part of the foot, the most usual seat of the affection being at the side of, or below the metatarsal joint of the great toe. Bunions appear to be caused by distortion of the foot from wearing narrow-soled and high-heeled shoes, by which the weight of the body is thrown forwards, while the toes are crowded together. The distortion consists in the great toe being thrust outwards (Fig. 241), by which means its meta- tarsal joint becomes prominent—a large corn usually forming over the projection, and either the normal bursa of the part, or one adventi- tiously developed, becoming enlarged and painful. The bunion is liable to repeated attacks of inflammation, and suppuration may occur, leading perhaps to the formation of a fistulous ulcer, accompanied by a carious condition of the bone, and disorganization of the joint, constituting the " perforating ulcer of the foot" of French writers. The treatment con- sists in the use of poultices or fomentations, followed by the application of nitrate of silver, to subdue inflammation, together with means adapted to restore the toe to its proper place. This may be best ac- complished by the use of Bigg's apparatus (the action of which may be SURGICAL DISEASES OF THE NERVOUS SYSTEM. 507 seen from Fig. 242); or, in more severe cases, by dividing subcutaneously the external lateral ligament of the metatarso-phalangeal joint, or the tendons of the adductor or flexor brevis pollicis. In mild cases, it may be sufficient to protect the part by the application of two or three thick- Fig. 241. Fig. 242. Bunion. Apparatus for the treatment of bunion. nesses of soap plaster, cut into a horseshoe form, as recommended by Brodie, and by the adaptation of a loose and well-fitting shoe. If the bunion contains fluid, and is uninflamed, attempts to promote absorp- tion may be made by applying an ointment of the red iodide of mercury (gr. x-§j), which is highly commended by T. Smith. If this fail, sub- cutaneous puncture and discission of the sac, followed by the external use of iodine, may be tried, and is, according to Gross, as satisfactory, as it is certainly a safer method, than excision, or incision with cauteri- zation. If suppuration occur, the bunion must be opened, and treated as an abscess. If caries and articular disorganization follow, amputa- tion through the metatarsal bone may be required, and will, I think, in this position, usually be preferable to excision of the joint—though the latter operation has been performed with good results by Kramer, Pan- coast, and several other surgeons. CHAPTER XXYIII. SURGICAL DISEASES OF THE NERVOUS SYSTEM. The affections of the nervous system which specially demand atten- tion from the surgeon, are Neuritis, Neuroma, Neuralgia, and Tetanus. Neuritis. Neuritis, or inflammation of a nerve, may occur as a consequence of rheumatism, etc., from exposure to cold, or from wounds or other inju- ries. The chief symptoms are pain, extending downwards in the course 508 SURGICAL DISEASES OF THE NERVOUS SYSTEM. of distribution of the nerve and aggravated by pressure, with general febrile disturbance. The line of the nerve is sometimes reddened and swollen, and there may be spasmodic jerking of the muscles of the part, with various reflex phenomena manifested in other portions of the body. The pathological appearances are swelling and increased vascularity of the neurilemma, with softening of the nervous structure itself. The treatment, in the acute stage, consists in the use of local depletion, with anodyne and emollient fomentations, together with laxatives and dia- phoretics, if there be much fever. Hypodermic injections of morphia may be employed if the pain be very intense. Colchicum may be used in cases of rheumatic origin, and iodide of potassium, quinia, etc., with counter-irritation, in those of a subacute or chronic character. Fig. 243. Neuroma. Neuromata are tumors developed on or between the fasciculi of a nerve. They are usually fibrous tumors, though a few appear to belong to the fibro-cellular variety, a few also contain- ing cysts. Billroth," and other modern pathologists, divide neuromata into the true and false, the latter being the fibrous or fibro-cellular growths com- monly found in connection with the nerves, while the former, or true neuro- mata, are "composed entirely of nerve filaments, especially of those with double contours; they appear to come only on nerves, and are very rare." Billroth is disposed to regard the " amyaline neuromata" of Virchow as really false neuromata, or, in other words, as fibrous tumors. Neuromata are almost exclusively confined to.the nerves of the cerebro- spinal system, are most common in the male sex, and grow slowly, sometimes attaining a very large size; they are commonly multiple, not less than 1200 sometimes coexisting, according to R. W. Smith, in the same patient. A neuroma is movable transversely, but not longitudinally on the nerve upon which it is developed. Neuromata may arise sponta- neously, or as the result of injuiy; they may occur in the continuity of a nerve, or at its cut extremity, as is seen in stumps after amputation (see page 106). They are often but not always painful, the pain being usually of a paroxysmal character, and sometimes excited only by pres- sure. In idiopathic neuroma, the pain is referred almost exclusively to the peripheral distribution of the nerve, but in traumatic cases, is fre- quently felt in other parts, as a reflex phenomenon. When present in very large numbers, neuromata are, fortunately, usually painless. The painful subcutaneous tubercle is believed by many writers to be a " true neuroma" (see page 477). It is advised by Brown-Sequard, that, in ex- amining a neuroma, the nerve should be firmly compressed above the tumor, so as to diminish the pain caused by the necessary manipulations. The treatment consists in extirpation of the tumor, which should, if pos- sible, be dissected from the nerve without dividing the latter; for the treatment of neuromata in stumps, see page 106. In cases of multiple Section of a neuroma; three nervous trunks terminating in it. The fibrous ar- rangement shown", as observed by the naked eye. NEURALGIA. 509 neuromata, operative interference can seldom be justifiable, but under such circumstances the hypodermic use of morphia may be resorted to as a palliative measure. Neuralgia. Neuralgia is an affection of the nervous system, characterized by intense pain of a paroxysmal form, usually referred to the course of particular nerves. Any discussion as to the nature and pathology of neuralgia in general, would be out of place in a work such as this, and I shall there- fore consider merely those forms of the disease which come particularly under the notice of the surgeon. Neuralgia occurs usually in persons who are debilitated, and is predisposed to by various depressing causes, such as exposure to miasmatic influence, etc. It frequently coexists with hysteria, and not seldom with anaemia. It maybe excited by some source of local irritation, as a decayed tooth, piece of necrosed bone, or exostosis, or may be a reflex phenomenon from irritation of another part, as in the toothache of pregnancy. The pain of neuralgia may follow accurately the course and distribution of a nerve, or may be felt over a considerable extent of surface, or in particular organs, such as the breasts, testes, or articulations—as in the cases of so-called " hysterical knee-joint." The pain may begin suddenly, or may come on gradually, and is, in different cases, of every variety of character and intensity; it is always paroxysmal, and often absolutely intermittent, and is uniformly aggravated by the supervention of any additional source of depression. There are almost always tender spots (points douloureux) in the course of the affected nerve, particularly where it penetrates a fascia, or emerges from a bony canal, and very constantly there is tenderness over the spinous processes of those vertebrse which correspond to the part of the spinal cord whence the nerve originates. Another peculiarity of neu- ralgic pain is that it is almost always unilateral. Neuralgia is some- times accompanied with spasm of the muscles supplied by the affected nerve; in other cases the surface becomes red, hot, and even slightly swollen, and there is often an increased secretion from " neighboring glands, as the salivary or lachrymal. Though any part of the body may be affected by neuralgia, its most frequent seats are the branches of the fifth pair of cerebral nerves, and the great sciatic; in the former situation it constitutes the disease known as " tic douloureux." The diagnosis is usually sufficiently easy: from inflammatory pain, neuralgia may be distinguished by its paroxysmal character, by the ab- sence of fever, by the superficial nature of the pain (often accompanied with marked cutaneous hypersesthesia), and by its being relieved rather than aggravated by pressure; if, however, as sometimes happens, neu- ralgia coexist with deep-seated inflammation, it may be extremely difficult to decide how much of the pain felt is to be attributed to one, and how much to the other affection. In cases of neuralgia affecting the joints, the diagnosis may be assisted by remembering that organic disease cannot long exist in an articulation without causing deformity or other physical alteration. The prognosis of neuralgia, as regards life, is usually favorable: the disease, however, is often very intractable, and may cause so much suffering as to render existence almost insupportable. The treatment must be both general and local. As the disease is almost always accompanied by debility, tonics are usually required: having first cleared out the bowels by means of a cathartic, the surgeon may begin at once the use of quinia, in doses of four grains, three or 510 SURGICAL DISEASES OF THE NERVOUS SYSTEM. four times a day; this drug, though particularly serviceable in cases of malarial origin, is adapted to all cases of neuralgia in which the par- oxysmal element is marked. Arsenic is another remedy of great value, and may be given in the form of arsenious acid, or of Fowler's solution. Iron is particularly adapted to anaemic cases, and valerianate of zinc, and assafcetida to those which are complicated with hysteria. Advan- tage may often be derived from sea-bathing, or from the systematic em- ployment of electricity, the cold douche, etc. In cases in which there is nocturnal exacerbation, the iodide of potassium is found a valuable remedy. The local treatment consists in the application of sedatives or counter-irritants, and, in certain cases, in excision of a portion of the affected nerve. Chloroform and aconite liniments, and the veratria ointment, are among the most useful applications, but the hypodermic injection of morphia is unquestionably the most powerful means we possess for controlling neuralgic pain: from eight to fifteen minims of Magendie's solution may be used at a time, the injection being re- peated in the course of three or four hours if the pain is not relieved. Advantage may be sometimes derived from the simultaneous adminis- tration, by the hypodermic method, of morphia and atropia. A quarter of a grain of the former with a thirtieth of a grain of the latter may be used, great care being exercised lest a poisonous effect be induced. Excision of a Portion of the Affected Nerve has been not unfrequently practised in cases of neuralgia affecting branches of the fifth pair, and occasionally with the happiest results. In many cases, however, the relief has proved but temporary, the pain recurring after an interval of a few weeks or months, in the same' or another branch. The Infra- orbital and Mental Nerves may be reached by simply cutting clown at their points of exit from the infra-orbital or mental foramina, the nerves being then isolated and a portion excised. The Inferior Dental Nerve may be reached by raising a semilunar flap from over the ramus of the lower jaw, and exposing the dental canal by means of a trephine; the nerve is then picked up with a blunt hook or director, and a portion of it excised. Prof. Gross has, by repeated applications of the trephine, succeeded in exposing and removing the whole extent of the nerve, from its entrance into the inferior dental canal to its exit at the chin—the por- tions of nerve thus exsected varying in length, in different cases, from two and a half to three inches, and the operation having been apparently followed by the best results. The Superior Maxillary Nerve may be reached, close to the foramen rotundum, by means of a Y-shaped or simple curved incision, both walls of the antrum being cut away with the tre-.^ phine, and the lower wall of the infra-orbital canal with cutting-pliers and'' chisels. The nerve being separated from the other tissues in the spheno- maxillary fossa, and traced beyond the Ganglion of Meckel, is divided from below upwards with blunt-pointed curved scissors. This bold and severe operation, which was introduced by Carnochan, of New York, has been at least temporarily successful in several instances; but that he relief is not permanent, would appear from the researches of Conner, of Cincinnati, who has collected thirteen cases, in seven of which the pain is Jtnown to have recurred, while in only two of the remainder was the subsequent history of the patient traced for more than a year. If the neuralgia arise from peripheral irritation, so that the affected portion of the nerve can be removed, an operation such as those which have been described, may probably suffice for a cure; if, however, the disease be of central origin, it is obvious that no operation could be of permanent benefit. It is almost needless to say that if the neuralgia TETANUS. 511 appear to depend upon the irritation caused by a decayed tooth, or by a spicula of necrosed bone, the effect of removing this should be tried before proceeding to any graver operation. Prof. Gross has recently described a form of neuralgia depending upon a morbid condition of the alveolus, and curable by removing that part with cutting-forceps. Tetanus. Tetanus is a disease of the nervous system, characterized by per- sistent tonic contraction of some or all of the voluntary muscles. In the large majority of cases tetanus results from a wound or is traumatic, though it is also met with (especially in warm climates) as an idiopathic affection. Tetanus occurs in both sexes and at all ages; excluding, however, cases of Tetanus Nascentium, and of Puerperal Tetanus, it is by far most common in males in early adult life, though, probably, not dis- proportionately so, in view of the peculiar liability of these to be exposed to traumatic lesions. It occasionally occurs as an epidemic, and appears to be predisposed to by hot weather and by sudden changes of tempera- ture. It is more frequent in the negro than in the white. Traumatic tetanus is the form of the disease which particularly demands the sur- geon's attention. It may follow upon a mere contusion, such as the stroke of a whip, but is chiefly seen after punctured or lacerated wounds, or after burns and scalds; the extent of the wound appears to have no causative influence, the slightest, being as often followed by tetanus, as the most extensive injuries. It may occur after any surgical operation, without regard to its severity. Tetanus is more frequently met with in military, than in civil practice, the proportion of cases in the Peninsular war having been 1 of tetanus to 200 wounded, in the Crimean war 1 to 500, in the Schleswig-Holstein campaign 1 to 350, and in our late war 1 to 242.1 Exposure of the wounded to severe cold, and more particularly a sudden change from heat to cold, has been found a prolific source of tetanus in military surgery. The disease is apt to occur in those who are depressed or debilitated; it thus seems occasionally to follow in the wake of secondary hemorrhage. Varieties.—Several varieties of tetanus have been distinguished, according to the group of muscles affected: thus, Trismus, or Lock-jaw, refers to the clenching of the teeth, from tonic spasm of the muscles of mastication; Opisthotonos, to spasm of the muscles of the back, the pa- tient with arched body resting merely on head and heels; Emprosthotonos (very rare), to a similar arching of the body in a forward direction; and right or left Pleurosthotonos, to a similar bending to one or the other side. Tetanus may occur very soon, even less than an hour, after the reception of a wound, or not for several weeks; usually, in temperate climates, from the fifth to the tenth day. The earlier the disease is developed, the more likely is it to prove fatal, cases occurring after the third week offering a comparatively favorable prognosis. Acute tetanus is much more fatal than the chronic form of the disease; of 327 cases of death from tetanus, analyzed by Poland, 79 occurred within two days, 104 from two to five days, 90 from five to ten days, 43 from ten to twenty-two days, and 11 after twenty-two days. The most rapid death occurred in from four to five hours, while the longest duration of a fatal case was thirty-nine days. 1 363 cases to 87,822 wounded. (Circular No. 6, S. G. O., 1865, p. 6.) 512 SURGICAL DISEASES OF THE NERVOUS SYSTEM. Symptoms.—The symptoms of tetanus may come on suddenly, or may be gradually and insidiously developed; occasionally a feeling of general discomfort precedes for some time the characteristic manifesta- tions of the disease, or there may be gastric and intestinal derangement, or the wound (if it have not healed) may become dry and unhealthy- looking. The first decided symptom is commonly a feeling of stiffness, with pain on motion, affecting the muscles of the lower jaw and tongue, and those of the back of the neck; in other cases, however, the cramps are first manifested in the muscles of the wounded limb. In a short time, great difficulty in chewing or swallowing is felt, and trismus soon becomes fully developed, with intense pain and slight tendency to opis- thotonos; violent pain reaching from the precordial region to the spine, and doubtless due to spasm of the diaphragm, is now experienced, and forms a very characteristic symptom of the disease; the abdominal muscles become tense, hard, and board-like, and all the voluntary muscles, except those of the hand, eyeball, and tongue, become more or less involved. The countenance assumes a peculiar, old-looking expression, being pale, anxious, and distorted into the so-called risus sardonicus or tetanic grin. This distortion of face sometimes persists after recovery, and Poland refers to a case in which it was still apparent after eleven years. During the height of the disease, the body is often arched back- wards, so that the patient is supported merely by his occiput and heels; while the muscular spasm is tonic, and never entirely disappears, it is paroxysmally aggravated—and the cramps are occasionally so violent as almost to hurl the patient from his bed; the pain is greatest during the cramps, which are also accompanied by profuse perspiration and great heat of skin (105°-110°.75 Fahr., according to Dr. Radcliffe).1 As the disease advances, the reflex excitability is much increased, the slightest touch or the least current of air being sometimes enough to bring on a paroxysm of cramp. Dyspnoea and want of sleep combine to render the condition of the patient still more deplorable. There is no delirium, and little or no fever, the heat of the skin being chiefly confined to the paroxysms, and the rapidity of the pulse being due to exhaustion rather than to febrile disturbance. Among the symptoms of less importance are constipation, retention of urine, priapism (pro- bably due to spinal meningitis), aphonia, accumulation in the mouth and fauces of viscid saliva, self-inflicted lacerations of the tongue or cheek, and permanently dilated or contracted pupils. Death may occur in a paroxysm, from apnoea; or at a later period, from simple exhaustion. There may be a certain degree of muscular relaxation previous to death, or tetanic rigidity may be, as it were, directly transformed into rigor mortis. Pathology.—The pathology of tetanus is involved in much obscu- rity. I have called it a disease of the nervous system, because it is through the medium of the nerves and spinal cord that its phenomena are manifested, and because the nervous system alone has as yet been found to present post-mortem changes with sufficient constancy to be considered significant. It is, however, quite possible that, as suggested 1 The temperature may continue to rise even after death; thus, in a case recorded by Wunderlich, the thermometer marked 108° before death, 112°.5 at the time of death, and 113°.5 a short time subsequently. Dr. Ogle, of London, and Dr. Keen, of this city, have recorded cases in which the evening, was higher than the morning temperature. PATHOLOGY OF TETANUS. 513 by Dr. Richardson, tetanus may eventually prove to be a blood disease, due to the absorption of some septic material. The nerve or nerves, in the immediate neighborhood of the wound, are commonly, though not invariably, found to be inflamed, lacerated, or contused, and it is at least possible that, even in those cases in which the nerves appear healthy, they may have been temporarily diseased, and that a nerve lesion has been really the starting-point of the affection. The most important post-mortem changes of tetanus are found in the spinal cord, and have been particularly investigated by Lockhart Clarke and Dickinson. The former writer ascertained, from an examination of six specimens, that there were, in several portions of the cord, marked patches of softening and disintegration affecting the gray matter, the cord itself being altered in shape. The structural change varied from mere granular softening to absolute fluidity, and was accompanied by numerous extravasations of blood. " In the walls of the bloodvessels, there was no morbid de- posit nor any appreciable alteration of structure, except where they shared in the disintegration of the part to which they belonged; but the arteries were frequently dilated at short intervals, and in many places were seen to be surrounded ... by granular and other exudations, be- yond and amongst which the nerve-tissue . . . had suffered disintegration. We have reason, therefore, to infer that the lesions of structure had their origin in a morbid condition of the bloodvessels, resulting in exu- dations with impairment of the nutritive process."1 The following are Mr. Clarke's conclusions as to the pathology of te- tanus : (1) it is probable that these lesions are not present in cases which recover, or, if present, are so in but a slight degree; (2) these lesions are not the effect of excessive functional activity of the cord, but result from a morbid state of the bloodvessels; (3) these lesions are not the sole cause of the tetanic spasms, as similar lesions exist in cases of paralysis unaccompanied by tetanus; and (4) the tetanic spasms de- pend, first, on an abnormally excitable state of the gray nerve-tissue of the cord, induced by the hypersemic and morbid state of its blood- vessels, with the exudations and disintegrations resulting therefrom (this state of the cord being either an extension of a similar state along the injured nerves from the periphery, or resulting from reflex action on its bloodvessels excited by those nerves), and secondly, on the persistent irritation of the peripheral nerves, by which the exalted excitability of the cord is aroused—the same cause thus first inducing the morbid sus- ceptibility of the cord to reflex action, and subsequently furnishing the irritation by which reflex action is excited. Dr. Dickinson's3 observations tend to confirm those of Mr. Clarke, and add the interesting fact that the situations of the various lesions cor- respond anatomically with the side on which the injury exists. "The irritation from the left hand, conveyed, as we must suppose, by certain of the left posterior roots, occasioned especial congestion of the left posterior horn, and further changes in the white matter in contact with it—that is, in the left posterior and lateral columns. The central and anterior parts of the gray matter were most extensively affected on the side opposite to that of the injury, as might have been anticipated from the decussation in the cord of the sensory fibres. The irritation having reached any column or segment of the cord, appeared to diffuse itself throughout its whole length with undiminished intensity. Although the 1 Med.-Chir. Trans., vol. xlviii., p. 264. 2 Ibid., vol. Ii., pp. 265-275. 33 514 SURGICAL DISEASES OF THE NERVOUS SYSTEM. cervical region must have been the first recipient of the morbid influ- ence, the lumbar part of the cord, both in the white and gray matter, was at least as severely affected." Diagnosis.—Tetanus may be distinguished from spinal meningitis, by the early fixation of the jaw, and by the occurrence of paroxysmal spasms, with permanent muscular rigidity in the intervals—the rigidity of spinal meningitis being, in a great degree, voluntarily assumed in order to prevent the pain of motion. From hydrophobia, the diagnosis may be made by observing that, in the latter disease, the spasmodic movements are clonic, not tonic, that the face is convulsed and restless (no risus sardonicus), and that delirium is as common as it is rare in tetanus. From poisoning by strychnia, the diagnosis is sometimes very difficult, particularly if comparatively small quantities of that drug have been re- peatedly administered. It is to be observed, however, that in strychnia- poisoning there may be complete intermissions between the paroxysms, and that (according to Poland) there is spasm of the muscles of respi- ration, with early and marked laryngismus, but no fixation of the jaw— the patient being able to open the mouth and swallow. Tetanus has been mistaken for rheumatism, and, on the other hand, hysteria has not unfrequently been mistaken for tetanus; the diagnosis could, however, scarcely be very difficult, unless (as in a case mentioned by Copland) tetanus and hysteria actually coexisted in the same patient. Prognosis.—The prognosis of acute tetanus is invariably unfavor- able. It is doubtful whether there be any authentic case of recovery under such circumstances. In the subacute or chronic cases, the disease being developed at a comparatively late period, and running a less vio- lent course, there is more hope of a successful issue, and by prompt treatment life may occasionally be preserved. Treatment.—This should be both general and local. The General Treatment should consist in the administration of such remedies as may diminish the morbid excitability of the spinal cord, and at the same time lessen the irritation of the peripheral nerves—it being probably to a com- bination of these two elements, that the production of the tetanic spasm is due. At the same time, concentrated nutriment in a fluid form should be given as freely as practicable, for death frequently results, as has been seen, from pure exhaustion. The modes of treatment which have been proposed for tetanus are almost countless,including such diverse remedies as venesection, active stimulation, profuse purgation, and the induction of narcotism with opium. All means fail in acute cases—each has been occasionally successful in those of the chronic variety. The drugs which have obtained most reputation of late years, have been opium, conium,1 cannabis Indica, woorara, hydrate of chloral, and the Calabar bean. Of these the first and the last are those upon which I should, at present, be disposed to place most reliance, and of which I would therefore re- commend the employment. Eighteen cases collected by Dr. Eben Wat- son, in which the Calabar bean was used, gave ten recoveries and eight deaths; upon the whole, a favorable record. The bean may be given in large doses (Holthouse gave 4£ grains of the extract at once, the patient recovering), the only limit to its administration being the effect pro- 1 Hypodermic injections of conia have lately been used with some success by Prof. C. Johnston, of Maryland (Am. Journ. of Med. Sciences, July, 1870, p. 112). DISEASES OF VEINS. 515 duced in controlling the spasms. It appears to act as a direct sedative to the spinal cord, and it has the additional advantage that it enables the patient while under its influence to take food with facility. It may be given by the mouth or rectum, or by hypodermic injection, a third of a grain of the extract being probably a large enough dose for the latter mode of administration. Opium in large doses may be properly given at the same time, as suggested by Holthouse, on account of its well- known sedative effect upon the peripheral nerves. A cathartic may ' sometimes be required at the beginning of the treatment, to remove any irritating matters from the bowels, and concentrated food and stimu- lus must be given, throughout the case, in as large quantities as the patient can be induced to take. The inhalation of ether or chloroform may be occasionally resorted to with temporary benefit, and the application of an ice-bag to the spine might be tried, though its use should be watched, lest it induce too great depression. The Local Treatment is likewise of importance: the wound should be explored, and any foreign bodies carefully removed. The afferent nerve or nerves (if any can be recognized) should be divided or partially ex- cised, or, if the operation be otherwise indicated, amputation may be per- formed, if a limb be the seat of injury. Though section of the nerve will promise best if resorted to at an early period, it should not be neglected even at a later stage of the case. If no special nerve-lesion can be detected, a \ incision down to the bone may be made, as advised by Lis- ton and Erichsen, so as to insulate the part. The wound itself should be dressed with narcotics—particularly opium, in the form of laudanum, or a solution of sulphate of morphia (gr. v-fij), or, if the wound is sloughing, powdered opium with charcoal Qj-3j)—and in cases of burn or scald, this will often be the only local treatment which can be em- ployed. The application of atropia, to the end of the divided nerve, or by hypodermic injection, has occasionally been found useful. If the wound were already healed, it would be proper to dissect out the cicatrix, as the entanglement of a nerve filament in the scar might prove to have been the starting-point of the disease. During the whole course of treatment, the patient should be kept in a rather dark, warm, and dry room, and should be carefully guarded from currents of air. CHAPTEE XXIX. SURGICAL DISEASES OF THE VASCULAR SYSTEM. Diseases op Veins. Phlebitis.—Phlebitis, or Inflammation of a Vein, may result from injuiy, or from the absorption of septic material. It is probably (as mentioned at page 170) by means of local inflammatory changes, in conjunction with coagulation of the contained blood, that veins are re- paired after division or rupture; and this clotting or thrombosis of the venous contents, is the most important element in connection with inflammation of a vein. It may be either a primary or a secondary phenomenon, either the cause or the consequence of the changes in the 516 SURGICAL DISEASES OF THE VASCULAR SYSTEM. venous coats, to which the term phlebitis is applied; thus the phlebitis of pysemia, and that seen after parturition (phlegmasia dolens), are the results of previous venous coagulation, while in many cases of lacerated wound, fracture, etc., the changes in the venous walls probably precede the formation of a clot. It is in the outer coats of a vein, according to II. Lee,1 who has particularly investigated the subject, that the changes of phlebitis are chiefly found. The cellular coat becomes preternatu- rally vascular and reddened, and is at the same time distended with serum, lymph, or pus, either separately or commingled. The circular fibrous coat is similarly affected, but in a less degree, becoming injected and thickened. The inner coat loses its normal transparency, becoming wrinkled or fissured, of a dull whitish color, and more or less stained by the venous contents, its hue varying with that of the contained coagulum. The inner and outer coats of an inflamed vein may be sepa- rated by the products of inflammation, the various layers of the inner coat becoming disintegrated, or flakes of its lining membrane being cast off into the interior of the vessel. Phlebitis destroys the natural plia- bility of the venous coats, so that when divided, an inflamed vein remains patulous like an artery. The formation of a clot in an inflamed vein, is obviously designed by nature to prevent the entrance of morbid materials into the general cir- culation, and hence, when the clot is well formed, and in a healthy person, the disease is local and unattended with any particular danger. The clot undergoes changes, becoming partially organized, and converting the vessel into a fibro-cellular cord ; or may contract so as to allow the partial resumption of the circulation; or may perhaps undergo a slow process of solution, and ultimately entirely disappear. Under other circumstances, the result is not so favorable: a large fragment of clot may become mechanically loosened and dislodged, and, being carried into the general circulation, may plug an important vessel (embolism), occasionally even causing a fatal termination, as has happened in cases of phlegmasia dolens; or, if the blood be in an unhealthy condition (as in pysemia), and the clot imperfectly formed, disintegration may follow, with capillary embolism, leading to the formation of pyaemic patches, or the so-called metastatic abscesses (see page 406). Symptoms.—An inflamed vein becomes hard, somewhat swollen, pain- ful, and cord-like; it has, besides, a peculiar knobbed feel and appear- ance, the knobs corresponding to the positions of its valves. The course of the vein is marked by a distinct dusky-red line, and the whole limb becomes somewhat stiff, and may be the seat of intense pain, sometimes of an intermittent or neuralgic character. There is always some oedema, along the course of the vein and in the parts below, owing to the ob- structed circulation and the consequent effusion of the fluid portion of the blood. This oedema may be soft, allowing pitting on pressure, or may be hard and tense. If the vein be deep-seated, the occurrence of tumefaction and pain may be the only evidences of phlebitis. The oedema usually subsides with the restoration of the circulation through the natural or collateral channels, though it may persist for a consider- able period. The constitutional disturbance attending phlebitis is rarely of a grave character. The conditions described by many writers as suppurative and diffuse phlebitis appear to be really examples of diffuse inflammation of the areolar tissue, or of cellular erysipelas, which often extend rapidly in the 1 Practical Pathology, vol. i., Lectures II.-IV. VARICOSE VEINS. 517 course of the veins, and which are apt to terminate in pysemia. (See pages 383, 398, 405, and 500.) Diagnosis.—The affection with which phlebitis is most likely to be confounded is angeioleucitis, which, however, may be distinguished by observing the brighter redness which it presents, and its invariable com- plication with adenitis. Deep-seated phlebitis may be mistaken for neuralgia, but the diagnosis may be made by observing that the pain of the latter affection is rather relieved than aggravated by pressure, and is not accompanied by oedema. The latter circumstance may also serve to distinguish inflammation of a vein from neuritis. Prognosis—Phlebitis in itself is rarely attended with risk to life: when, however, inflammation of a vein is a mere concomitant of pysemia, or other grave constitutional condition, the question is very different; and even traumatic phlebitis, occurring in a person who is broken down in health, should be looked upon as a grave affection. Treatment.—In the treatment of phlebitis, all depressing measures should be avoided, the chief risk of the affection being from deteriora- tion of the general health and consequent disintegration of the venous coagulum. If the tongue be heavily coated, with fever and anorexia, half a grain of blue mass with two grains of quinia may be given every two or three hours, until about three grains of the mercurial have been taken, but beyond this, the remedy should not, usually, be pushed. The quinia may be continued, eight or twelve grains being given in the course of twenty-four hours ; and the muriated tincture of iron may be added, in combination with the spirit of Mindererus if the use of a dia- phoretic be indicated. In milder cases, of course, less energetic measures will be required. The diet should be nutritious and easily assimilable, and stimulus may be given or withheld, according to the general condi- tion of the patient, who should be kept in bed and at perfect rest. The local treatment, in mild cases, may consist merely in the use of warm fomentations or evaporating lotions, as most agreeable to the patient; but if the inflammation appear disposed to extend upwards, with severe constitutional disturbance, an effort may be made to prevent its spread by the operation proposed by H. Lee, which consists in acupressing a healthy portion of the vein at two points about three-fourths of an inch apart, and then dividing the vessel subcutaneously between them. The oedema may be relieved by position, by gentle friction, and by the subsequent use of an elastic bandage. Varix, Varicose Vein, or Phlebectasis, consists in a morbid dilatation of a vein, usually accompanied by thickening of its walls. Any veins may become varicose, but those most commonly affected are the veins of the lower extremity, scrotum, and rectum. The varicose condition may be limited to the principal venous trunks of the part, or may affect the subcutaneous venous plexus, giving the appearance of a network of a purple hue. The branches of the internal saphena are most frequently affected among the superficial veins, but it is probable that in the majority of cases the deep vessels are likewise more or less involved. The anatomical conditions of varicose veins vary in different cases: thus, together with the dilatation, there is often elongation, rendering the vessel tortuous; or the walls may be thinned instead of thickened; or the dilatation may be sacculated, forming pouches which generally cor- respond to the points of intercommunication with other veins. The causes of varicose veins are twofold : (1) such as pump into the veins an abnor- mal quantity of blood, as unusual muscular exertion, walking, etc.; and 518 SURGICAL DISEASES OF THE VASCULAR SYSTEM. (2) such as mechanically impede the venous circulation, as the pressure of a tumor, or that of the pregnant uterus. A depressed or feeble state of health appears sometimes to act as a predisposing cause, while in some cases, the occurrence of varicosity has been attributed to the effect of hereditary influence. Any occupation which requires the maintenance of the erect posture, predisposes to varix. Varicose veins are rare in early life, and are rather more frequent in women than in men. The symp- toms of superficial varix are easily recognized, the dilated and tortuous condition of the affected veins being quite characteristic. The patient often has a sensation of weight and fulness in the part, with some numbness, and occasionally loss of power, and frequently a dull, aching pain which is aggravated by exercise. The limb is sometimes oedema- tous. Deep varix is more difficult of recognition, the subjective symp- toms commonly existing for some time before the implication of the superficial veins renders the nature of the disease apparent. Muscular cramps are, according to Mr. Gay, quite significant of a varicose condi- tion of the deeper veins. Varicose veins are liable to be attacked by phlebitis and thrombosis, while inflammation of the surrounding tissues may lead to various troublesome conditions, such as the occurrence of eczema, or of ulceration (giving rise to the varicose ulcer), or to a scle- rematous condition of the part analogous to the Arabian elephantiasis. A varicose vein occasionally gives way by rupture or by ulceration, the accident leading to profuse, or even to fatal hemorrhage. The Treatment of varicose veins may be either palliative or radical, the former being alone proper in the large majority of cases. The Pal- liative Treatment consists in giving support to the part, with gentle and equable pressure, by means of a carefully applied flannel bandage, or an elastic stocking—the general health being maintained by the use of laxatives to prevent constipation, with tonics, especially the muriated tincture of iron, if, as usually happens, the patient be in a feeble and relaxed condition. Hemorrhage from a varicose vein may be checked by elevating the limb and applying a firm compress. The Radical Treat- ment may be employed, if the varicose vein be evidently so altered in Fig. 244. Application of pins to varicose veins. structure as to be useless for carrying on the circulation (particularly if it be also painful), if its coats be so attenuated as to threaten hemorrhage, or if it be connected with an ulcer which cannot be induced to heal. This mode of treatment consists in the obliteration of a portion of the vein, and it is radical as far as that portion is concerned, though ANEURISM BY ANASTOMOSIS. 519 it by no means insures a cure of the general disease, which, indeed, in most instances, must be looked upon as incurable. Various means have been proposed for the obliteration of varicose veins, such as (1) the ap- plication of caustic, so as to form eschars over the line of the vessel; (2) the injection of coagulating agents; (3) the passage of an electric current through the vessel; (4) the subcutaneous section of the vein; (5) its compression at various points by means of a pin passed beneath the vessel, with a compress or piece of bougie above, the two being fast- ened together with a thread, or wire, in the form of a figure-of-8 (Fig. 244); and (6) the application of a metallic ligature. Probably the best plan is that recommended by H. Lee, which consists in (7) securing the vein at two points, about an inch apart, by passing acupressure-needles beneath, but not through the vessel; applying, over.the ends of the needles, elastic bands or figure-of-8 ligatures; and then subcutaneously dividing the vein at an intermediate point. The needles, which are removed in three or four days, serve to approximate, without injuring, the sides of the vein, while obliteration of the vessel takes place at the point of subcu- taneous section, the parts healing in about a week. Vascular Tumors or Angeiomata.1 (Arterial Varix, Aneurism by Anastomosis, Naevus.) Arterial Varix or Cirsoid Aneurism, is a disease which consists in the simultaneous elongation and dilatation of an artery. When, as is frequently the case, the capillary network is also involved, the disease receives the name of Aneurism by Anastomosis or Racemose Aneurism, but the two affections are, in every essential respect, the same. The vessels become tor- tuous, and in parts sacculated, their coats (especially the middle) being thin, and causing the artery to resemble a vein. This affec- tion is most common about the scalp and face, but may occur in other parts, as the tongue, extre- mities, internal viscera, and bones; it is chiefly met with in early adult life, and its development is often attributed to a blow or other in- jury. Aneurism by anastomosis forms a tumor or outgrowth, of variable size and shape, usually of a bluish hue, compressible, and communicating to the touch a spongy or doughy sensation, ac- companied by a whiz or thrill, sometimes amounting to pulsa- tion, and synchronous with the cardiac impulse. This thrill dis- appears when the arteries leading to the tumor (which are them- selves usually dilated and tor- tuous) are compressed, and returns with an expansive pulsation when the pressure is removed. Auscultation gives usually a loud, superficial, Fig. 245. Aneurism by anastomosis. 1 See page 475. 520 SURGICAL DISEASES OF THE VASCULAR SYSTEM. cooing bruit, though occasionally a softer blowing sound. The tempera- ture of the part is somewhat elevated. The diagnosis from ordinary aneurism, may be made by noting the position of the growth (probably at a distance from any large artery), its doughy and compressible cha- racter, and the thrill, rather than distinct pulsation, which accompanies the re-entrance of the blood, when, after compression of the neighbor- ing arteries, the pressure is removed. The bruit is more superficial than that of aneurism, and compression of the arterial trunks does not so completely mask the physical signs of the disease, as in that affection, blood still entering the part from other sources. When occurring in bone, aneurism by anastomosis may be mistaken for encephaloid, with which, indeed, it may coexist. The treatment should vary with the size and position of the growth. Excision or Ligation, in the way which will be described when we come to speak of nsevus, is the mode of treatment to be preferred when the affection is not very extensive, and suitably situated, as on the lip, scalp, Fig. 246. Aneurism by anastomosis of one of the parietal bones. or extremities. If excision be employed, the knife must be carried wide of the disease, in order to avoid profuse, or possibly fatal hemorrhage. If the tumor be too large for ligation or excision, it will usually be pru- dent not to interfere, unless the integument be so thinned as to threaten rupture. When it is decided to operate, several methods are open to the surgeon, the most promising being electro-puncture, the injection of coagulating fluids, and deligation of the main artery of the part. The use of coagulating injections is generally preferred by French surgeons; Broca has reported a case in which, after the failure of acupressure to the nutritive arteries, he effected a cure by injections of perchloride of iron, the passage of the styptic being limited by surrounding the points of injection with rings of lead, and the tumor being attacked in sections by dividing it into lobes by means of tubes of caoutchouc. Heine, from a study of sixty cases, concludes that for small tumors, simple excision is the best remedy, while for those which are larger, preliminary ligation of the carotid or nutrient arteries, and subsequent excision at one or more sittings, are to be preferred. Ligation of the main artery is the plan which has been most frequently employed, particularly when the affection has involved the orbit. In such a case the primitive carotid is the vessel to be tied; but if the disease were limited to the scalp, it might be better to adopt Bruns's suggestion, and tie one or both external NAEVUS. 521 carotids instead. Thirty-one cases of ligation of the«common carotid for erectile tumor, etc., tabulated by Norris, gave eighteen recoveries and eight deaths. In other cases, again, it might be preferable to tie the various arteries in the immediate vicinity of the vascular growth, surrounding the latter at the same time by deep incisions, as was suc- cessfully done by Gibson. The only treatment to be recommended for aneurism by anastomosis occurring in the long bones, is amputation. Naevus is an affection very analogous to the preceding, but differs from it in involving chiefly the capillaries or veins. When congenital, naevus constitutes the so-called mother's mark. 1. Capillary Nsevi, which are commonly, if not always, congenital, occur as flattened elevations, of a red or purple hue, usually upon the face or upper part of the trunk, but occasionally in other situations. They may involve a considerable extent of surface, but rarely give any annoyance except from the attendant deformity. Sometimes, however, they ulcerate and bleed. They consist of a congeries of capillary vessels, and may accompany the aneurism by anastomosis on the one hand, or the venous nsevus on the other. 2. Venous Nasvi occur as prominent tumors or outgrowths, of a reddish- purple hue, smooth or lobated in outline, and somewhat compressible, doughy, and inelastic to the touch ; they are less exclusively confined to the upper part of the body than the capillary nsevi, and, in their struc- ture, consist of thin tortuous and sacculated veins, often interspersed with cysts. Venous naevi may occur subcutaneously, when they form tumors which may be partially emptied by pressure, slowly filling again when the pressure is removed, and becoming distended by violent ex- ertion or struggling on the part of the patient. Treatment.—Cutaneous nsevi which are small and not disposed to spread, may often be left without treatment—when they may disappear spontaneously; and, on the other hand, a nsevus may involve such a large extent of surface as to forbid any attempt at its removal. The shrivelling of small cutaneous nsevi, may sometimes be hastened by the application of tincture of iodine. Moderately large, or subcutaneous, or even small cutaneous nsevi, if they are so placed as to cause disfiguration, may be removed by several methods. Various plans have occasionally proved successful, such as vaccination over the growth, the use of a seton, the introduction of heated wires, electro-puncture, or subcutaneous discission with compression; the best modes of treatment, however, are commonly the application of caustics, the use of coagulating injections, excision, and ligation. (1.) When the nsevus is superficial, and so situated that the presence of a scar will not be particularly objectionable, the application of nitric acid or the Vienna paste may suffice to effect a cure, the application being repeated if there be any tendency to a recurrence of the affection. (2.) Injection of a solution of the perchloride or persulphate of iron, by means of an ordinary hypodermic syringe, maybe employed for small nsevi in certain situations, as the eyelid or orbit, where other modes of treatment would be inapplicable; the quantity injected should be very small (not more than two or three drops at a time), and compression should be made upon the returning veins, lest some of the injected fluid should enter the general circulation, and perhaps cause death. (3.) Excision may be practised when the nsevus is of large size, and in the form of a distinct tumor, the incisions being carried wide of the disease, except when, as occasionally happens, the growth is sur- 522 SURGICAL DISEASES OF THE VASCULAR SYSTEM. rounded by a capsule, and when therefore, as advised by Teale, enuclea- tion may be safely practised. This condition is, according to Erichsen, most common in cases of nsevus associated with fatty or cystic growths. (4.) Ligation is in most instances the best mode of treatment, and may be applied in several ways. If the nsevus be very small, it may be suffi- cient to pass harelip pins in a crucial manner beneath the growth, and throw a ligature around their ends, or a double ligature may be intro- duced, and the nsevus tied in two halves. In other cases the quadruple ligature should be employed. This may be applied by passing beneath the nsevus, two strong needles, eyed at the points, and crossing each other at right angles—the skin over the growth being, if healthy, previ- ously reflected in flaps by means of a crucial incision (Fig. 247). The Fig. 247. Fig. 248. Diagram of tied nsevus. needles may be passed un- armed, the ligatures — which may be of strong silk or whipcord—being in- troduced as they are with- drawn. The nooses are then cut, and an assistant holds six ends firmly, while the surgeon knots the other two, this process being re- peated until the whole nse- vus is strangulated in four Naevus ; application of the quadruple ligature. Sections, as shown in Fig. 248. When the nsevus is flat and elongated, a better plan is that described by Erichsen, which consists in passing a double ligature of whipcord, three yards long and stained black for half its length, in such a way as to have a series of double loops, about nine inches in length, on each side of the tumor (Fig. 249). The black loops being then cut on one side, and the white on the other, the ends are secured as in Fig. 250, so as to strangulate the growth in numerous sections. After either operation, the tumor sloughs, and comes away in a few days, leaving an ulcer which heals by granulation. Various modifications must be adopted, according to the locality of the disease. In dealing with a nsevus over the fontanelle, there might be some risk, if the ordinary needles were used, of punctur- ing the membranes of the brain; and hence in this situation, after incis- ing the skin with a lancet, the ligature should be carried beneath the growth by means of an eyed probe. The scalp is so adherent to a nsevus in the cranial region, that no attempt should usually be made to preserve DISEASES OF ARTERIES. 523 the skin in this locality. For nsevus of the tongue, the use of the ecra- seur may be advantageously substituted for that of the ligature. H. Lee has recently recommended, in cases of vascular tumor of the face and neck, the use of India-rubber thread, instead of the common liga- Fig. 249. Fig. 250. Diagram of ligature of flat and elongated naevus. Diagram of tied flat and elongated nsevus. ture, the elastic contraction of this agent serving to divide the tissues without hemorrhage, and thus effecting rapid and painless removal of the morbid growth. Diseases of Arteries. Arteritis and Arterial Occlusion.—Arteritis, or Inflammation of the Arterial Tunics, may occur as a primary affection, the result of injury or exposure to cold, but in the immense majority of cases is secondary to Arterial Occlusion, the result of thrombosis, or more fre- quently of embolism, the plug being derived from a fibrinous heart-clot. The repair of arteries after division is, as has been already mentioned (p. 176), due to the formation of a clot, together with the union of the cut edges by means of local inflammatory changes. The alterations in the arterial coats produced by inflammation, are analogous to those which we have studied in the walls of a vein, as the result of phlebitis. Thus the external coat and sheath become vascular, pulpy, and distended with the products of inflammation; the middle coat contracted, thickened, and softened; while the inner loses its smoqfch and polished appearance, and becomes pulpy and stained from contact with the coloring matter of the blood. The clot which forms in cases of arteritis, and which indeed, as has been said, is commonly the cause of the arterial inflammation, may consist merely of masses of a fibrinous substance, which do not com- pletely occlude the vessel—or may form a complete plug, usually of a conical form, the lower part of which consists apparently of white blood corpuscles and fibrin, and often adheres to the sides of the artery, while the upper part is of the color of ordinary clotted blood, and projects tail-like into the upper part of the vessel. The symptoms of arterial occlusion consist of acute pain in the course of the affected artery, and in the parts which it supplies, with a feeling of tension, great hyperaesthesia, and loss of muscular power. If the artery be superficial, it can be felt as a cord, and is either pulseless, or the seat of a sharp and jerking pulsation, according to the degree of its 524 ■ SURGICAL DISEASES OF THE VASCULAR SYSTEM. obstruction. If the artery be one of importance, gangrene may result, though, in young and healthy subjects, the collateral circulation may be established with sufficient promptness to avoid this result. The arterial clot may become organized, the vessel being converted into a fibro-cellu- lar cord; or a fragment may be detached and plug the artery at a lower point (this double occlusion almost invariably producing gangrene); or the clot may become completely disintegrated, and capillary embolism (arterial pyaemia) result. The treatment consists in the administration of opium to relieve pain, and of tonics, stimulants, and concentrated food to maintain the patient's strength, with application of external warmth to the affected part in order to avert mortification. The subject of gangrene as the result of arterial occlusion, and the question of amputation under such circum- stances, have been sufficiently considered in previous chapters (pages 92, 194). Chronic Structural Changes in Arteries.—The most important of these are Fatty Degeneration, Atheroma, Ossification, and Calcification. 1. Fatty Degeneration occurs in the inner coat of arteries, espe- cially the aorta, carotids, and cerebral arteries, giving rise to small, rounded or angular, whitish spots, which project slightly above the surface; the fatty change takes place in the connective tissue corpuscles of the part, and at a later period, the intermediate substance softening, the masses of fat granules fall apart, and the current of blood carrying away the fat par- ticles, velvety-looking depressions are pro- duced, which constitute a form of what Virchow calls fatty-usure.1 2. Atheroma, which is usually accom- panied by the fatty change of the internal coat above described, appears to occur pri- marily in the external layer of the inner Fatty degeneration in inner arterial , J . ,, . .. .«• .n -i .n. -l\ i.u coat coat, at the junction of the latter with the middle coat, and forms a pultaceous (or atheromatous) mass, consisting of granular matter, fat globules, plates and crystals of cholestearine, and half-softened fragments of tissue which have not yet undergone degeneration (Fig. 252). During the early stage of atheroma, the appearance presented is that of a whitish, somewhat elevated spot, projecting into th%vessel, but still covered by a portion of the inner coat of the latter.2 As the process continues, the inner coat becomes perforated, the atheromatous mass is evacuated into the vessel, and the so-called atheromatous ulcer results (Fig. 253), just as in the affec- tion known as ulcerative endocarditis. While this change is occurring between the inner and middle coats of the artery, its outer coat becomes thickened and indurated, thus tending to maintain the strength of the vessel, which at the same time becomes comparatively rigid and inelastic. Atheroma is usually spoken of as a degenerative change, but according to Virchow, Billroth, Niemeyer, W. Moxon, and others, should be con- sidered a result of inflammation. 1 Cellular Pathology, Chance's transl., pp. 339-340. 2 Mr. Moore, in his essay in Holmes'1 s System of Surgery, vol. in., adopts the view formerly held by Rokitansky, that atheroma is a deposit on the lining membrane of the artery, derived from the blood. CHRONIC STRUCTURAL CHANGES IN ARTERIES. 525 3. Ossification is a rare, but, according to Virchow, an occasional change met with in the inner arterial coat. It may coexist with or may take the place of the atheromatous change (atheromasia), and, like that, results, according to Virchow, from inflammatory proliferation. Fig. 252. Fig. 253. Fatty granules, -with crystals of cholestearine, from athero matous deposits in the aorta. 4. Calcification is frequently met with, and, unlike atheroma, often in the peripheral arteries ; it occurs chiefly in the middle coat of the ves- sel, and has no necessary connection with the atheromatous change. It consists in the deposit of earthy matters, principally phosphate, with a little carbonate of lime, and occurs in the form of plates, rings, or tubes, constituting the several varieties of the affection, known as lami- nar, annular, and tubular calcification. When in the superficial arteries, it is readily recognized by the touch. These various structural changes may exist independently, or, as is more common, may coexist in the same person. They may occur at any age, but are by far most frequently seen in those who have passed the period of middle life. They are more frequent in men than in women, and are said to be predisposed to by intemperate habits and by syphilis; when occurring in the limbs, they are usually symmetrical. The effect of these structural changes is, in the first place, to diminish the calibre of the affected artery, and, secondly, by lessening its natural resiliency, to lead to its irregular dilatation and elongation ; hence, an atheromatous or calcified artery may become tortuous, and is peculiarly apt to become the seat of aneurism. Rupture may take place through an atheromatous ulcer, and lead to fatal hemorrhage, as has been occasionally seen in the aorta;1 while both atheroma and calcification render an artery more apt to be ruptured by external violence, and interfere with the success of haemostatic measures—a ligature perhaps cutting through at once, or becoming prematurely detached and leading to secondary hemorrhage. Finally, the loss of smoothness in the lining surface of an atheromatous or calcified artery, hinders the circulation, and offers a nidus for the oc- currence of arterial thrombosis, thus leading indirectly to occlusion and perhaps gangrene; or, on the other hand, particles detached from an 1 Similarly, fatty degeneration of the cerebral arteries, is a very common ante- cedent to the occurrence of apoplexy. (See Paget, Lectures on Surgical Pathology, 3d edit., p. 106.) Atheromatous ulcer of aorta. 526 SURGICAL DISEASES OF THE VASCULAR SYSTEM. atheromatous ulcer may produce capillary embolism, and give rise to one form of arterial pyaemia. Little can be done in the way of treatment for these structural changes, beyond attention to the general health of the patient; if wide-spread, they would of course render the surgeon cautious in recommending any cutting operation, that was not impera- tively required. Should occlusion and gangrene occur, the case should be treated on the principles laid down in previous portions of the work. Aneurism. Aneurism, as the term is used in this work, is a disease of the arteries, consisting in a circumscribed dilatation of one or more of the arterial coats. Varieties.—We have already considered those forms of aneurism which result from wounds (see page 195), as well as the general dilata- tion of an artery which constitutes the disease known as arterial varix or cirsoid aneurism; there remain for discussion three varieties of an- eurism, which maybe called respectively: 1, the tubular or fusiform; 2, the sacculated; and 3, the dissecting aneurism. 1. Tubular or Fusiform Aneurism.—This is a circumscribed dilatation of all the coats of an artery, in its whole circumference. It is accompanied by elongation of the vessel, with thickening and structural change of its coats. It is most common in the aorta, but also occurs in the iliac and femoral arteries, and has been seen in the basilar artery. Several fusiform aneurisms may coexist in the course of the same vessel, the intervening portions of the artery remaining healthy. Tubular aneurisms of the aortic arch may attain a very large size, running a chronic course, and doing harm chiefly by pressure on important parts. They may cause death by impeding the circulation, and thus causing syncope; or by compressing other parts, as the oesophagus or bronchi; or, when occurring in the intra-pericardial portion of the aorta, by burst- ing into the pericardial sac (Fig. 254). More commonly, however, a sac- culated aneurism forms upon one or other side of the tubular dilatation, and, becoming the more important disease, leads more rapidly to a fatal result. 2. A Sacculated Aneurism is a sac-like dilatation which forms upon one side of an artery, or of a previously existing fusiform aneu- rism, and which communicates with the interior of the vessel, by means of a comparatively small orifice, called the mouth of the sac. Sacculated aneurisms are divided into true and false; the true sacculated aneurism being one in which all the arterial coats enter into the formation of the sac-wall, and the false sacculated aneurism (which is by far the more common) being one in which, the inner and part of the middle coat having given way, the sac-wall is formed by the thickened outer coat of the artery, with perhaps the external layers of the middle coat. A true saccu- lated aneurism must be of small size, and with a large mouth to its sac; for it is scarcely conceivable that a large sac could be formed from the portion of arterial wall corresponding to the area of a small sac- mouth. It is very probable, however, that a considerable number of sacculated aneurisms are at first true, and subsequently, as they increase in size, become false by rupture of the inner coats of the sac-wall. False sacculated aneurisms are further classified by surgical writers as circum- CAUSES OF ANEURISM. 527 scribed and diffused, the aneurism being circumscribed as long as its sac remains entire, and becoming diffused when its sac gives way—the contained blood being then either widely spread among the adjoining tissues, or being still confined by an adventitious envelope of condensed Fig. 254. Fig. 255. Sacculated aneurism of ascending aorta. connective tissue. The subdivision of aneurisms into true and false, is not of much practical importance—the fact being that it is often impos- sible, even after careful dissection, to distinguish one from the other; while a diffused aneurism is in reality nothing more than an aneurism, the sac of which has given way. 3. Dissecting Aneurism is almost exclusively met with in the aorta, and is a rare form of the disease, in which the blood makes its way between the coats of the artery itself; a sac may thus be formed in the arterial wall; or the blood may dissect up the coats of the vessel for some dis- tance, at last bursting through the external tunic, and probably causing death by syncope; or, finally, the blood may re-enter the artery through a softened patch of the inner coat, thus giving the appearance of a double aorta. The only contingency in which a dissecting aneurism would be likely to demand the special attention of the surgeon, would be in case the pressure of the effused blood should threaten gangrene, by occluding the trunk of the affected vessel. Causes of Aneurism.—The chief Predisposing Cause is unquestion- ably the existence of structural changes (particularly fatty degeneration and atheroma) in the arterial walls. Calcification does not directly tend to cause aneurism, but rather lessens the dilatability of the artery which it affects; it has, however, an indirect influence, the want of elasticity which it produces tending to increase the strain upon other portions of the vessel, and thus predisposing them to aneurismal disease. Age has been looked upon as a predisposing cause, aneurism usually occurring Large fusiform aneurism of ascending aorta, bursting into pericardium. 528 SURGICAL DISEASES OF THE VASCULAR SYSTEM. during the middle period of life; the explanation is, that at this age, while atheromatous changes have begun, the laborious occupations of youth are commonly still continued. Similarly, though aneurism is unques- tionably much more frequent in the male sex than in the female (about seven to one1), it is probably not more so than might be expected from the greater liability of men to structural arterial changes, and from their being more commonly engaged in occupations which themselves predispose to aneurismal disease. Any occupation which requires intermittent violent muscular exertion, predisposejs to aneurism, by inducing occasional vio- lent action of the heart, and consequent over-distension of the arteries; thus hotel-porters, soldiers, and sailors, or those who, usually leading sedentary lives, indulge occasionally in athletic sports, are said to be more liable to aneurism than those whose occupation is uniformly labo- rious. Climate appears to exercise some predisposing influence, aneu- rism being probably more common in the British isles, and particularly in Ireland, than in any other portion of the world. The disease is com- paratively rare in this country. Anything which tends to obstruct the arterial circulation, may predispose to aneurism, by increasing the ten- sion of the arterial walls; it is thus, as we have seen, that calcification produces its effect, and it is thus that aneurism may be developed above the seat of occlusion of an artery by embolism,8 or above the point of application of a ligature. The position of an artery may itself predis- pose the vessel to aneurism ; thus the exposed situation of the popliteal artery renders it peculiarly liable to the development of aneurismal disease. The Exciting Causes of aneurism, are wounds, blows, and sudden strains. The effect of wounds has already been considered (see page 195); blows and strains, which may cause rupture of a healthy artery, may still more readily induce partial dilatation of one which is weakened by disease, thus giving rise to a tubular, or to a true sacculated aneurism; or (which is commoner) may cause the giving way of the portion of the inner coat which covers an atheromatous patch, leading to the evacuation of the latter, and the consequent formation of a false sacculated, or of a dis- secting aneurism, according to the particular circumstances of the case. Number, Size, and Structure of Aneurisms.—Aneurisms are usually single, but two or more may coexist in the same person. When aneurisms are multiple, they may affect one or different arteries; thus there may be an iliac and a femoral, or a femoral and a popliteal aneu- rism in the same limb, or, on the other hand, a popliteal aneurism may coexist with one of the subclavian or carotid artery, or with one of the aorta. Popliteal aneurism is frequently symmetrical. When a large number of aneurisms coexist, as in cases recorded by Pelletan and Clo- quet, the patient is sometimes said to suffer from the aneurismal diathesis. Aneurismal tumors vary in size, from that of a pea,3 to that of a child's head; the size varies in different situations, according to the 1 In the internal aneurisms the proportion is four to one, and in the external (excluding carotid aneurism, which affects both sexes equally) it is thirteen to one; dissectmg aneurism is twice as frequent in women as in men (Crisp, Structure, Diseases, and Injuries of Bloodvessels, p. 115). 2 According to Church, embolism is the most frequent cause of intra-cranial aneurism in young persons (St. Bartholomew's Hosp. Reports, vol. vi., p. 99). 3 The miliary aneurisms found by Charcot, and others, in the capillary vessels of the brain, in cases of apoplexy, are much smaller, the diameter of these aneu- risms rarely exceeding a millimetre, or about *V of an inch. SYMPTOMS OF ANEURISM. 529 Ficr. 256. degree of resistance offered by surrounding parts, and the force of the distending blood current. The largest aneurisms are hence commonly those which occur in the aorta, or, externally, in the axilla, neck, groin, and ham. If a sacculated aneurism is laid open, its structure, going from with- out inwards, is found to be as follows: (1) an investment of condensed areolar tissue, forming an adventitious sac; (2) the true aneurismal sac, con- sisting either of the thickened exter- nal, with, perhaps, part of the middle coat (false aneurism), or of all the coats (true aneurism), in which case the inner and middle coats may some- times be recognized by the atheroma- tous and calcareous patches which they contain; (3) concentric layers or laminae of decolorized fibrinous clot, which appear to have been successively separated from the blood, as if by whip- ping, and of which the inner layers are softer and redder than the outer; and (4) an ordinary loose "currant-jelly" coagu- lum, which may be either of ante-mor- tem, or of post-mortem formation. The laminated fibrinous coagulum serves an important purpose in strengthen- ing the sac-wall, lessening the contain- ing capacity of the sac itself, and, by its tough and inelastic character, di- minishing the force of the arterial cur- rent in the sac, thus, in every way, tending to limit the spread of the dis- ease, and even to lead to its sponta- neous cure. The mouth of the sac, which is round or oval in shape, is of variable size, but always of much less area than a section of the sac itself; in a false aneurism the inner and usually the middle coat cease abruptly at the mouth of the sac, and even in a true aneurism they can rarely be traced for more than a short distance beyond the same point. The structure of the tubular, and that of the dissecting form of aneurism, have already been referred to (pages 526, 527) ; another point in which these differ from the sacculated aneurism, is in containing little or no laminated fibrinous clot. Section of aneurism of calf, undergoing spontaneous cure: (a) black recent coagu-- lum, lying in centre of laminated fibrin ; (6) posterior tibial nerve stretched. Symptoms of Aneurism.—Patients are sometimes conscious of the formation of an aneurism—experiencing a distinct sensation of something having given way, or a sharp pain, as if from the stroke of a whip—or (as in the case of intra-orbital aneurism) hearing a sudden sound, as of the explosion of a percussion-cap—a small, pulsating tumor being, per- haps immediately, or soon after, discovered upon examining the part. In other cases, the development of an aneurism is very gradual, the patient perhaps not becoming aware of its existence until it has attained a con- siderable size. The symptoms of aneurism may be divided into those which are peculiar to the aneurismal nature of the affection, and those 34 530 SURGICAL DISEASES OF THE VASCULAR SYSTEM. which depend merely upon its size or position—its pressure effects— and which might equally be due to any other tumor of the same bulk, and in the same locality. The peculiar symptoms of aneurism are made apparent by auscultation and manual examination, and depend upon the flow of blood through the aneurismal tumor, and, in the case of the ordi- nary sacculated form of the disease, upon the communication which exists between the sac and the artery upon which it is developed} in certain in- ternal aneurisms, the auscultatory signs alone are available for diagnosis. General Characters.—An external aneurism presents the appearance of a rounded or oval tumor, situated in the course of a large artery, somewhat compressible and elastic, and becoming flaccid by pressure on the artery above, and tense by pressure on the artery below the tumor. If the aneurism contain but little laminated clot, it will be quite soft and compressible, but if, on the other hand, the sac contain a large amount of fibrinous clot, it will be comparatively hard and inelastic; the skin over an aneurism is usually healthy, though stretched; as the tumor grows it may, however, become discolored, thinned, or even ulcer- ated, and suppuration may occur in the subcutaneous areolar tissue. Muscular weakness of the part, stiffness, and a tired feeling, are fre- quent accompaniments of aneurism. Pulsation—The pulsation of an aneurism is peculiar, being of an eccentric, expansive character, separating the hands when placed on either side of the tumor—the fluid pressure of the blood entering the sac being, according to a well-known law of hydraulics, exerted equally in all directions. This pulsation is most marked when the mouth of the sac is large, and when the sac contains but a small quantity of laminated clot—the pulsation of a partially consolidated aneurism, if at all perceptible, being comparatively obscure, and sometimes scarcely distinguishable from that transmitted to a solid tumor by a subjacent artery. The characters of the pulsation are rendered less distinct by pressure above, and more distinct by pressure below the aneurism, or by elevating the part in which the tumor is seated. By firmly compress- ing the artery above the sac, the pulsation in the latter ceases, and it becomes flaccid; if now the hands be placed on either side of the tumor, and the compression be suddenly removed, the entering blood redis- tends the sac, with a forcible, expanding beat, which is almost pathogno- monic. The pulsation of the artery below the tumor is sometimes greatly diminished; this is a sign of considerable value in certain cases of intra- thoracic aneurism, in which the radial pulse of the affected side may be much weaker than on the sound side, or altogether absent. This, in particular instances, may be due to arterial occlusion front arteritis, to the rigidity produced by calcification, or to external pressure, but, in the majority of cases, is probably owing to the mechanical action of the sac-walls in equalizing the blood current and thus lessening pulsation, just as the air-chamber does in the ordinary " hydraulic ram." Bruit.—This is the name given to the intermittent sound which is heard by applying the ear to an aneurismal tumor, and which is clue to the rush of blood from a narrow, into a dilated cavity: the bruit varies a good deal in different cases, being usually of a rasping or sawing cha- racter, and most distinct in tubular aneurisms, and in those with large sac- mouths. It may be scarcely perceptible, or entirely absent, in an aneu- rism with a very small mouth, or which is nearly filled with laminated coagulum; in cases of femoral or popliteal aneurism, the bruit may often be rendered more distinct by causing the patient to lie down, and by SYMPTOMS OF ANEURISM. 531 elevating the limb. The bruit, which is usually accompanied with a pecu- liar thrill, is synchronous with the aneurismal pulsation, and ceases with the latter, if the artery be compressed above the tumor—returning imme- diately when the pressure is removed. Pressure Effects—Among the more common pressure effects of aneu- rism, are venous congestion and oedema, from compression of the deep- seated veins. In some cases, a varicose condition of the superficial veins may result from the same cause, and gangrene may even follow from the obstruction to the returning circulation. The risk of gangrene may be further increased by pressure of the aneurismal sac upon its own or neighboring arteries, thus leading to an insufficient vascular supply to more distant parts. Pressure upon nerves, gives rise to intense pain, usually of a lancinating character, and, in certain situations, may lead to serious consequences by interfering with the functions of important parts: thus hoarseness and spasmodic dyspnoea may result from com- pression of the recurrent laryngeal nerve, dyspnoea, or (as in a case recorded by W. F. Atlee) uncontrollable eructation, from pressure on the pneumogastric, and, in cases of intra-cranial aneurism, facial paralysis, deafness, ptosis, strabismus, or blindness, from compression of various cerebral nerves. Pressure upon secreting glands, or their ducts, may cause trouble by interfering with the functions of the part. Pressure upon bones and joints, often leads to serious consequences, the flat bones (as the sternum or ribs) becoming eroded and perforated, or caries and Fig. 257. Fig. 258. Ribs perforated by an aortic aneurism. Aneurism of the innominate artery, compressing and stretching the recurrent laryngeal nerve, and pushing the trachea to the left side. (Back view.) disorganization of articulations ensuing, and seriously complicating the treatment of the case. The erosion of bone by the pressure of an aneurismal tumor, is often attended by a distressing sensation of burning or boring pain, as in the vertebral column in cases of aneurism of the aorta. Finally, serious consequences may result from pressure on im- portant viscera; thus dyspnoea may be due to compression of the trachea, bronchi, or lungs; dysphagia to compression of the oesophagus; and pro- gressive emaciation to pressure on the thoracic duct—while hemiplegia 532 SURGICAL DISEASES OF THE VASCULAR SYSTEM. may result from the compression exercised by an intra-cranial aneurism on the brain. Symptoms of Diffused Aneurism.—When an aneurism becomes diffused by rupture of its sac, the symptoms undergo a certain change. The tumor loses its definition^of outline, while it becomes rapidly very much larger; the pulsation, bruit, and thrill become faint, or entirely disappear; the part becomes oedematous, and often cold and livid, from venous con- gestion ; the pain is suddenly increased, and syncope may occur; the swelling becomes hard, from coagulation—and, in some rare cases, a boun- dary of clot and condensed areolar tissue serves to limit the further spread of the disease, which may possibly in these circumstances undergo a spontaneous cure. Usually, however, the swelling continues to in- crease, with or without pulsation, or evidence of inflammation, and the case ends in gangrene, from conjoined arterial and venous obstruction; or, the clot becoming disintegrated, with suppuration, and ultimate giv- ing way of the skin, death follows from external hemorrhage. In some cases, rupture of the aneurismal sac leads to wide extravasation of blood among the tissues of the part, the accident being accompanied with much shock and pain, faintness perhaps resulting from the loss of blood from the general circulation, and gangrene ensuing at no distant period. Diagnosis.—The affections with which aneurism is most likely to be confounded, are various forms of tumor, abscess, and simple arterial dilatation. Internal aneurism may be mistaken for rheumatism or neu- ralgia, but if the disease be situated externally, such an error could scarcely be made, except from want of care in the examination of the case. From Pulsating Tumors of a vascular or encephaloid nature, aneurism may usually be distinguished by its more circumscribed form, its more forcible and distinct pulsation (which is of a peculiar eccentric cha- racter), its louder, deeper, and more defined bruit, and its situation in the course of a large artery. If, however, a vascular or encephaloid growth occur in a locality in which aneurism is common, as in the pop- liteal space, the diagnosis may become extremely difficult—and the most experienced and careful surgeons have, under these circumstances, occasionally been led into error. Cysts, or Solid Tumors, seated over an artery, may have a pulsation communicated from the latter, and may thus simulate aneurism; the diagnosis may usually be made by observing that the growth can be lifted from, or pushed to one side of the vessel, when the pulsation will diminish or disappear; that the pulsation itself is not of an eccentric or expansive character; that there is no bruit, or at least merely a dull, beating sound, such as may be produced by compressing an artery with a stethoscope; and that the degree of tension of the tumor is not affected by compressing the artery at a point nearer the heart. In some cases, however, a tumor may be connected with several arteries which surround or penetrate its substance, and the diagnosis in such a case might be impossible. Non-Pulsating Tumors, of a glandular or cancerous nature, may be mistaken for aneurisms in which consolidation has progressed so far as to obscure their pulsation—though the mistake is more apt to be the other way, such an aneurism being taken for a solid tumor. The diagnosis may be sometimes made by observing the mobility of the tumor; thus, by its moving with the larynx in the act of deglutition, a lobular enlarge- ment of the thyroid gland may be distinguished from a carotid aneurism. SPONTANEOUS CURE OF ANEURISM. 533 Aneurisms have not unfrequently been mistaken for Abscesses, and have been hastily opened in consequence ; the error may arise from an aneurism becoming diffused, ceasing to pulsate, and exciting inflammation and suppuration in the surrounding tissues, or from the formation of an actual communication between an aneurism and the cavity of an abscess. Errors of diagnosis, under these circumstances, have been made by no less eminent surgeons than Desault, Dupuytren, and Liston. It is pro- bable that, in some of these cases, careful auscultation might reveal a bruit, even if all the other signs of aneurism were absent. General Dilatation of an Artery may simulate aneurism, especially one of the tubular variety ; the diagnosis is made by observing the absence of the characteristic symptoms of the latter disease. Terminations of Aneurism.—An untreated aneurism may termi- nate in a spontaneous cure, or may cause death by pressure on important parts, by inducing syncope, by rupture, and consequent hemorrhage, or by causing gangrene. 1. Spontaneous Cure.—This, which is unfortunately a rare termi- nation, may be effected in several ways; and it is to be observed that the modes of treatment which will be presently discussed, are but imita- tions of nature's methods of effecting a cure. (1.) Gradual Consolidation by Deposit of Laminated Coagulum.—This is the most frequent mode of spontaneous cure, and is seen almost ex- clusively in sacculated aneurisms and those occurring in arteries of the second or less magnitude. A case, however, occurred to Stanley, in which an aortic aneurism was spontaneously cured in this way. The sac of the aneurism, acting as a diverticulum, allows contraction of the artery below, which, together with the enlargement of the collateral branches given off above, tends to lessen the force of the current through the aneurism, and thus to encourage the separation of fibrin and conse- quent formation of the laminated clot. This mode of cure is imitated in the medical treatment of aneurism as well as in the surgical treatment by compression on the cardiac side of the sac, by flexion, by the Hunterian mode of ligation, and to a certain extent by Wardrop's operation. A modification of this mode of spontaneous cure, is that which is said to occur from the compression of the artery by the aneurism itself, or by another aneurism or solid tumor. (2.) Occlusion of the Artery below or above the Sac by Means of a Fibrinous Plug.—This mode of spontaneous cure is occasionally seen; the artery below the sac may be plugged by the detachment of a fragment of the laminated clot, or, possibly, the artery above the sac, by a similar fragment derived from the heart or a higher aneurism. The former oc- currence is imitated in the treatment by manipulation and in Brasdor's operation, and the latter in Anel's method. (3.) Inflammation of the Sac may possibly cause coagulation, and consequent cure of the aneurism, though the soft clot formed in this way is more apt to become subsequently disintegrated, leading to sup- puration and rupture of the sac. This mode of cure is imitated by the use of direct pressure, galvano-puncture, the injection of coagulating fluids, etc. (4.) Finally, a spontaneous cure may, perhaps, occasionally result from Suppuration and Gangrene, leading to the extrusion of the aneu- rismal sac as a slough, while hemorrhage is prevented by the occlusion of the artery by inflammation. This mode of cure is imitated in what 534 SURGICAL DISEASES OF THE VASCULAR SYSTEM. Fig. 259. is called the "old operation," or that of Antyllus, which is practically equivalent to an excision of the sac. The evidence of the occurrence of a spontaneous cure, consists in the more or less gradual disappearance of the aneurismal pulsation and bruit, the sac at the same time becoming firm and contracted, and the circulation being carried on by means of collateral branches. 2. Modes of Death.—An aneurism may prove fatal by (1) pressure on important parts, as the phrenic or pneumogastric nerve, the trachea, heart, or lungs; (2) syncope, which may occur from a large aneurism becoming suddenly diffused, and is sometimes the immediate cause of death in cases of aortic aneurism; (3) rupture of the sac, and hemorrhage^which may be internal, into the brain or spinal canal, pleura, peri- cardium, trachea, oesophagus, or abdom- inal cavity—or external, as when an aortic aneurism perforates the sternum and bursts upon the surface of the body; and (4) gangrene, which is apt to occur when an external aneurism becomes dif- fused, and which is usually complicated with hemorrhage. The rupture of an aneurism on the cutaneous surface, is commonly effected by the occurrence of suppuration and pointing, with the formation of a small slough, as in an abscess; on a mucous surface, by the occurrence of a small circular ulcer; and on a serous sur- face, by the formation of a fissured or star-like opening. Stellate rupture of an aoriic aneurism into pericardium. Treatment of Aneurism. This may be conveniently divided into the medical or non-operative, and the surgical or operative treatment of aneurism. The former is the only mode generally applicable to aneurisms of the thoracic aorta, and is the safer mode in certain other cases—while it may be used as a valu- able adjuvant to the surgical treatment of aneurism in any situation whatever. Medical Treatment.—This aims to promote the cure, or at least retard the progress, of aneurism, by inducing, if possible, a deposit in the sac, of laminated fibrinous coagulum. To effect this, the patient should, in the first place, be kept at perfect rest—in bed, if possible— and should limit his diet, particularly avoiding irritating or indigestible food, stimulants, and large quantities of liquid. Small but repeated bleedings were highly commended by Valsalva, and form a prominent feature of the method of treatment which bears his name. They have been likewise employed with success by Pelletan, Hodgson, and others. Venesection has also been advantageously resorted to by Porter, Broad- bent, and others, for the relief of dyspnoea, in cases in which this has been a troublesome symptom. Various drugs have acquired a certain reputa- tion in the treatment of aneurism, especially the acetate of lead and the iodide of potassium, which is very highly spoken of by Balfour, of Edin- burgh. Digitalis and veratrum viride have also been used with advan- TREATMENT OF ANEURISM BY LIGATION. 535 tage, while Langenbeck has lately employed with success hypodermic injections of ergotine. The local application of ice has been of use in some cases, but is a dangerous remedy, having, according to Broca, induced gangrene of the skin. The pain of a growing aneurism may sometimes be relieved by the use of anodyne plasters or embrocations, while a hemlock or lead plaster may be used to give external support, in a case in which rupture of an aneurism is impending. Surgical Treatment.—This embraces a number of different methods which may be considered in succession. I. Ligation.—Ligation may be employed on both sides of the aneu- rismal sac, constituting what is known as the "Old Operation;" on the Cardiac Side, as in Hunter's and Anel's methods; and on the Distal Side, as in the plans of Brasdor and Wardrop. 1. The " Old Operation."—This, which until the early part of the last century, was, with the exception of amputation, the only operation employed in the treatment of aneurism, is also spoken of as the Antyl- lian method, from Antyllus, who was one of the first, if not the first, to employ it. It consists in opening the sac, and applying ligatures above and below, as was directed in speaking of traumatic aneurism (see page 195), though it would appear that by the older surgeons the ligatures were sometimes applied first, and the sac subsequently laid open, or even totally excised. The operation is often a very severe one, and is more liable to be followed by hemorrhage than the Hunterian operation, on account of the artery being tied in immediate proximity to the sac, and where, therefore, it may probably be diseased. In certain situations, however, as in the axilla, root of the neck, or gluteal region, this operation may be sometimes properly employed, and was, under such circumstances, several times resorted to by the late Prof. Syme, with the most brilliant and gratifying success; it may also be practised in cases of diffused femoral aneurism, as a substitute for amputation; and in any locality, if an aneurism have burst or have been accidentally laid open, it may often be the most eligible mode of treatment. 2. Ligation on the Cardiac Side of the Tumor.—The method of ligating an artery for aneurism which, when practicable, is now employed in preference to any other, is that known as the Hunterian Method (Fig. 261), from the illustrious John Hunter, by whom it was first resorted to in IT85. In this operation, the vessel is tied at a distance from the sac (which is not opened), thus securing a healthy portion of the artery for the application of the ligature, and still allowing a certain amount of blood to pass through the sac by means of the collateral circulation; the cure is thus effected by the deposition of laminated coagulum, and not by the sudden clotting of the whole contents of the tumor. Anel's Method (Fig. 260), which is spoken of by most French writers as identical with Hunter's, con- sists in the application of a proximal ligature immediately above the sac: it was employed Fig. 260. Fig. 261. 536 SURGICAL DISEASES OF THE VASCULAR SYSTEM. by Anel in 1710, in a case of traumatic aneurism of the brachial artery, and apparently as a mere experimental variation upon the old method.1 It does not seem to have been repeated, except once by Desault, and fell into oblivion until after the promulgation of Hunter's plan of operation. Anel's method is defective in not allowing any current through the sac, except from the distal end—imperfect coagulation and suppuration being therefore apt to follow—and in requiring the ligature to be applied to a part of the vessel which is very liable to be diseased, thus exposing the patient to a considerable risk of hemorrhage; the operation is, more- over, difficult, on account of the displacement of the artery by the tumor, and not free from danger. In performing the Hunterian operation, those precautions are to be observed which were mentioned when speaking of ligation in the continuity of arteries (page 185); before tightening the ligature, it is well to make distal compression for a few seconds, so as to insure the distension of the sac. The immediate effect of deligation is to arrest the aneurismal pulsation and bruit, the limb below the ligature rising in temperature,8 and often becoming painful and hyperaesthetic; loss of muscular power is also occasionally met with. The consolidation of the aneurism usually begins at once, and in favorable cases is commonly completed in the course of a few clays—the tumor gradually contracting subsequently, though it often remains quite perceptible to the touch for weeks or even months. The establishment of the collateral circulation, after the Hunterian ope- ration, usually requires the enlargement of two sets of anastomosing ves- sels—one around the seat of ligation, and another around the aneurism itself—unless in the rare cases in which the sac becomes obliterated, still leaving a channel for the normal flow of blood. If, however, the artery be tied near the sac, as in aneurism of the primitive carotid or external iliac—or in any case by Anel's method—but one set of collateral vessels is needed. If the collateral circulation above the sac be too rapidly established, the operation may fail, the pulsation of the aneurism being renewed as forcibly as at first; in most cases, however, enough coagula- tion takes place while the circulation is temporarily arrested, to insure the continuance of the clotting process, and the attainment of ultimate success. When two sets of collateral branches are enlarged, the lower arch of anastomosis is commonly first developed, owing to the aneurismal swelling itself having led to previous dilatation of the neighboring vessels. If the lower anastomosis be defective, consolidation of the tumor may not take place, and suppuration of the sac, or even gangrene, may follow. Causes of Failure after the Hunterian Operation.—There are several circumstances which may lead to failure after the Hunterian method of ligation; these are, (1) hemorrhage from the point of ligature, (2) return of pulsation from too free development of the upper collateral circula- 1 Keyslere subsequently (in 1744) modified the old operation by substituting com- pression for the distal ligature, retaining, however, the incision of the sac (Pelletan, Clinique Chirurgicale, t. i., p. 144). 2 This statement is in accordance with the result of my own observation, and corresponds with the doctrine of Holmes; most writers, however, teach that the temperature at first falls, and" subsequently rises when the collateral circulation is established. But, according to Broca, as quoted by Holmes, this rise of temperature does not take place in animals, although in these the collateral circulation is most rapidly established. The increased temperature is apparently due to capillary con- gestion, caused by the sudden removal of the vis a tergo of the heart's action, aided perhaps by a positive dilatation of the capillaries, brought about through the agency of the nervous system. LIGATION ON CARDIAC SIDE OF TUMOR. 537 tion—that above the sac, (3) suppuration and sloughing of the sac, often accompanied by hemorrhage, and (4) gangrene of the limb from the combined influence of arterial occlusion and venous congestion. (1.) Secondary Hemorrhage from the Point ofDeligation.—This (which, according to Crisp, usually occurs from the seventh to the fifteenth clay) is more frequent in the upper, than in the lower extremity, on account of the greater freedom of arterial anastomosis in the former situation, but is apt to occur in any locality in which large branches are given off in close proximity to the point of ligation—the clots, upon which arterial occlusion after the use of the ligature depends, being, under such cir- cumstances, insufficient to resist the force of the circulation. It is this which renders ligation of the common femoral artery such an unsuccess- ful procedure; secondary hemorrhage has occurred, according to Porta and Erichsen, in more than half of the recorded cases of this operation. The treatment of hemorrhage from the point of ligation, in a case of aneurism, is the same as for bleeding after ligation in the continuity of an artery in any other case, and is to be conducted on the principles laid down at page 194. (2.) Recurrent Pulsation is met with when the upper anastomotic arch allows an unusually free flow of blood into the artery; between the sac and point of ligation, and is proportionally most frequent in cases of caro- tid aneurism, for in these the circle of Willis allows the collateral circula- tion to be very quickly established. In many cases, the recurrent pulsa- tion consists of a mere thrill, without any bruit; but it is occasionally as distinct as before the operation. It usually occurs within twenty- four hours after the tightening of the ligature, though sometimes not for four or six weeks, and more rarely at an intermediate period. The prognosis of these cases is usually favorable, the pulsation again disap- pearing as consolidation is completed—though, occasionally, a fatal result ensues from suppuration and sloughing of the sac. Pulsation sometimes recurs several months after the consolidation and contraction of the aneurismal tumor, and the case is then properly called one of secondary aneurism, though it is probable that in most instances the new tumor is developed at a slightly higher point of the artery than the seat of original disease. Enlargement of the sac, after ligation, with- out pulsation, is due to the reflux of blood from the artery on the distal side. If excessive, it may lead to serious consequences—inducing gan- grene, by obstructing the venous circulation. Treatment.—Before tightening the ligature, in an operation for aneu- rism, the surgeon should ascertain, by pressure with the finger, that doing so will entirely arrest the pulsation in the sac. By neglect of this precaution, the aneurismal current might be kept up by means of a vas aberrans or unusual arterial distribution, and the success of the operation in consequence prevented. The treatment of recurrent pulsa- tion may usually be satisfactorily conducted by elevating the limb, making moderate compression upon the sac, and perhaps cautiously applying cold. If the pulsation persist, a ligature may be applied lower down, as in Anel's method; but if sloughing of the sac be imminent, the surgeon's only resources will be amputation and the "old operation"— the former being indicated in cases of popliteal or axillary, and the latter in those of cervical or inguinal aneurism. (3.) Suppuration and Sloughing of the Sac.—This may occur as a consequence of recurrent pulsation—or may result from imperfect de- velopment of the lower collateral circulation (preventing consolidation of the tumor), from the size of the sac itself and the thinness of its walls, 538 SURGICAL DISEASES OF THE VASCULAR SYSTEM. Fig. 262. from the circulation through the sac being completely arrested (leading to coagulation en masse, instead of to the deposit of laminated clot), or from external violence, or even careless handling of the tumor before or after operation. The symptoms are those which characterize the occur- rence of suppuration in general, the sac finally giving way, and (in about twenty-five per cent, of the cases in which this accident happens) death resulting from hemorrhage. Bleeding is particularly apt to occur in those cases which have been marked by recurrent pulsation, and then follows immediately upon the giving way of the sac; in other cases it may not occur for several days; while if suppuration takes place at a late period, the arteries communicating with the sac may be sufficiently occluded not to allow any hemorrhage at all. Suppuration of the sac is most common in cases of axillary and inguinal aneurism, though it may occur in other situations. The treatment consists in laying open the sac, evacuating its contents, and promoting healing by granulation, a provisional tourniquet being applied as a matter of precaution: should hemorrhage occur, an attempt must be made to secure the bleeding orifice with a ligature, or by the appli- cation of the actual cautery—and, if these fail, amputation should be prac- tised, provided that the situation of the aneurism admits of such a course. (4.) Gangrene of the Limb usually results, as has been mentioned, from the combined effects of arterial occlusion and venous congestion; it is particularly apt to occur in cases of very large or of diffused aneu- rism, and is predisposed to by loss of blood, by erysipelas, or by the exposure of the limb to undue pressure, cold, or excessive heat. It is most frequent in the lower extremity, and oc- curs usually from the third to the tenth day, being invariably of the nature of moist gangrene from implication of the veins. In order to pre- vent the occurrence of gangrene, those measures should be adopted which were advised in speak- ing of gangrene from arterial occlusion (page 194); in some cases it may be proper (in order to relieve the venous trunks from pressure) to lay open the sac and evacuate its contents—and indeed it is one of the recommendations of the old operation, over that of Hunter, that it is less apt to be followed by mortification. If gangrene have actually occurred, amputation must be performed, usually at the shoulder-joint, in the case of the upper limb, and at the junction of the upper and middle thirds of the thigh, in that of the lower extremity. Beside the above, which are the common causes of death after ligation for aneurism, there are certain special risks in particular situa- tions. Thus Cerebral Disease causes more than one-third of the deaths after ligation of the com- mon carotid (ninety-one out of two hundred and fifty-nine, according to Pilz), and Intra-thoracic Inflammation about two-fifths of the deaths obliteration of femoral vein after ligation of the third part of the subclavian by inguinal aneurism. (ten out of twenty-five, according to Erichsen). LIGATION ON DISTAL SIDE OF TUMOR. 539 Indications and Contra-indications for Ligation.—The application of the ligature, in the treatment of aneurism, is indicated (1) in cases in which the disease is active and advancing, and so situated that, while pressure, flexion, etc., are not applicable, the use of the ligature is not attended with unusual risk, (2) in any case in which less dangerous modes of treatment have been tried and failed, (3) in case an aneurism has burst into an articulation, (4) in case an aneurism has become diffused, and yet not so widely diffused as to require amputation, and (5) in case an aneurism has burst or is about to burst externally, and in case, there- fore, the operation is imperatively required to prevent death from hemor- rhage. The use of the ligature is, on the other hand, contra-indicated (1) by the presence of any complication—such as extensive arterial or cardiac disease, the existence of internal aneurism, old age, or the prevalence of erysipelas—which would probably render the operation peculiarly dan- gerous, (2) by the locality of the aneurism being such that pressure or flexion would probably be sufficient to effect a cure, as in many aneurisms of the brachial, femoral, and popliteal arteries, and (3) by the locality of the aneurism being such that, from the proximity of anastomosing branches, or from any other cause, the operation would almost certainly terminate unsuccessfully—the imminence of rupture being in such a case the only circumstance that could justify operative interference. Multiple aneurism is usually, though not always, a contra-indication; thus, if two aneurisms exist on the same limb, they may both be cured by the same operation, or double popliteal aneurism by ligation of both femoral arteries; in most cases, however, the existence of more than one aneurismal tumor contra-indicates, though it may not positively forbid ligation. Though I have said that ligation is contra-indicated in many cases of popliteal aneurism, yet I believe that in other instances it is the best mode of treatment. The operation, however—which, though delicate, is not in itself very dangerous—should not, of course, be indiscriminately resorted to. If the aneurism be quite sm,all, pressure will probably suf- fice for a cure, and even if it fail, will do little or no harm; and hence, in such a case, should certainly be tried. If, on the other hand, the tumor be very large, or if it have become diffused, the risk of gangrene may be so great as to render amputation preferable to either compression or ligation. There is, however, an intermediate set of cases, in which pres- sure would not be likely to succeed, and in which, if persisted in, it would certainly increase the obstruction to the venous circulation, and thus lessen the chances from subsequent ligation. In such cases, compres- sion should be employed, if at all, with great caution, and ligation should be promptly resorted to, if pressure be not quickly productive of benefit. The surgeon will in this, as in other instances, advance both his own reputation and the interests of his patients, rather by adapting his remedies to the exigencies of each particular case, than by advocating and invariably employing any exclusive mode of treatment. 3. Ligation on the Distal Side of the Tumor.—This operation is attributed to Brasdor, whose name it bears. It was recommended by Desault, but first practised by Deschamps, and subsequently by Wardrop—being indeed often spoken of as Wardrop's method. Though this surgeon, however, successfully employed Brasdor's operation, the plan which he himself suggested, and which properly bears his name, is 5-10 SURGICAL DISEASES OF THE VASCULAR SYSTEM. somewhat different. In Brasdor's opera- tion, the whole circulation on the distal side of the sac is arrested—in Wardi-op's, only a part of the distal circulation, by the application of a ligature to a branch of the main trunk, or to one of several arteries proceeding from the aneurism. Thus distal ligature of the carotid for carotid aneurism, would be an example of Brasdor's method, but the same opera- tion for innominate aneurism, would be properly called Wardrop's. The former aims to produce entire, and the latter par- tial arrest of the circulation through the sac. The risks, beside those incident to the Hunterian mode of ligation, are that the sac, being still distended by the car- diac impulse, may continue to increase in size, the operation thus failing, even if suppuration and sloughing do not lead to a fatal termination. Hence, except in par- ticular cases, as of aneurism of the root of the carotid, or of the innominate, the distal ligature is not to be recommended. II. Acupressure has been successfully employed in a few cases of aneurism, but does not appear to present any particular advantages over the use of the ligature. Various modifications of this method, under the name of temporary ligature, etc., have also been employed by Stokes and others, but not often enough to enable us to say whether they will ultimately be found any better than the methods of treatment which have been longer before the profession. (See page 189.) III. Compression.—Compression may be made directly upon the aneurism, or indirectly upon the artery at a point above or below the tumor (proximal or distal compression); it may be effected by the hands of the surgeon or his assistants (digital compression), or by means of instru- ments (instrumental compression). Direct Pressure upon the aneuris- mal sac, was introduced by Bourdelot, in the seventeenth century, and has since been successfully employed, from time to time, by various surgeons, but is so uncertain, and occasionally so dangerous a method, that it is now generally abandoned as an exclusive mode of treatment— while Distal Compression, which was proposed by Vernet, in the last century, failed in its author's own hands, and has been rarely, if ever, employed since his time. Both direct and distal compression may, how- ever, prove valuable adjuvants to pressure on the proximal side of the sac. The treatment of aneurism by Compression on the Cardiac Side of the Tumor, was employed by Hunter, Blizard, and particularly Freer, in England, and by Pelletan, Dupuytren, and others, in France, but did not attain the position which it now occupies in the estimation of the profession, until it was, about thirty years ago, revived and systematized by the Irish school of surgeons, particularly by Hutton, Bellingham, Tufnell, and Carte. It is not necessary, as was formerly supposed, to make such firm pressure upon an artery which is the seat of aneurism, as to entirely interrupt the flow of blood—and still less to excite such a Fig. 263. Fig. 264. INSTRUMENTAL COMPRESSION. 5H degree of inflammation as might lead to the obliteration of the vessel • on the contrary, the object being to imitate nature in her mode of effect- ing a spontaneous cure, by inducing the gradual deposition of laminge of fibrinous clot, it is sufficient to exercise enough compression to arrest or even to diminish by about one-half the pulsation of the sac, without pre- venting the flow of blood through it. This mode of treatment is par- ticularly applicable to sacculated aneurisms, though it may also suc- ceed in cases of the tubular variety, in which, however, the cure is effected rather by the gradual contraction of the aneurismal dilatation, than by the deposit of fibrin. The chances of success by compression are greatest when the sac contains, only fluid blood, coagulation in an already partially consolidated aneurism being apt to occur suddenly, and in an imperfect manner. After recovery, the sac is commonly entirely filled up, but in some cases a channel remains, through which the normal circulation is carried on. During the treatment by compression, the patient should of course be confined to bed, and the hygienic and other means spoken of under the head of Medical Treatment, put in force. Nervous irritability and pain should be controlled by the free use of opium, and in certain cases, in which the needful pressure cannot otherwise be borne, ether or chloro- form may be administered by inhalation. 1. Instrumental Compression may be effected by the use of various forms of apparatus, such as a Siguoroni's, or a Skey's tourniquet (Figs. Fig. 265. Fig. 266. Gibbons's modification of Charriere's compressor. 27,28), Lister's compressor (Fig.29),Reade's,or Carte's apparatus (in the latter of which (Fig. 265) elastic force is applied by means of vulcanized India-rubber bands), or a simple conical weight, held in position by means of a leather socket. In situations in which a considerable extent of artery can be dealt with (as in the thigh), alternate pressure upon several points may be practised, by means of an instrument such as that represented in Fig." 266, which was modified from one of Charriere's, by Dr. Gibbons, of this city. The points which require special care, in the application of in- Carte's compressor for the groin. 542 SURGICAL DISEASES OF THE VASCULAR SYSTEM. strumental compression, are to see that the artery is fairly pressed against the bone, while the pressure is not so widely diffused as to cause great venous congestion from implication of the deep-seated veins, and to guard against excoriation of the skin by carefully shaving and powder- ing the part, and by occasionally changing the point of pressure. In situations in which very deep pressure is necessary to control the circula- tion, and in which, therefore, the treatment becomes very painful (as in compressing the aorta, common iliac, or subclavian), anaesthesia may be previously induced, as proposed by Murray, and may be steadily kept up for as many hours as may be thought safe. Rapid Pressure Treatment of Aneurism.—Murray, Heath, Mapother, and other surgeons, have succeeded in curing aneurisms of the iliac and femoral arteries, and even of the abdominal aorta, by completely arrest- ing the flow of blood through the sao by means of instrumental compres- sion, applied above or on both sides of the tumor, and kept up in some cases for many hours, the patient meanwhile being under the influence of chloroform. The mechanism, by which the cure is effected in these cases, seems to be the coagulation en masse of the contents of the aneurismal sac, the mode of treatment being thus assimilated to Anel's and Bras- dor's operations. While " the rapid pressure treatment" is unquestion- ably a valuable addition to the surgeon's means of dealing with aortic and inguinal aneurisms, it cannot, in my judgment, replace, in the treat- ment of aneurisms in other situations, the ordinary mode of making instrumental compression—which aims to effect a cure by inducing a gradual formation of laminated coagulum, and which I believe to be safer, if less brilliant, than the rapid method. 2. Digital Compression, which was first proposed by Vanzetti, of Padua, about twenty-five years ago, and which has been successfully resorted to by Knight, of New Haven, Parker and Wood, of New York, S. W. Gross, of this city, and many others, may be employed as an ex- clusive measure of treatment, or as an adjuvant to compression by means of instruments. For its use in the former mode, constant relays of skilled assistants are often required, and these can frequently not be obtained; hence, though its statistical results are very favorable (the average duration of treatment in successful cases being, according to Gross and Fischer, about three days), it is principally as an aid to instrumental compression that it is likely to be generally resorted to. The statistics of digital compression have been particularly studied by Fischer, of Hanover, who finds that 188 cases (in all situations) gave 121 successes, and 67 failures. In 17 of the successful, and in 33 of the unsuccessful cases, instrumental compression and other means were also employed. Death occurred in 19 instances, once after digital compres- sion alone (from gangrene), three times after digital and instrumental compression, ten times after subsequent ligation, three times after ampu- tation, and twice after opening the sac. Digital compression is esti- mated by Fischer to be five per cent, more successful than instrumental compression, and is considered by him superior to any other mode of treatment except flexion, which he thinks should be preferred in any case in which it is applicable.1 When it is resolved to attempt the cure of an aneurism by pressure, the patient being prepared as has been directed, and the circulation 1 Archives Generales Medecine, Janvier, 1870, p. 108. ADVANTAGES AND DISADVANTAGES OF COMPRESSION. 543 through the aneurism controlled by the application of a suitable instru- ment, compression should be steadily maintained, if possible, until con- solidation is complete, or at least measurably advanced. This may usually be accomplished by using an instrument such as that of Dr. Gibbons, or by employing digital compression during the intervals in which the pressure of the instrument is relaxed. A cure has, indeed, been obtained in cases in which pressure has occasionally been intermit- ted for several hours at a time, but it seems probable that, when appli- cable, moderate but continuous pressure is more likely to prove beneficial than that which is more forcible but not steadily maintained. It is well, before applying compression to the cardiac side, to insure the complete distension of the sac by the use for a few minutes of distal compression. The contraction of the aneurismal sac may also be pro- moted by making gentle direct pressure upon the tumor, during the whole course of treatment, by means of a carefully-applied bandage. Advantages and Disadvantages of Compression.—The advantages of this mode of treatment are very obvious; it is certainly far safer (in most cases) than ligation of the artery, and, in cases in which it proves successful, is not materially more tedious. In many instances, a cure has been effected in from a few hours to three or four days, and the average duration of treatment, in successful cases, is, according to Hutchinson's statistics (for popliteal aneurism), about nineteen days, or about the same time as is commonly required for the separation of a ligature from the femoral artery. Its disadvantages are that it often fails—eighty- five cases of popliteal aneurism thus treated gave, according to Hutch- inson, only forty-nine cures—and that when it fails, the chances -of sub- sequent successful deligation are less than they would have been, had the latter operation been primarily employed. This fact is, indeed, denied by many surgeons, and it is even claimed that previous compres- sion, by favoring the establishment of the collateral circulation, lessens the chance of gangrene after the use of the ligature; but, as long ago pointed out by Porter, the risk of gangrene after operations for aneu- rism, is more from venous congestion, than from arterial deficiency; and that compression tends rather to increase than to diminish venous congestion will probably not be doubted. Nor is it fair to assert that the long list of failures after compression, is entirely due to want of care in its application; for the advocates of the ligature might as justly re- spond, with the late Mr. Syme, that most of the untoward results of that operation were due to the operator's want of skill—Syme himself, as is well known, having tied the femoral artery thirty-five times, with but a single death. In what cases, then, should compression be used? The answer should, I think, be somewhat as follows: (1) Compression should be employed, by preference, in all cases in which, from the age or general condition of the patient—from the existence of heart disease, of other aneurisms, or of marked structural change of the arterial coats—or from the pre- valence of erysipelas, pysemia, etc., the operation of ligation would be attended by particular risk; (2) in all cases in which the aneurism, being detected at an early stage, would be in the most favorable condition for the use of compression, and in which the pressure treatment, if even it failed, would not seriously lessen the prospect of benefit from subse- quent ligation; and (3) in all cases, on the other hand, in which the aneurism, from its locality or size, would not probably be amenable to the ligature, and in which, therefore, pressure should be at least tried 5-44 SURGICAL DISEASES OF THE VASCULAR SYSTEM. before resorting to such formidable measures as amputation, or the "old operation." Finally, compression may be tentatively employed in almost every case—even in popliteal aneurisms of moderate size, which are those specially adapted to the use of the ligature. If, however, decided benefit be not obtained in a short time—two or three days, or after a still shorter trial, if venous congestion, oedema, and pain are markedly in- creased by the treatment—the surgeon should, I think, unhesitatingly abandon compression and resort to the Hunterian operation, which, under such circumstances, I cannot but believe to be a preferable mode of treatment. IV. Flexion. — This mode of treatment was introduced by Mr. Ernest Hart, in 1858,1 and has since been successfully employed by Shaw, Pemberton, and several other surgeons. Its efficacy depends chiefly upon the interference with the arterial circulation caused by bending the vessel to an acute angle, but is assisted by the direct com- pression exercised upon the sac by the contiguous surfaces between which it is thus placed. Flexion is applicable in cases of popliteal aneurism, and of aneurism at the bend of the elbow, or in the axilla. Its application is very simple, consisting merely in the retention of the limb in the flexed position by means of a double collar or figure-of-8 bandage. If flexion is to be employed by itself, the limb should be bent so as to completely check the aneurismal pulsation. In most cases, however, it is preferable to employ moderate flexion, using it as an ad- juvant to digital, or to mild instrumental compression. The statistical results-of the flexion treatment have been studied by Stapin and by Fischer; the former writer finds that 49 cases gave 26 successes and 23 failures, 11 of the successes having been due to flexion alone, and 15 to this in combination with other methods; while Fischer finds that 57 cases gave 28 successes (20 by flexion alone) and 29 failures.2 It is probable that a combination of flexion with alternate instrumental and digital compression, would be found in many cases as satisfactory, as it would be certainly a less irksome mode of treatment than either plan by itself. V. Manipulation.—This method consists in squeezing or kneading the aneurismal sac, in such a way as to break up the contained laminated coagulum—a fragment of which it is hoped may plug the artery at the distal side, and thus lead to the consolidation of the tumor. This plan was introduced by Fergusson, and has been successfully employed by Little, Teale, and Blackman, of Cincinnati, having been combined by the last-mentioned surgeons with proximal compression. The dangers of this mode of treatment are that rupture of the sac and consequent dif- fusion of the aneurism, or inflammation and gangrene, may be caused by the application of too much force; and that (in cases of subclavian or carotid aneurism, for the former of which Fergusson employed it) a fragment of clot may occlude the carotid or vertebral artery, and thus lead to grave if not fatal cerebral disturbance. Cases are mentioned by Esmarch and Teale, in which death followed the occurrence of this ac- cident, during the mere preliminary examination of patients suffering from carotid aneurism. 1 It is said to have been previously employed both by Fergusson, and by Maunoir, of Geneva. 2 Archives Generales de Medecine, Janvier, 1870, pp. 106, 110. TREATMENT OF PARTICULAR ANEURISMS. 545 VI. Galvano-puncture was first employed by B. Phillips in 1838, and has since been resorted to in a number of cases of aneurism, by Petrequin and others. Both poles of the battery may be introduced into the sac, or (which Althans prefers) the negative pole alone. The great risks of the operation are that coagulation en masse will probably occur, and that sloughing of the aneurismal wall may take place at the points of puncture—an accident which would be apt to be followed by hemorrhage. The statistics of this mode of treatment are not very favorable; fifty cases collected by Ciniselli gave twenty-three cures, twenty failures, and seven deaths, grave accidents having likewise occurred in six of the cures and seven of the failures. The only cases, therefore, to which galvano-puncture seems appropriate, are such as forbid either compres- sion or ligature, and yet require active treatment. VII. Injections of Coagulating Liquids, and especially of the perchloride of iron, have been practised upon several occasions, and sometimes with success. This is, however, a very dangerous method of treatment (the principal risks being from inflammation, gangrene, rup- ture, and embolism), and its use is rarely justifiable except in localities in which both cardiac and distal compression can be maintained until coagulation is complete—in localities, in fact, in which either compres- sion or ligation would be equally applicable, and certainly preferable. VIII. Acupuncture, and the Introduction of a Coil of Fine Wire, have been tried—each aiming to effect a cure by furnishing a starting- point for coagulation ; the former plan has, I believe, never succeeded, while the latter proved fatal in Mr. Moore's case, the only one in which it has so far been employed. IX. Strangulation has been successfully employed for very small aneurisms, two needles or harelip pins being passed beneath the tumor, and a ligature thrown around their extremities, as in cases of naevus. X. Caustic has likewise been used with success as an application to very small aneurisms. XI. Amputation.—Finally, amputation might be required, if an aneurism in a limb should become diffused and threaten gangrene, if the pressure of the tumor should cause extensive caries of the neighboring bone, or if hemorrhage should occur from external rupture. Amputa- tion may also be required in the event of the failure of ligation. Arterio-Venous Aneurism.—As the result of ulcerative action, a preternatural communication may occasionally be formed between an artery and a contiguous vein, constituting a non-traumatic variety of aneurismal varix. The symptoms and treatment do not differ from those of the traumatic form of the disease, which has been already de- scribed (see page 196). Treatment of Particular Aneurisms. From a consideration of the principles laid down in the preceding pages, and from an examination of the statistical results, as far as they can be ascertained, of various modes of treatment, we may arrive at the following conclusions as to the best course to be adopted in dealing with aneurismal disease in various parts of the body. 546 SURGICAL DISEASES OF THE VASCULAR SYSTEM. Thoracic Aorta.—No permanent benefit has hitherto been obtained from operative treatment in aneurism of the aortic arch. In a case under the care of Mr. Heath, supposed to be one of innominate aneurism, the carotid and third part of the subclavian were tied at the same operation, the dyspnoea and other symptoms being greatly relieved, and life pro- longed for four years. External rupture ultimately took place, when the autopsy showed the disease to have been aortic. A similar case, operated on by Maunder, proved fatal on the sixth day, as did another, in which Heath was obliged to leave the operation uncompleted, on account of the aneurism extending much further than had been anticipated. In four other cases, the carotid alone has been tied, without any benefit to the patient—and the same want of success has attended the treatment by coagulating injections, and that by the introduction of a coil of wire, which was tried in a patient under the care of Mr. Moore; death occurred in the latter case on the fifth day. Galvano-puncture has been employed with temporary benefit in several instances by Decristoforis, of Milan, as has distal pressure, in cases recorded by Dr. Lyon and Mr. Edwards, and referred to in Mr. Heath's pamphlet; but the only treatment to be ordinarily recommended, in a case recognized as aneurism of the thoracic aorta, is the medical and hygienic treatment described at page 534. Innominate Artery.—The chief operative treatment applicable to innominate aneurism, is the distal ligature, applied to the carotid, to the subclavian or axillary, or to both vessels, consecutively or at the same time. The carotid appears to have been tied for innominate aneurism nineteen times,1 with four recoveries and fifteen deaths—the successful cases being those of Evans and Morrison, and two related by Pirogoff. The subclavian or axillary has been tied four times—by Wardrop, Laugier, Broca, and Blackman—all the cases terminating fatally, though in two (Wardrop's and Broca's) temporary relief was obtained. The double ligature has been employed in six cases, the arteries having been tied consecutively in three (by Fearn, Wickham, and Malgaigne), and simultaneously in an equal number (by Rossi, Hutchison, and Sands)— only one of each category (Fearn's2 and Sands's cases) proving success- ful. Heath's and Maunder's cases have already been referred to, while Cuvillier's (which was likewise supposed to be one of innominate aneu- rism) proved after death to have been subclavian. We thus see that as far as statistics bear upon the question, the advantage is with the double operation ; hence, if the ligature is to be used at all,3 both vessels should be tied, and preferably at the same time, as was done in the successful case of Dr. Sands, of New York. The risk of simultaneous, would be little if at all greater than that of consecutive ligation, while the aneu- rismal sac would be, by the former method, evidently placed in the best condition for a favorable termination. As, however, the operative treat- ment by any plan is so unsatisfactory, a fair trial should always be first given to the effect of rest and medical treatment, aided perhaps by distal 1 Erichsen, Science and Art of Surgery, p. 626. 2 Fearn's patient died four months after the last operation, from causes uncon- nected therewith, and the case is properly considered as successful {Holmes's Syst. of Surgery, 2d ed., vol. hi., p. 574). s Cheever, of Boston, in a case of innominate aneurism, attempted unsuccess- fully the operation «by double ligature; the position of the carotid artery could not be detected, and in endeavoring to secure the subclavian artery, the accompanying vein was ruptured; death occurred two hours subsequently (Boston City Hosp. Reports, 1870, p. 470). CAROTID AND SUBCLAVIAN ANEURISMS. 547 pressure, which proved of benefit in a case under the care of Mr. Syme. In a case of Luke's, repeated bleedings, and the use of digitalis, effected a cure, while Coote has lately obtained an equally happy result by the enforcement of rest and the application of ice. Carotid Artery and Branches.—Carotid aneurism is usually looked upon as specially adapted for the treatment by ligation. The operation of tying the common carotid is, however, attended in itself by very considerable risk—the mortality, according to Norris's1 statistics, being over thirty-six per cent., and according to those of Pilz,3 over forty-three per cent.' As more than one-third (ninety-one out of two hundred and fifty-nine) of the deaths after this operation have resulted from cerebral disease due to the interference with the circulation of the brain, it is evident that in any case in which it is practicable to do so, liga- tion of the external should be substituted for that of the common carotid. If, however, as is usually the case, the aneurism involves the common trunk itself, and pressure proves unavailing, ligation of the primitive carotid must be resorted to. Ligation by the Hunterian method has, according to Pilz, been done in eighty-seven cases, with fifty-five known recoveries and thirty-one deaths, the result of one case not having been ascertained. For traumatic aneurism at the root of the carotid, the surgeon may choose between Brasdor's, and the "old operation," which was in one case successfully employed by Syme. For non-traumatic aneu- rism, the "old operation" would be unsuitable; for the surgeon could not be absolutely sure that the disease might not involve the innominate, or even the aorta; and hence, in such a case, the distal ligature (first prac- tised by Wardrop) is the plan of treatment most to be recommended. Seven cases, tabulated by Erichsen, give three recoveries and four deaths —a sufficiently favorable record to encourage a resort to the operation under suitable circumstances.* Internal Carotid and Branches.—Aneurisms of the internal carotid and its branches, including intra-cranial and intra-orbital aneurism, may require ligation of the common carotid artery, though digital compres- sion with medical treatment should always be first tried in these cases. The results of carotid ligation for intra-orbital aneurism are very favor- able, twenty-nine cases, collected by Noyes, giving twenty-five recoveries and but one death.5 Subclavian Aneurism.—The statistics of this serious affection have been particularly investigated by Sabine,8 of New York, Koch,7 and Poland.8 The following table shows the results of various modes of treat- ment, in 122 cases collected by the last-named writer:— 1 Am. Journ. of Med. Sciences, July, 1847. 2 Half-Yearly Abstract of Med. Sciences, vol. xlviii. (Jan. 1869). 3 Both carotids have been tied in twenty-seven cases—once simultaneously (fatal in tweuty-four hours), and twenty-six times with a greater or less interval between the operations; only five of the latter cases proved fatal. 4 Pilz gives thirty-eight cases of ligation of the common carotid by Brasdor's method, for all aneurisms, recovery having been obtained in twelve, with twenty- five deaths, and one unaccounted for {Half- Yearly Abstract of Med. Sciences, vol. xlviii., p. 158). -*-5 N.Y. Med. Journal, March, 1869, p. 667. 6 Am. Med. Times, vol. ix. (1864), Nos. 7-10. ' Archives Gen. de Medecine, Aout, 1869, p. 213. 6 Guy's Hosp. Reports, 3d s., vol. xv. etseq. 548 SURGICAL DISEASES OF THE VASCULAR SYSTEM. Mode of treatment. Cases. Recovered.or in process of recovery. Died. Uncer- tain. 1. None, or medical treatment only............ 2. Moxa and hypodermic injection of ergot..... 3. Direct compression......................... 4. Compression on cardiac side................ 5. Injection of coagulating fluids---.......... 6. Acupressure of axillary and innominate..... 7. Manipulation.............................. 8. Galvano-puncture.......................... 9. Operation for ligation of innominate or sub- clavian, begun, but not completed......... 10. Ligature of subclavian (3d portion), embrac- ing cases of subclavio-axillary aneurism... 11. Ligature of subclavian (1st portion), subcla- vio-axillary in one case.................. 12. Ligature of innominate..................... 13. Ligature of innominate, carotid, and vertebral. 14. Ligature of subclavian and carotid........... 15. Ligature of subclavian, carotid, and vertebral. 16. Ligature of axillary j (Brasdor)............ 17. Ligature of carotid J v ' 18. Amputation at shoulder-joint............... 49 1 3 1 2 1 4 1 21 11 12 1 1 1 4 1 1 13 1 3 1 31 12 11 12 i 1 4 1 122 33 84 From the above figures it will be seen that the most promising methods of treatment are the medical and hygienic, with compression in suitable oases. Manipulation and galvano-puncture are also worthy of further trial. The Hunterian operation is justifiable in cases in which the aneu- rism is situated in the third portion of the vessel, so that a ligature can be applied outside of the scaleni muscles, or even between them—the case under such circumstances approximating to one of axillary aneurism. When, however, the disease involves the second portion of the artery, the surgeon can only choose between ligation of the innominate (first practised by Mott), ligation of the first part of the subclavian, and some form of the distal operation. To the thirteen cases of innominate ligation given in the above table, there may be added two operated on by Bujalski, with another in which the artery was acupressed by Porter, and a fourth in which the artery was tied by Hutin, for secondary hemorrhage. Of these seventeen, all terminated fatally except one, that of Smyth, of New Orleans, in which the carotid and vertebral arteries were likewise tied. Ligation of the first part of the subclavian has been practised in thirteen cases, or in fourteen (if we include Cuvillier's case of traumatic aneurism, in which the carotid was also tied), and always with a fatal termination. We thus have thirty or thirty-one cases of the proximal operation, with only one recovery—surely not enough to justify a repe- tition of the proceeding, unless in very exceptional circumstances. If the operation is to be done at all, Dr. Smyth's example should be followed, and the vertebral and carotid secured, as well as the innominate. The distal operation, as may be seen from the above table, is equally unpromising. What course, then, is to be pursued for an aneurism which involves the first or second portion of the subclavian, and which resists bloodless treatment? Amputation at the shoulder-joint (which would act as a modified distal operation) would under such circum- ANEURISMS OF THE ARM AND FOREARM. 549 stances probably be the best procedure. It would, as pointed out by Fergusson, who suggested this plan, have the advantage over the ordi- nary distal method, of diverting the force of the circulation by removing the part which previously demanded an arterial, supply. This method has been put in practice by Prof. Spence, of Edinburgh, with very grati- fying results, and might also be properly adopted in cases of aneurism of the third portion of the artery, in which, from any circumstance, the vessel could not be reached beyond the scaleni muscles. Axillary Aneurism.—This, which is a less frequent affection than subclavian aneurism, admits of several modes of treatment. Compres- sion upon the third portion of the subclavian, either by the finger, or instrumentally (the patient being anaesthetized), should be tried, and may in some cases prove successful; advantage might also be obtained from the flexion method, the arm being bandaged across the chest. If it be determined to resort to severer measures, the surgeon must choose between ligation of the axillary below the clavicle, ligation of the third portion of the subclavian, the old operation, and amputation at the shoulder-joint. Ligation of the axillary below the clavicle, has been done for aneurism (as a Hunterian operation) in 21 cases,1 with 8 deaths, giving a mortality of 38 per cent. The statistics of ligation of the third part of the subclavian, for axillary aneurism, are slightly more favorable, 67 cases, according to Koch, giving but 23 deaths—a mortality of only 34 per cent. Hence, the latter operation should, I think, be preferred, particularly as on theoretical grounds it would seem to be safer—ligation below the clavicle being of the nature of Anel's, rather than of Hunter's method. Ligation of the third portion of the subclavian is, however, in itself a very serious operation,2 and it is, therefore, worth while to inquire, with Mr. Syme, whether the old operation might not in some cases be preferable. Statistics are as yet wanting to decide this question, but the operation, which was twice successfully resorted to by Syme himself, is at least worthy of further trial. Amputation at the shoulder-joint for axillary aneurism was successfully performed by Syme, and likewise by Morton, of this city, for hemorrhage and gangrene after ligation of the second portion of the subclavian. Either this, or the "old operation," would be necessarily indicated in any case of axillary aneurism which bad become diffused, or which threatened external rupture, or gangrene of the limb. Amputation would probably be the safer proceeding, but would of course have the disadvantage of necessarily sacrificing the upper extremity. Hemorrhage during either operation might be pre- vented by compressing the subclavian over the first rib, through a pre- liminary incision above the clavicle. Aneurisms of the Arm and Forearm.—Aneurism of the upper- most part of the brachial artery, immediately below the axilla, may be treated by direct compression, or by flexion, and if these fail, by the " old operation," or by amputation, either of which would probably be safer than ligation of the axillary, whether in the armpit or below the clavicle. For aneurism of the brachial at a lower point, or of either of its branches, 1 Koch gives 26 cases, of which, however, 5 appear to have been for subclavian aneurism (distal operation); one of these was the case in which Porter acupressed the axillary artery, and subsequently the innominate. 2 The mortality for all causes is, according to Norris's statistics, 43^ per cent. {Am. Journ. of Med. Sciences, July, 1845), and according to Koch's, no less than 51 per cent. 550 SURGICAL DISEASES OF THE VASCULAR SYSTEM. if compression fail, the Hunterian operation should be employed. The traumatic and arterio-venous aneurisms met with at the bend of the elbow, as the result of venesection, are best treated by the "old opera- tion" (see pages 196, 197). Abdominal and Inguinal Aneurisms.—Dr. Murray,1 of New Cas- tle-on-Tyne, cured an aneurism of the abdominal aorta by instrumental compression above the sac, in five hours (the patient being under the effect of chloroform); and Dr. Heath,2 of Sunderland, is said to have been equally successful by pressure, without anaesthesia, continued for twenty minutes—irregular compression for ten hours, with chloroform, having previously failed. These most gratifying results bring within the range of surgical treatment an affection otherwise almost hopeless. The instru- ment to be employed maybe either Lister's or Skey's (Figs. 28, 29),and the pad must be accurately held in place over the aorta, as complete in- terruption of the circulation is required. The distal ligature has proved futile in cases of aortic aneurism, while the Hunterian operation is mani- festly out of the question. Aneurism of the common iliac artery may be treated by compression on the cardiac side of the sac, the patient being in a state of anaesthesia. Cases are recorded by Mapother, Heath, Eck, and others, in which satis- factory cures have been in this way obtained. If possible, the compress- ing pad should be applied over the iliac artery itself, but if the size of the tumor will not permit this, over the aorta. Ligation of the abdominal aorta for inguinal aneurism, was first per- formed by Sir Astley Cooper,3 in 1817, and has been since repeated by James, Murray, Monteiro, South, McGuire, of Richmond, Ta.,* Stokes, of Dublin (by Porter's method of modified acupressure), and Watson, of Edinburgh.5 All of these cases proved fatal, though Monteiro's patient survived until the tenth day. In Cooper's, James's, and Watson's cases the incision was made through the linea alba, and in all the others on the left side, as in ligating the common iliac. The uniformly fatal result of this operation should forbid its employment, unless under very excep- tional circumstances. If, however, the patient were dying from hemor- rhage, and the common iliac could not be secured, as happened in the cases of Cooper, McGuire, and Watson, ligation of the aorta would seem to be not only justifiable, but absolutely necessary. Ligation of the common iliac artery (which was first practised, in 1812, by Gibson, of this city, in a case of gunshot injury) may be re- quired in cases of aneurism involving the common iliac artery, or either of its branches. To the 32 cases collected by Dr. Stephen Smith,8 1 Med.-Chir. Transactions, vol. xlvii., p. 187, and " The Rapid Cure of Aneurism by Pressure," London, 1871. 2 New Syd. Soc. Biennial Retrospect for 1867-8, p. 293. 3 Sir Astley Cooper's operation, perhaps the boldest in the history of surgery, has been much criticized—many surgical writers following Guthrie in believing that it is always possible to secure the common iliac, through an incision on the opposite side of the abdomen. That this is not always so, is shown by Stokes's case, in which the incision was made on the left side for a right iliac aneurism, and yet "any attempt to deligate the common iliac would," it was found, "be imprac- ticable," on account of the overlapping and adhesion of the aneurismal tumor. {Dub. Quart. Journal of Med. Sciences, Aug. 1869, p. 5.) 4 In this case, it was intended to tie the common iliac, but the aneurism was found to involve the aorta, and burst during the examination. {Am. Journal of Med. Sciences, Oct. 1868, p. 415.) 6 For secondary hemorrhage, after previous ligation of the common iliac. 6 Am. Journ. of Med. Sciences, July, 1860, p. 19. ANEURISMS OF INTERNAL ILIAC AND BRANCHES. 551 of New York, may be added the successful operations of Bickersteth, of Liverpool, Brainard, of Chicago, and Luzenburg, of New Orleans—with the fatal cases of Gurlt (two in number), Dugas, of Charleston, Ham- mond, of San Francisco, Hargrave, Maunder, and Watson,1 and three others, recorded in Circular No. 6 (S. G. 0., 1865, p. 78). We have, then, 45 operations, with only 10 recoveries; or, if cases of aneurism alone are considered, 23, with 7 recoveries—a record which, though gloomy, warrants a resort to this proceeding, in cases in which milder measures fail. It is probable that the old operation would, in some cases of aneu- rism of the common iliac, be preferable to ligation of that vessel, as it certainly would be to ligation of the aorta. This procedure has, how- ever, not yet been employed; it was attempted by Cooper in the case in which that surgeon tied the aorta, and was believed to have been per- formed in a case of iliac aneurism operated on by the late Mr. Syme. In this instance the loss of blood was prevented by the use of Lister's aortic compressor, and the patient recovered from the operation, but died about three months afterwards from pleurisy—when an autopsy showed the aneurism to have been of the external iliac, the ligatures having been really applied below the bifurcation of the common trunk. Aneurisms of Internal Iliacand Branches.—Aneurisms of the internal iliac, and of the pudic artery, are extremely rare, there being, according to Erichsen, but one case of each known. Aneurisms of the gluteal and ischiatic arteries are more common, and may be treated in a variety of ways. Fischer2, of Hanover, has particularly investigated the statistics of these affections, and from an analysis of 35 cases (14 of traumatic, and 21 of spontaneous aneurism), concludes that the injection of the perchloride of iron is the best mode of treatment. If this method fail, or if it be not thought proper to employ it, it would further appear that for traumatic aneurisms the "old operation," and for those of a non-traumatic nature ligation of the internal iliac, are the measures to be preferred. The following table is compiled from Fischer's paper:— Mode of Treatment. None, or medical only......... Compression.................. Galvano-puncture............. Old operation................., Ligature of gluteal............, " " internal iliac......:, " " common iliac....... Injection of perchloride of iron. Summary. 2 ..! 2 1 1 1 ..1 1 1 .. 1 4 1 .., 2 2 .. ! 2 1 ..] 1 ••'l 8 1 ;14 Spontaneous. 10 o b< i 1 5' 1 1 V 1 1 3 1 1 5 5 3 4 2 15 18 2 The old operation is particularly adapted to cases of traumatic aneurism, as in these the communication with the artery will be certainly within reach; but in a case of spontaneous gluteal or ischiatic aneurism, 1 In this case, the aorta was subsequently tied for hemorrhage. 2 Archiv. fur Klin. Chirurgie (Langenbeck), xi. band, 3 heft, s. 827. 552 SURGICAL DISEASES OF THE VASCULAR SYSTEM. the surgeon could not be sure that the sac did not extend within the pelvis, and hence in such a case, ligation of the internal iliac would be a safer procedure. This artery has been tied on at least fourteen occa- sions, seven times successfully, by Stevens,_Arendt3 White, Mott, Syme, Morton, and Galozzi, and seven times with a fatal result, by Atkinson, Thomas,Rogers, Altmuller, and Higginson, and twice for hemorrhage, during our late war.1 Iliac and Femoral Aneurisms.—Aneurisms involving the external iliac or common femoral arteries, should be treated, if possible, by com- pression on the cardiac side of the tumor, but if this fail, ligation of the external iliac, or possibly of the common trunk, will be required. Dr. Norris,a of this city, collected, in 1847,118 cases of ligation of the external iliac (first performed by Abernethy, in 1796), to which may be added 35 collected by Dr. Cutter,3 of Newark, and 16 tabulated in Circular No. 6. This gives 169 operations for all causes, the mortality being 61, or a little over 36 per cent. If cases of aneurism alone are considered, the results are still more favorable, 126 cases then giving 35 deaths, a mor- tality of less than 28 per cent. Aneurism of the Deep Femoral Artery (Profunda) is very rare, only four cases, according to Erichsen, being on record. The treatment would consist in compression at the groin, or, if this should fail, in liga- tion of the common femoral, or, which would probably be safer, of the external iliac. Ligation of the common femoral artery is recommended by Holmes for these cases, and for those of aneurism of the superficial femoral, which are situated at too high a point to admit of ligation below. the place of bifurcation; and ten cases of the former operation are referred to, of which only three proved fatal. Other writers, however, give a different estimate of the results of this procedure, twelve cases having furnished, according to Erichsen, but three recoveries. The operation is certainly attended with more risk of hemorrhage than ligation of the external iliac, but has, on the other hand, the advantage of being much more easily performed. In the American Journal of Medical Sciences for July, 1868, p. 134, is recorded a case in which I secured the common femoral artery by acupressure. Aneurisms of the Superficial Femoral and Popliteal Ar- teries are the most frequent of all external aneurisms, the former vessel giving 66, and the latter 137, out of 551 cases of aneurism of all parts, collected by Crisp. The treatment consists in compression, or in ligation by the Hunterian method. The considerations which should guide the surgeon in choosing between these modes of treatment have already been set forth, and need not be again referred to (pages 539,544). Popliteal aneurisms are particularly adapted to the treatment by flexion. Ligation of the superficial femoral artery would appear to be a more successful operation when performed for femoral, than when for popliteal aneurism, the reason being that the risk of gangrene from venous congestion is much greater in the latter case than in the for- mer. This is seen very clearly from Norris's4 statistics, which embrace 22 cases of ligation for femoral aneurism, with only one death (from 1 Circular No. 6, S. G. O., 1865, p. 78. 1 Am. Journ. of Med. Sciences, Jan. 1847, p. 14. 3 Ibid., July, 1864, p. 42. • Ibid., Oct. 1849, p. 314. INFLAMMATORY DISEASES OF BONE. 553 hemorrhage), and 154 cases of the same operation for popliteal aneu- rism, with 39 deaths—of which no less than 19 were from gangrene. Norris's tables embrace in all 204 cases, with 50 deaths and 154 reco- veries; or, if femoral and popliteal aneurisms alone are considered, 176 cases, with 40 deaths and 136 recoveries—consecutive amputation hav- ing been performed in 5 of the successful, and in 6 of the unsuccessful cases. The mortality of ligature of the femoral artery for femoral and popliteal aneurism is, according to these statistics, 22.7 per cent., or about one in four and a half. Crisp's statistics are more favorable, giv- ing 122 cases, with 107 recoveries (7 after amputation) and only 15 deaths, a mortality of but a little over 12 per cent. Syme's remarkable record of 35 operations, with only one death, has already been mentioned. Diffused aneurism of the popliteal artery usually requires amputation; while, if the femoral be the vessel affected, the "old operation" may be advantageously substituted, as has been done, with the most gratifying results, by Birkett and by Forster. Aneurisms of the Arteries of the Leg and Foot are extremely rare, but if met with, should be treated by compression, etc., or, if neces- sary, by ligation on the cardiac side of the tumor. The lines for the ligation of the various arteries have already been given (pages 197-205). CHAPTER XXX. DISEASES OF BONE. The diseases of bone may be divided into those which depend upon the inflammatory process, and those which involve structural, non- inflammatory changes. The affections which are to be considered under the first head, are Periostitis, Osteitis, Osteo-myelitis, Abscess, Caries, and Necrosis. Inflammatory Diseases op Bone. Periostitis, or Inflammation of the Periosteum, is a frequent conse- quence of wounds or other injuries, or of certain diseases, as Syphilis. It may be primary, or may be secondary to inflammation of the bone itself, or of its medulla. The Pathological Changes in periostitis, consist in swelling (temporary hypertrophy) of the periosteum, followed by rapid cell-proliferation of its deep or osteogenetic layer, or a rapid accumula- tion of wandering cells (see pages 37 and 221), and resulting in the pro- duction of inflammatory lymph; these changes may be quickly arrested, the part returning to its former condition, and the newly formed material being gradually utilized in the normal maintenance of the bone—or the part may remain permanently thickened, or in a state of sclerosis or in- duration. These changes are usually accompanied by a softening or medullization of the superficial layer of the bone. If the irritation be more intense (as is seen in diffuse periostitis), there may be a rapid formation of pus, when necrosis of the subjacent bone is apt to follow. 554 DISEASES OF BONE. Symptoms.—The symptoms of ordinary periostitis are those of deep- seated inflammation in general, viz., swelling, corresponding to the extent of inflamed periosteum, heat, pain, tenderness on pressure, etc. The pain is apt to be worst at night. The attachment of the periosteum to the subjacent bone is loosened, giving sometimes a puffy or even boggy feel to the part. In diffuse periostitis (which is much the most serious form of the affection, and which chiefly involves the long bones, espe- cially the femur, tibia, or humerus, and is usually the result of injury, in young persons of a strumous diathesis), the inflammation rapidly spreads, frequently involving the periosteal covering of the entire shaft, and, if (as is sometimes the case) complicated with osteo-myelitis, perhaps attacking the epiphyses and neighboring joints as well. In this form of the disease, the production of lymph, and subsequently of pus, is rapidly effected, giving rise to the condition known as Subperiosteal Abscess. There is usually a good deal of constitutional disturbance, and fatal pyaemia not unfrequently occurs in the course of the affection. Diagnosis.—The ordinary circumscribed form of periostitis is easily recognized: the diffuse variety may be mistaken for diffuse inflammation of the areolar tissue, or for rheumatism. From the former it may be distinguished by its not spreading beyond the neighboring joints, and from the latter by the history of the case, and by the early occurrence of suppuration. Treatment.—The treatment of circumscribed periostitis consists in the application of poultices, preceded perhaps by a few leeches, with opium to relieve pain, and, in the more chronic stages, in the use of blisters and the administration of the iodide of potassium. Advantage may often be derived from a free or subcutaneous incision, so as to relieve the tense state of the periosteum, and encourage resolution. In the treatment of the diffuse form of the disease, no time should be lost in making free incisions through the inflamed periosteum, so as to relax the parts, and allow the escape of pus, if there be any; these incisions should be so arranged as to allow of free drainage, and should be repeated as often as necessary. At the same time, the strength of the patient must be maintained by the use of concentrated food ami stimulus, and by the administration of tonics (especially quinia), with anodynes, to relieve pain. In favorable cases, the patient may recover with the loss of more or less bone by necrosis, but pyaemia will often lead to a fatal termina- tion. If the destruction of bone be evidently too great for the recupe- rative powers of nature to cope with, and particularly if the neighboring joints become implicated (pyarthrosis), showing that the affection is probably complicated with suppurative osteo-myelitis, amputation should be performed—if the patient is in a condition to bear it—and I have under such circumstances removed the arm at the shoulder-joint, with the happiest result. The statistics of amputation for subperiosteal abscess, particularly in the femur, are, however, so gloomy, that the operation can only be looked upon as a last resort. Osteitis, or Inflammation of the Osseous Tissue itself, is seldom if ever met with as a primary affection, though it is a very frequent secondary complication of either periostitis or osteo-myelitis. In fact, in the large majority of cases, whichever constituent of bone is first affected, all are sooner or later involved. The first Pathological Change due to osteitis, is a softening or medullization of the bone tissue. Absorption of the earthy constituents occurs, while the Haversian canals, lacunae, and canali- OSTEITIS. 555 culi become widened, many disappearing by the coalescence of numer- ous spaces and canals. " The enlarged Haversian canals," says Paget, " present the appearance of medullary spaces, and are filled with a soft, rapidly growing tissue not unlike that of granulations." This process is rapidly accomplished, Oilier having seen complete medullization of the phalanges, without necrosis, in the short space of twenty days. As the result of this medullization, the bone becomes enlarged (though it loses in weight), the layers of its walls becoming separated, and thus givino- a porous appearance—whence this condition is called rarefaction or osteo- porosis. The bone often at the same time becomes elongated, from trans- ference of irritation to the epiphyseal cartilages. Fig. 267. Fig. 268. Osteoporosis of femur. Sclerosis and eburnation of femur. If the irritation be intense or continued, the process of medullization, or decalcification, as it is also called, may run on to the occurrence of suppuration, with perhaps caries and necrosis; in other cases, the deposit of bony matter is renewed, the part, perhaps, eventually becoming abnor- mally solid and heavy, the walls being thickened and the marrow-cavity encroached upon—when the condition known as sclerosis or eburnation results. These various conditions are frequently seen in different parts of the same bone, one specimen thus often exhibiting at once osteo- porosis, eburnation, and necrosis. Symptoms—The symptoms of osteitis are those of periostitis, with which the disease is almost invariably complicated. The osteocopic pains are perhaps more marked, and the tenderness greater, while the limb feels heavier and more helpless. Treatment—The treatment is essentially that recommended for peri- ostitis ; if a deep incision do not afford relief, a longitudinal section should be made through the bone, down to the medullary canal, with a Hey's saw, or (which is better if the disease have run on to suppura- 556 DISEASES OF BONE. tion), a small disc of bone may be removed by means of a trephine. The escape of pus, if there be any, is thus permitted, and the part placed in the most favorable position for recovery. Osteo-myelitis, as the term is used in these pages, signifies Inflam- mation of the Medulla or Marrow of Bone. This disease has been made a subject of special study by Dr. John A. Lidell, of New York, who has published by far the best account of the affection to be found in our own, if not in any language. Osteo-myelitis may ocur as a primary affection, or may be secondary to inflammation of the periosteum, or of the bone itself—being, indeed, almost invariably accompanied by osteitis, or periostitis, or both. It may occasionally occur idiopathically, but is usually a traumatic affection, resulting particularly from contusions or contused wounds of bone, and hence is of special interest in military practice (see page 169). Several varieties of osteo-myelitis have been described by surgical writers, as the acute and chronic, or the diffused and circumscribed. A better classification would appear to be one founded upon the pathological condition in different cases, according as the inflammatory change is limited to cell-proliferation and the produc- tion of lymph, or runs on to suppuration, or to sloughing. We may thus speak of—1, simple; 2, suppurative ; and 3, gangrenous osteo-myelitis. 1. Simple Osteo-myelitis is constantly met with in connection with osteitis and periostitis. It is present in a circumscribed form in many cases of simple fracture, in which, by causing a retrograde metamorphosis into bone, it gives rise to the so-called pin callus. The pathological change which characterizes simple osteo-myelitis, is called by Lidell carnifi- cation, or hepatization of the marrow. "The first anatomical alteration in osteo-myelitis beyond mere hyperaemia of the involved bloodvessels, appears to be," according to Dr. Woodward,1 " cell multiplication affect- ing the connective tissue corpuscles of the marrow, and of the connective tissue surrounding the bloodvessels in the canals of Havers. As a consequence, the true osseous tissue is encroached upon, and the por- tions of it which immediately adjoin the multiplying connective tissue disappear/ . . . It appears probable .... that the bone cells which occupy the lacunae next to the multiplying connective tissue, themselves enlarge and multiply, the matrix between them being absorbed, and that thus the bone cells themselves contribute to the resulting granulation tissue. The fat in the adipose tissue cells of the marrow is also absorbed, and these cells appear to contribute by their multiplication to the granulation tissue formed, as is the case in inflam- mation of the subcutaneous adipose tissue." This granulation tissue of simple osteo-myelitis, can be well seen in the florid button of granula- tions which covers the sawn end of a bone, in the stump of an amputa- tion. Carnified marrow is of a tough, almost fibrous, consistence, and usually of a more or less vivid red color, sometimes yellowish from the admixture of fat or of imperfectly organized lymph, or deep red, or almost black from hemorrhagic extravasation, which Lidell calls apoplexy of the marrow. Carnified marrow may gradually return to its normal state, or may run on to suppuration, or, on the other hand,* may undergo a retrograde metamorphosis, giving rise to the formation of a cylinder of bone, and perhaps to complete obliteration of the marrow cavity. This is a not infrequent termination of simple osteo-myelitis. > Circular No. 7., S. G. 0., Washington, 1867, p. 79, note. OSTEO-MYELITIS. 557 2. Suppurative Osteo-myelitis may be regarded as a later stage of the preceding. In the large majority of cases, suppurative is preceded by simple osteo-myelitis, the lymph corpuscles of the granulation tissue of the latter being converted into pus corpuscles, and suppuration beginning in several distinct foci, which afterwards coalesce. In some instances, how- ever, under the depressing effect of bad hygienic or constitutional influ- ences, the production of pus is so rapid as to render the suppurative form of the disease to all intents and purposes a primary affection. If the pyogenic change be limited to a small area, the condition known as Circumscribed Suppuration, or Abscess of Bone, is produced—an affec- tion which is quite amenable to treatment (see page 558). If, on the other hand, the medullary suppuration be diffused,1 involving perhaps the whole marrow cavity, the affection becomes one of the gravest cha- racter—wide-spread necrosis resulting as an almost necessary conse- quence, even if the occurrence of pyaemia do not lead to a fatal result. 3. Gangrenous Osteo-myelitis is a comparatively rare affection. It oc- curs, just as inflammatory gangrene in other parts, from a higher grade of irritation than is concerned in the production of the simple or suppura- tive varieties. When attacked by gangrenous osteo-myelitis, the mar- row assumes a very dark, almost black hue, and has a gangrenous odor. When examined with the microscope, the cell-formations are, according to Lidell, found to have been destroyed, amorphous matter (the debris of pre-existing histological structures) alone remaining, with perhaps some connective tissue—all stained of a dark color by decomposing haematoidin. The same bone may be, at the same time, affected in a different part by each of these varieties of osteo-myelitis. Osteo-myelitis, in whatever form it appears, has a marked tendency to spread towards the trunk—the upper portions of the long bones (at least in the case of the femur and humerus, which are the bones most often affected) being almost always more seriously involved than the lower. In a case, however, of osteo-myelitis affecting the tibia, observed by Dr. H. Allen, the lower portion of the medulla was most inflamed. Beside the immediate risks of osteo-myelitis, of which the chief is unquestionably the occurrence of pyaemia, serious consequences may ensue from the implication of the other constituents of the affected bone; thus, as the result of secondary osteitis, there may be caries, or necrosis, which may involve the internal laminae only (central necrosis), or, if accompanied with diffuse periostitis and subperiosteal abscess, may involve the external laminae only (peripheral necrosis), or may cause the destruction of the whole thickness of the shaft (total necrosis). Again, from extension in a longitudinal direction, separation of the epiphyses may follow, or, the epiphyses themselves being involved, ulcer- ation of the articulating cartilages and secondary pyarthrosis of the neighboring joints may ensue. Symptoms and Diagnosis of Osteo-myelitis.—Simple osteo-myelitis is ordinarily attended by no recognizable symptoms, being indeed usually a conservative process which can scarcely be called morbid. When it does pass the border line between health and disease, its symptoms are indistinguishable from those of the osteitis and periostitis by which it is accompanied. Even suppurative and gangrenous osteo-myelitis can rarely be recognized during life, unless the bone affected be in an un- healed stump, when the protrusion from the marrow cavity of a suppu- 1 This is the only form of the disease which is recognized under the name of osteo-myelitis by many systematic writers, such as Erichsen and Holmes. 558 DISEASES OF BONE. rating or sloughing fungous mass, or an exploration with the finger or probe, would, of course, indicate the nature of the affection. Under other circumstances, the symptoms will be usually completely masked by those of the accompanying diffuse periostitis; if, however, as remarked by Dr. Lidell, the free incisions which were recommended for the latter affection should fail in any case to give relief, the surgeon would properly infer that the medullary cavity was involved. A similar inference would be justifiable from the occurrence of pyarthrosis, or epiphyseal separa- tion, or even from the pain and constitutional disturbance being more intense than could be accounted for by the existence of osteitis and peri- ostitis alone. Treatment.—The treatment of simple osteo-myelitis is essentially that recommended for osteitis, the longitudinal section with Hey's saw being equally applicable in these cases. If the existence of suppurative osteo- myelitis be ascertained, an attempt may be made to preserve the limb by making one or more openings with the crown of a small trephine, so as to expose the marrow cavity and allow the exit of pus. This plan was employed in the year 1798, by the late Dr. Nathan Smith, with the happiest results. If the affection involve the whole extent of the medulla—particularly if pyarthrosis have occurred—amputation or excision, according to the nature of the bone, will be required. If a short bone, such as the astragalus, be involved (which is seldom the case), excision may suffice; but in the case of the long bones, the choice will lie between amputation and disarticulation. Amputation in the continuity of the affected bone should be rejected, as the disease would almost certainly recur in the part that would be left; hence, disarticula- tion, in the case of the humerus or femur, and the same, or amputation of the thigh or arm, in the case of the bones of the leg or forearm, are the operations to be recommended. Disarticulation, under these cir- cumstances, proved very successful in the hands of J. Roux and Arlaud, 20 cases, of which 2 were at the hip-joint, having all terminated in re- covery.1 The operation should be performed, if possible, before the development of pyaemic symptoms, but has been resorted to with suc- cess even at a later period, by Prof. Fayrer, of Calcutta. Gangrenotis osteo-myelitis, if recognized during life, would require amputation even more imperatively than the suppurative form of the disease. It is perhaps scarcely necessary to say that amputation should not in any case be employed, unless not only the surgeon is well convinced that diffuse suppurative, or gangrenous osteo-myelitis is actually present, but unless also the affection is running so acute a course as to endanger life —and unless conservative treatment, especially the use of the trephine, has failed to give relief. A large number of cases of osteo-myelitis run a comparatively chronic course, producing more or less extensive necrosis, but at no time placing life in imminent danger: as a rule, no amputation would be justifiable under such circumstances, but the dead bone should be dealt with as in cases of necrosis from any other cause. Circumscribed Suppuration or Abscess of Bone.—This pain- ful affection may occur in any part of a bone, but is most common in the articular extremities, as in the head of the tibia. The course of the disease is usually very chronic, and is marked by symptoms of localized osteitis, especially tenderness and pain, which is most severe at night, 1 Roux reports in all 22 cases, of which 4 were at the hip-joint (all successful); 2 of the hip-joint cases were, however, for affections other than osteo-myelitis. ABSCESS OF BONE. 559 and is aggravated by walking or other exertion. There is often some swelling and redness of skin, with concomitant periostitis. Abscess of bone has been met with under several conditions, which have been de- scribed as distinct affections, though the pathology of all is the same. Thus (1) there may be caries of the superficial portion of the bone, a narrow channel leading down Fig. 269. to the focus of suppuration (as in the celebrated case recorded by Hey, of Leeds); or (2) there may be what Dr. Markoe, of New York, has well de- scribed as " chronic sinuous abscess of bone," in which an abscess originating in the interior of a bone makes its way towards the surface, and ob- tains an -imperfect vent by perforating the exter- nal compact surface; or (3) there may be an abscess entirely surrounded by bone-structure, as in cases recorded by Sir Benjamin Brodie. The only affec- tions with which abscess of bone is likely to be confounded, are osteitis, circumscribed osteo- myelitis stopping short of the production of pus, central necrosis, and cystic growths originating within the bone. A mistake under these circum- stances would, however, be of no practical impor- tance, as the same treatment would answer in either contingency. Treatment.—The treatment consists in perforating the compact sub- stance with a trephine at the most tender point, so as to give free vent to the contained pus, as was done by Dr. Nathan Smith, in 1798, in a case of diffused medullary suppuration (see page 558). A small tre- phine should be used, the bone being first exposed by means of a suit- able incision; and if the abscess be not reached by the opening thus made, perforations in various directions may be made through the aperture with a drill or other suitable instrument. The cavity of the abscess is sometimes found lined with granulations, forming what is called a pyogenic membrane—or the surrounding bone may be rough and carious. In the latter case, the gouge should be freely used ; while if a sequestrum be found,the opening maybe enlarged in order to effect its removal, as will be described in speaking of necrosis. The use of the trephine for abscess in bone, is usually said to have originated with Brodie, and to that distinguished surgeon is undoubtedly due the credit of having popularized the operation in modern times. It is, however, really an old mode of treatment, having been distinctly described by David, in an essay which received the prize of the Royal Academy of Surgery, in 1764, and by Bromfeild, in 1773. Still earlier the opera- tion had been performed by Petit (who died in 1750), and by Walker, of Virginia (in 1757); and at a later period by Hey, of Leeds (1787), and by Simons, of South Carolina (1825)—Brodie's first case not occurring until 1828. The operation should be performed as soon as the deep-seated pain and other symptoms render the existence of an abscess probable; and even if no pus is found, relief will probably be afforded by the diminution of tension and pressure. If the operation should be delayed, there would be reason to fear that the abscess would perforate the articular cartilage, and involve the neighboring joint—an accident which might make it necessary to resort to excision, or possibly amputation. 560 DISEASES OF BONE. Caries.—Caries is the name applied to Ulceration of the Osseous Tis- sue,1 and it bears precisely the same relation to inflammation of bone, that ordinary ulceration does to inflammation of the soft Fig. 270. parts. Several varieties of caries are described by systematic writers—such as the circumscribed, diffuse, or phagedaenic—the simple, scrofulous, syphilitic, etc. In caries, as in common ulceration, the dead tissue is thrown off in a state of solution, or in very minute par- ticles ; whereas iu necrosis (as in ordinary gangrene) considerable masses are ejected at once. The term caries necrotica is used by some writers to signify an intermediate condition, analogous to what might be called gangrenous ulceration of the soft tissues. The term caries is strictly applicable only to the degenera- tive process in which the effete material is cast off or ejected—that in which the products of degeneration are absorbed being more properly designated as interstitial absorption. Carious bone is porous and fragile, usually of a dark gray or brown hue, and presents numerous hollows and cavities, which are filled with the products of disintegration, often intermingled with necrosed frag- ments. The surrounding bone is usually indurated, though, especially in the scrofulous variety, it is often in a state of medullization—fungous granulations over- lapping and masking the carious portion. Carious caries. bone is sometimes though not usually sensitive, bleeds when touched with a probe, and may be felt to be softer than in the normal condition. The disintegrated material derived from carious bone consists of oil globules, blood, and various debris, with granular inorganic substances corresponding in chemical composition to the salts of bone. Superficial caries is accompanied with localized periostitis, the periosteum being loosened and thickened, and presenting a pink, villous appearance; these villous-looking granulations occupy the depressions of the subjacent bone. The symptoms of caries are those of osteitis complicated by an ab- scess leading to the softened bone; there cannot be true caries without suppuration. When the bone can be felt (as it usually can, by using Sayre's jointed probe, or Steel's flexible wire instrument), the diagnosis is easy—but under other circumstances, can only be made by observing the persistence of the suppuration and other symptoms, without obvious cause, and by chemical examination of the pus, which, when proceed- ing from diseased bone, contains an excess of phosphate of lime. Caries may be secondary to disease of the soft parts (as in certain inve- terate ulcers, particularly of the lower extremities), or may be a primary affection. In the latter case, it particularly involves the cancellated tissue, and is thus most common in the short or spongy bones, and in the articulating extremities of the long bones—in which situation it not unfrequently leads to destructive disorganization of the neighboring joints. Recovery from caries, as from ulceration of the soft parts, is effected by granulation and cicatrization—a dense fibrous structure, or an imperfect form of bone, taking the place of the tissue which has been destroyed. 1 Some writers limit the term caries to scrofulous ulceration of bone; while others (as Erichsen) consider it a distinct disease, analogous to, but not identical with, ulceration. TREATMENT OF*CARIES. 561 Treatment.—The treatment of caries must be both constitutional and local. If the patient be syphilitic, iodide of potassium may be adminis- tered, or if of a scrofulous diathesis, cod-liver oil with the iodide of iron. The hygienic condition should receive careful attention, and in many cases a change of air, especially residence at the seashore, will prove of great benefit. The local treatment during the early stages of the disease, while the ulcerative process is advancing, should usually consist merely in keeping the parts clean and free from external sources of irritation. When the acute symptoms have subsided, an attempt may be made to remove the diseased bone, by means of applications of iodine or of the mineral acids. Chassaignac has highly recommended the use of dilute muriatic acid, which is injected through the fistulae which lead to the carious bone. Mr. Pollock employs dilute sulphuric acid, applied with a camel's-hair brush, after turning back the soft parts. The use of caustics, or even of the actual cautery, has likewise been advised by various surgeons, and may occasionally prove useful. The "Liqueur de Villate," which was introduced by Notta, may be used as an injection, and has been favorably spoken of by many surgeons. It may be made according to the following formula: R. Zinci sulphatis, cupri sulphatis, aa gr. xv; liq. plumbi subacetatis f^ss; acid. acet. dilut. f^iijss. M. Great advantage may often be derived from the use of an oakum seton drawn through the carious bone, as recommended by Sayre, of New York. When the carious bone can be reached from the surface, it may be scraped or cut away with gouge, or gouge forceps, or with a burr-head drill or Fig. 271. Fig. Gouge-forceps. Burr-head drill. osteotrite. The process should be continued until all the diseased bone has been removed, which may usually be known by the hardness and density of the surrounding healthy part; if the latter be softened by inflammation, the surgeon may know that he has gone far enough, when the detritus retains its red color in spite of washing—carious bone when washed becoming white, gray, or black. When the disease is very ex- tensive, as where it involves the whole or greater part of one of the tar- sal bones, or the articulating extremity of a long bone, very free gouging (which Se'dillot has recommended under the name of evidement) may be employed, though in many cases excision will be preferable. Finally, amputation may be necessary to prevent fatal exhaustion. Before, how- ever, resorting to so grave an. operation—and this remark applies in a less degree to any cutting operation for caries—the surgeon must con- sider that the affection with which he has to deal is essentially of a 36 562 DISEASES OF BONE. chronic nature, and may persist for many years, ending, perhaps, event- ually, in spontaneous recovery; hence, in many cases, particularly with patients who from their social condition can afford to be invalids, it will be more prudent, so long as life is not endangered, to avoid modes of treatment which are in themselves necessarily attended with consider- able risk. Necrosis.—Necrosis is the name given to mortification of bone; like gangrene of the soft parts, it may be acute or chronic, dry or moist, inflammatory, senile, etc. Causes.—The most frequent immediate cause of necrosis is osteitis, occurring as a complication of periostitis, of osteo-myelitis, or of both. Necrosis may, however, result (just as gangrene of the soft tissues) from external violence depriving the part of vitality, without the inter- vention of inflammation. Under these circumstances, or in any case in which the bone is suddenly killed, if the cancellated structure be in- volved (the blood and other fluids remaining in the part), the necrosis is of the moist variety: this form of necrosis corresponds to the mephitic gangrene of bone of Dr. Lidell. In the large majority of cases, however, necrosis is slowly developed, by the affected bone being deprived of its normal supply of blood; the compact structure is then chiefly involved, and the phenomena of dry or ordinary necrosis are presented. Thus in osteitis, the capillaries of the Haversian canals become strangulated, as it were, against the surrounding bony walls, and death of the part results as a consequence of arrested circulation. Among the more remote causes of necrosis may be particularly mentioned scrofula and syphilis, expo- sure to heat or cold, the application of caustics, expo- sure to the fumes of phosphorus, etc. The bones most often affected are the tibia, femur, humerus, phalanges, skull, lower jaw, clavicle, and ulna; unlike caries, ne- crosis attacks the shafts, in preference to the articu- lating extremities of the long bones. Necrosis is not very common in young children (though it may occur among the sequelae of the eruptive fevers), being most frequent in early adult life; it is sometimes seen, like ordinary senile gangrene, as a consequence simply of the diminished vitality of old age. Bone deprived of its periosteum usually, though not necessarily, becomes necrosed: if both periosteum and medulla perish, ne- crosis is almost certain to follow. Dry Necj~osis.—Bone affected with dry or ordinary necrosis, is hard, and of an opaque, yellowish-white hue, though it may become blackened from exposure; it is insensible, sonorous when struck with a probe, and does not bleed. It may be, according to the part affected, peripheral, central, or total (see p. 557). The dead bone is at first connected with the surrounding parts, but becomes gradually loosened, and is finally separated and thrown off as an exfoliation. While the process of loosening is going on, the periosteum, if not destroyed, furnishes new bone, which often forms a sheath around the dead portion, which is then said to be invaginated, and when separated constitutes a sequestrum. The separation is effected, not, as was formerly supposed, at the expense of the dead part, by Fig. 273. m Central necrosis; Dew bone with clo- NECROSIS. 563 absorption, but at the expense of the surrounding living bone, which undergoes medullization, and is converted into a layer of granulations. The free surface of an exfoliation, or of a sequestrum, is pretty smooth, but the edges and deeper surfaces present a ragged or worm-eaten appearance, with depressions corresponding to the granulations by which they have been surrounded. The sheath of bone which enve- lops a sequestrum, is called the involucrum; this usually presents numerous round or oval openings, which are called cloaca, and through which the extrusion of the sequestrum is eventually accomplished. It occasionally happens, in cases of total necrosis, that, while the original bone is perishing, and the periosteum furnishing a new osseous sheath, the medulla, likewise, by a process of retrograde metamorphosis becomes partially ossified, and the sequestrum is thus surrounded on both sides by living bone. Moist Necrosis.—This, which is a comparatively rare form of necrosis, is well described by Lidell under the name of Mephitic Gangrene of Bone. This form of the disease manifests its peculiarities chiefly in the cancellated structure of bone, which when thus attacked is moist, more or less softened, and of a dirty gray or greenish brown hue, with an extremely offensive odor. This form of necrosis may occasionally be seen in compound fractures, in what Dupuytren called primary splinters (see pp. 164, 230), if these be not promptly removed; it may also result from violent contusion of bone, being thus more frequent, probably, in military than in civil practice. Moist necrosis is always total—involving, that is, the whole thickness of the affected bone: there is little or no effort at repair on the part of nature in these cases, the periosteum either itself sloughing, or at best furnishing but a few imperfect nodules of bone. Symptoms of Necrosis.—The symptoms of necrosis may be described as belonging to two periods, that in which the bone is dying, and that in which its separation as an exfoliation or sequestrum is effected: in moist necrosis, as the bone is at once deprived of vitality, the first stage is absent. The symptoms of the first stage of necrosis are those of osteitis, it being impossible to decide, before the occurrence of suppura- tion, whether necrosis is or is not about to occur. The death of any por- tion of the osseous skeleton is usually, though not invariably, attended by extensive suppuration of the soft parts, the abscesses thus formed gradually contracting to sinuses, through which, if a probe be passed, the necrosed bone can be readily recognized by the hard and rough sensa- tion which it communicates. In cases of central necrosis, the diagnosis can only be certainly made if cloacae exist, through which the dead bone can be felt: if there be no cloacae, the affection may be indistin- guishable from chronic osteitis, or (as already mentioned) from circum- scribed abscess of bone. The first stage of necrosis is attended with' a good deal of constitutional disturbance, which measurably subsides upon the occurrence of suppuration, though occasional exacerbations may be observed during the whole process of exfoliation. During the second stage, the dead bone acts as a foreign body, keeping up the dis- charge, and furnishing the necessary irritation to effect its own separa- tion, and to excite the osteogenetic function of the periosteum by which the process of repair is chiefly accomplished. The time required for the separation of a necrosed portion of bone varies from a few weeks to many years: it is usually less for the upper, than for the lower extremity, and., other things being equal, is proportionably shorter, as the necrosis is more circumscribed and superficial. 564 DISEASES OF BONE. Prognosis.—The prognosis of necrosis, in the large majority of cases, is favorable. It is very seldom that the disease attacking the shaft of a bone, extends beyond the epiphyseal lines, and, after the removal of the dead part, the repair will usually be found so complete as to preserve the utility of the limb. In some very acute cases, as in necrosis result- ing from subperiosteal abscess, life may be endangered during the first stage of the affection, and at a later period, death may occasionally occur from exhaustion or from pyaemia. The latter disease not unfrequently causes a fatal result in cases of moist necrosis. Special risks attend necrosis in certain situations; thus in the skull, there is danger of secondary meningitis or cerebral abscess; in the ribs, of empyema; and in the patella, of destructive inflammation of the knee-joint—while an exfoliation from the posterior surface of the femur, may penetrate the popliteal artery and lead to fatal hemorrhage. Treatment.—The treatment of the first stage of necrosis, consists in endeavoring to moderate the inflammation upon which the affection depends, and in freely opening any abscesses which may form. During the time occupied by the loosening of the dead bone, no operative treat- ment is, as a rule, admissible, and the surgeon should content himself with such measures as may serve to maintain the patient's health. As soon as the necrosed portion has become detached (not before, unless in very exceptional cases), it should be removed, nature being rarely able to effect its extrusion—though occasionally (especially in children) a piece of dead bone will be found protruding from the soft parts, when it may be readily pulled away. In case of an exfoliation (if there is no invaginating sheath), it will be sufficient, when the bone is found by the probe to be loose, to divide the soft fjo. 274 parts, and tilt up the detached fragment or scale from the subjacent granulations, by means of a director or elevator intro- duced beneath its edge—when the loose bone may be readily drawn away with forceps. If the necrosed bone be in the form of a sequestrum, the operation is more complicated: an incision should, in this case, be made down to the bone, in the line of the principal cloacae, joining two or more of them, if there be several, in such a manner as to avoid the chief vessels and nerves. In some cases, if a cloaca be large, it may be possible to with- draw the sequestrum through it, dividing the dead bone, if necessary, into two por- tions by means of cutting-pliers previously introduced. The cloacae may be enlarged with trephines or chisels, or the portions of new bone between them may be divided with Hey's saw, gouge-forceps, or strong cutting-pliers, the sequestrum being then drawn out with suitable forceps, whole or piecemeal, as the exigencies of the case may require. It is usually possible to de- termine beforehand that a sequestrum is loose, by introducing a probe through a sequestrum forceps. cloaca, or by introducing two probes TREATMENT OF NECROSIS. 565 through different openings, when a see-saw motion may often be de- tected. It sometimes happens, however, that, at the operation, the sequestrum is found to be only partially detached, bringing with it, when wrenched away, a portion of living and vascular bony tissue. The cavity left by the removal of a sequestrum, is commonly lined by a layer of granulations—though in scrofulous cases a sequestrum may be sur- rounded with carious bone, which must then be removed with the gouge. The after-treatment consists in applying a light dressing, and in placing the limb, if the involucrum be thin, on a suitable splint, so as to pre- vent deformity from bending. In acute necrosis, resulting from subperiosteal abscess, when the whole diaphysis of a long bone has perished, Mr. Holmes recommends that the part should be removed as soon as the patient has rallied from the first shock of the affection. The operation requires a very free incision, dividing the periosteum which will be found entirely separated, the bone being then bisected with a chain-saw, and wrenched from its epiphyseal lines by means of the lion-jawed for- ceps (Fig. 297). Even if the limb be left perfectly flail-like at the time, it may be hoped that it will become consolidated, and ultimately useful. The rule which has been given, not to operate in cases of necrosis until nature has effected the separation of the dead fragment, applies particu- larly to cases of ordinary dry ne- crosis. In the moist variety of the disease, should it be recognized dur- ing life, it would be, I think, right to attempt the removal of the dead bone at an earlier period. The risk of pyaemia would probably be thus lessened, while the condition of the patient could not be seriously aggra- vated. Necrosis, affecting one of the spongy bones, as of the tarsus, or the articular extremity of a long bone, may require excision, or possi- bly amputation. The latter opera- tion may also become necessary, if the disease be so situated that the sequestrum cannot be safely re- moved, as in the femur represented in the accompanying illustration, from a case in which my colleague, Dr. W. S. Forbes, amputated at the hip-joint; or amputation may likewise be required in any case, if life be endangered from exhaustion and long-continued suppuration. Necrosis of femur, following gunshot fracture. (From a specimen in the museum of the Episco- pal Hospital.) 566 DISEASES OF BONE. Non-inflammatory Structural Diseases of Bone. Under this head, may be enumerated Hypertrophy and Atrophy, Rickets, Osteomalacia, Tubercle, Scrofula, Syphilis, and various forms of Tumor. Hypertrophy, when not the result of inflammation, appears as a form of exostosis, constituting the variety known as Osteoma (see page 474); when resulting from inflammation, it receives the name of Perios- tosis. In neither case does the affection admit of treatment. Atrophy of bone often occurs simply as a senile change, but may also result from injuries, as contusions or fractures, or from mere disuse. It is not unfrequently met with as the result of a fall, in the neck of the thigh-bone in old persons, where it gives rise to shortening and may be mistaken for fracture of the part (Fig. 276). The only admissible treatment consists in the application of a high-soled shoe. Rickets is described by many writers as a dis- ease of the bones, but is in this work considered to be a general affection, and as such has already received attention (see page 417). Osteomalacia, Mollities Ossium, or Fra- gilitas Ossium.—Two affections, according to Paget, appear to be included under these names; one, which is the more common, consists in fatty degeneration, and the other, to which the name osteomalacia should be strictly confined, consists in an absorption of the earthy constituents of bone, the part affected being more or less reduced to a cartilaginous state. The latter form of the disease attacks particularly the bones of the trunk, especially the pelvis (where in the female it may impede parturition), while the former is more common in the bones of the extremities. Several bones are usually affected. The softening process begins at the centre and spreads outwards; the cancellous structure is dilated, its cells being filled with a red jelly-like matter, consisting of fat, oil, blood, and nucleated corpuscles. If the compact structure be not involved, the bone is rendered brittle and liable to fracture, as in remarkable cases reported by Tyrrell, Arnott, and Joseph Jones, of Louisiana. If the whole thickness of the bone, on the other hand, be involved, it becomes pliable and easily bent, the most curious distortions resulting, as in the oft-quoted case of Madame Supiot. The disease seldom occurs in childhood, but usually in early adult or middle life; it is more common in women than in men, and often appears to have been induced by pregnancy or parturition. It is some- times hereditary. Symptoms.—The early symptoms are generally obscure, consisting chiefly in vague pains, which are probably considered rheumatic. Some- times the giving way of the limbs, the bones being either fractured or bent, is the first circumstance which attracts attention. The urine, and sometimes the other secretions, contain an abnormal quantity of phos- phates ; and in a case recorded by Dr. Maclntyre, the urine contained also Penile atrophy of neck of thigh-bone. TUBERCLE AND SCROFULA. 567 a large amount of animal matter of an albuminous nature. As the disease progresses, the patient becomes bedridden, and may remain in this state for many years, eventually dying from simple exhaustion, or from some independent affection; in other cases, the viscera may become fatally deranged by the pressure of the distorted bony parietes. Diagnosis.—In its early stages, osteomalacia is liable to be confounded with Rheumatism, and the diagnosis may not be possible, until the ap- pearance of phosphates in the urine, and the morbid condition of the bones, reveal the nature of the affection. From Rickets it may be dis- tinguished by observing that osteomalacia1 is a disease of adult life, and rachitis of infancy. The tendency to fracture, which gives to the disease the name of fragilitas ossium, may likewise arise from simple Atrophy, or from Cancer. The former affection maybe distinguished by investigating the history of the case, and the latter by observing the presence of car- cinomatous disease in other parts of the body. Treatment.—-The treatment of this affection is as unsatisfactory as its pathology is obscure. The surgeon can do little beyond endeavoring to maintain the general health of the patient, to prevent the formation of bed-sores, and to relieve pain by the use of opium. The internal admin- istration of alum, appeared to produce temporary benefit in the case reported by Maclntyre. Tubercle of bone is a rare affection—rarer probably than is usually believed, many cases of supposed tuberculous deposit, being in reality instances of chronic inflammation, attended by the formation of pus which becomes inspissated, and undergoes cheesy degeneration (see page 414). True tubercle does, however, apparently occur in bone, where it may be either circumscribed (encysted), or diffused (infiltrated). The circumscribed variety is the rarer, and occurs chiefly in the skull and the articular extremities of the long bones, especially the tibia; it pro- duces no disturbance until softening occurs, when it leads to an intract- able form of caries, and, if in the neighborhood of a joint, often involves the latter in a destructive form of inflammation. The diffused tubercle affects particularly the shafts of the bones, and is, according to Holmes, less apt to run into softening than the circum- scribed variety. ■ Scrofula manifests its in- fluence on the osseous system by predisposing to destructive inflammation and caries. Scro- fulous, differs from Simple Os- teitis,in its greater tendency to spread and to induce disorga- nizing changes, and in the absence or feebleness of the natural efforts at repair. The affected bone is soft, light, and oily, the proportion of fat and ' of soluble salts being increased, and that Of Calcareous matter Scrofulous osteitis; magnified 230 diameters. 1 Osteomalacia is sometimes called Rachitis Adultorum. 568 DISEASES OF BONE. and of the organic matrix markedly diminished. The symptoms of scro- fulous osteitis are those of scrofula in general, superadded to a chronic and indolent form of bony inflammation. The treatment consists in the administration of remedies adapted to the scrofulous diathesis, with such local measures as may, if possible, prevent the occurrence of suppuration. After the subsidence of the acute symptoms, advantage may be often derived from pressure, applied by strapping the part with the compound galbanum, or with soap plaster. Should suppuration occur, the resulting caries must be treated as directed in the preceding pages, it being re- membered, however, that the prognosis of operations, in both scrofulous and tuberculous cases, is less favorable than when there is no constitu- tional taint (see pages 415 and 417). Syphilitic Affections of Bone have already been referred to at page 449. Tumors in Bone.—1. Cystic Growths in bone may occur as independent formations, or may be secondarily developed in solid tumors. Serous and Mucous Cysts are met with in the jaws, and possibly in other bones. They form smooth, indolent tumors, and, when large, give a sensation of semi-fluctuation, with a peculiar crackling sound, from the thinning of their bony investment; the superficial veins are often enlarged and tortuous. The treatment consists in removing a portion of the wall, with a trephine, or otherwise, the cavity being then stuffed with lint, so as to induce contraction and healing by granulation. Hydatids occurring in bone would closely simulate the simple cystic formations above referred to: the treatment should consist in excision or amputation, according to the part affected. Sanguineous Cysts.—Travers excised the greater part of a clavicle, on account of a cystic tumor containing blood. In most instances, sanguineous cysts appear in connection with solid growths, of a fibro- cellular, fibro-cartilaginous, myeloid, or malignant character. The treat- ment consists in excision or amputation, according to the situation and extent of the growth. 2. Non-Malignant Solid Tumors.—The non-malignant solid tumors met with in bone, belong ordinarily to the fibrous, cartilaginous, myeloid, and osseous varieties. The symptoms and treatment of these various affections, have been sufficiently considered in Chap XXVI. A caution may, however, be here given as to the removal of a bony tumor from the neighborhood of a joint: in this situation, exostoses frequently induce repeated attacks of synovitis, which may leave the synovial sac so thickened and dilated, that it is exposed to injury in any attempt to remove the growth. Hence, it is better, as a rule, not to interfere with these tumors, unless in a locality where no special risk can attend the operation. In dealing with any non-malignant tumor of bone, enuclea- tion may (as pointed out by Paget) be occasionally preferable to ex- cision or amputation. 3. Malignant Tumors.—Any form of malignant tumor may occur in bone, by far the most frequent, however, being the encephaloid, or medullary cancer. This may originate in the interior of a bone, when it is said to be central or interstitial, or may be primarily developed in and beneath the periosteum, when it is called periosteal or peripheral. In other instances it is said to be infiltrated, when the whole bone is softened and MALIGNANT TUMORS. 569 filled with cancerous material—a condition'which, as already remarked, has been confounded with osteomalacia. The central or interstitial cancer occurs chiefly in the cancellated structure of the flat bones and of the articular extremities of the long bones, producing long-continued pain, and (if in a long bone) often pre- disposing to fracture. As the tumor increases in size, the bone wall under- goes expansion, becoming thinned, and crackling on pressure (whence the old name "spina ventosa"), until finally the morbid growth makes its escape, when it grows with renewed rapidity. The peripheral or periosteal cancer occurs principally in or beneath the periosteal covering of the shafts of the long bones, the bony tissue itself re- maining comparatively free from dis- ease, though it occasionally becomes softened, when fracture may occur. In this form of cancer, partial ossification not unfrequently takes place. Symptoms.—The symptoms of cancer in bone, are the presence of a rapidly growing lobulated tumor, elastic and semi-fluctuating to the touch, with sharp lancinating pains, and great distension of the subcutaneous veins. A thrilling pulsation, sometimes ac- companied with a blowing sound, is occasionally perceptible. As the disease advances, the neighboring soft tissues. and lymphatic glands become involved, while the " cancerous cachexia" is often rapidly developed. Diagnosis.—Cancer occurring in bone is to be distinguished from Abscess, by the history of the case, the lobulated character of the tumor, the absence of inflammatory symptoms, and, if necessary, by the employ- ment of the exploring-needle. From partially consolidated Aneurism, and from Aneurism by Anastomosis, it may usually be distinguished by attention to the early history of the case, when this can be ascertained. From Non-malignant Tumors, especially the myeloid or enchondroma- tous, the diagnosis is often difficult, and may be occasionally impossi- ble, except by the aid of a microscopic examination. Treatment.—This consists in excision or amputation : excision is to be employed in the case of the flat bones (as the scapula), or those of the face (as the upper jaw), but is rarely justifiable if the disease have passed the limits of the bone itself, involving the soft structures or lym- phatic glands. Amputation is to be preferred in the case of the long bones, and should be performed at as early a period as possible. It is usually advised to remove the limb at or above the nearest joint, but it would appear from cases recorded by Collis, Pemberton, and others, that amputation in the continuity, or through the epiphyseal line, may occasionally suffice: probably a safe rule would be, in the case of the forearm or leg to remove the limb just above the elbow or knee, in that of the humerus at the shoulder-joint, and in that of the femur (unfor- tunately the most common of all) at as low a point as would insure the removal of the whole disease. Medullary cancer of humerus. 570 DISEASES OF JOINTS. 4. Pulsating Tumors of Bone.—Most of the pulsating tumors met with in bone are in reality of an encephaloid or myeloid character; some, however, are probably of the nature of aneurism by anastomosis, and still others, possibly, true aneurisms of the osseous arteries. The latter alone should receive the name of Osteoid Aneurism. The disease origi- nates in the cancellated structure (usually of the head of the tibia), aud gradually distends the compact wall, which becomes thin and yielding, crackles on pressure, and finally gives way. When fully developed, the affection is attended with a marked pulsation usually accompanied with thrill: by compressing the main trunk, the pulsation stops, and the tumor may then be emptied by pressure, a cavity surrounded by a bony wall being perceptible. The pulsation may disappear when the resistance of the periosteum is overcome. The bruit, which is commonly distinct in pulsating encephaloid of bone, is often absent in the osteoid aneurism. In the treatment of this affection, the surgeon may (if the tumor be small and situated in one of the long bones) attempt extirpation of the growth with the knife, or, which is probably better, with caustics or the hot iron: if excision be practised, the surface of bone from which the disease springs should be likewise removed. Ligation of the main artery has been occasionally employed, but usually with only temporary if any benefit. If the disease be far advanced, or if other measures have failed, amputation, as in malignant disease, is the only resource. Pulsating Tumors of the Cranial or Trunk Bones are almost invariably of an encephaloid character, and rarely admit of successful treatment. , CHAPTER XXXI. DISEASES OF JOINTS. The older surgeons confounded together all diseases of the joints, under the common names of arthritis and white swelling, and it is within a comparatively recent period only, and in a great measure through the labors of Sir Benjamin C. Brodie, that a more accurate classification has become possible. The tendency, at the present day, as justly re- marked by Holmes, is to run to excess in the other direction; and the student is apt to be confused by the minute divisions of systematic writers, and to be disappointed, on entering practice, to find that he is unable to discriminate between affections, which are actually indistin- guishable, and which in the large majority of instances really coexist in the same cases. The various constituents of a joint, synovial membrane, cartilages, bony articulations, etc., are so intimately connected with each other, that a morbid condition of one is almost sure to involve the others secondarily. An exception should, perhaps, be made in the case of the synovial membrane, and I shall, therefore, in the following pages, first describe the affections which are limited to that tissue, considering, sub- sequently, those which involve the joints as a whole. Synovitis. Inflammation of the synovial membrane may arise from traumatic causes, or from exposure to cold; it may be uncomplicated, may be SYNOVITIS. 571 modified by the patient's being of a scrofulous, rheumatic, or gouty dia- thesis, or maybe a mere secondary occurrence in the course of puerperal fever, pyaemia, gonorrhcea, or syphilis. Simple or uncomplicated synovitis may be acute or chronic, the difference being comparative, and referring to the intensity of the affection, rather than to any specific diversity. Pathology.—The first effect of inflammation on a synovial membrane is to produce increased vascularity, with a diminution of the natural shining appearauce of the part. The amount of synovia is abnormally increased, being at first thin and serous, but subsequently cloudy, from the admixture of shreds of epithelium, inflammatory lymph, the coloring matter of the blood, and (if the disease be not checked) pus. In many cases, the disease terminates in resolution, the parts gradually resuming their natural state, or perhaps remaining somewhat thickened, where there is a liability to relapse: occasionally the joint is left distended by serous effusion, constituting the condition known as Hydrarthrosis, or Hydrops Articuli. In other instances, further morbid changes are ob- served: the synovial membrane assumes in parts an appearance of granulation, and, while the intra-articular effusion becomes purulent in character, the cartilages become involved and perforated by ulceration, until finally the articulating extremities of the bones themselves may become inflamed and carious. At the same time, the surrounding tissues, which at first were inflamed and infiltrated with lymph, undergo disor- ganization; abscesses form, and make their way into the joint, or toward the surface, upon which they open by sinuous tracks: the ligamentous structures become elongated, thickened, and softened, and partial or complete dislocation may occur. Symptoms.—The symptoms are usually well marked. There is pain, often accompanied by a feeling of distension, and usually referred to the affected joint, but occasionally to others ; thus pain in the knee attends inflammation of the hip. The pain is increased by motion or pressure, is often worse at night, and in some cases (as in the synovitis of pyaemia) is attended by marked cutaneous hyperaesthesia. Swelling, varying with the amount of intra-articular effusion, is a characteristic symptom—the shape of the joint being altered by the distension of the synovial capsule. In the shoulder and hip, this alteration consists in a general enlargement of the part, while in the elbow, the swelling is most marked on either side of the olecranon and beneath the tendon of the triceps, and in the knee, on either side of the patella (which floats on the effusion) and beneath the tendon of the quadriceps femoris. Fluctuation, which is distinct in the early stages, when the effusion is of a serous character, becomes less so as the disease advances, from the production of inflam- matory lymph and the infiltration of surrounding structures. Heat and redness vary according to the superficial or deep character of the joint, and the degree to which the superincumbent tissues are involved. The position in which the patient involuntarily places the joint, is character- istic : in the early stages, this position is such as to allow the greatest mechanical distension of the synovial capsule, while at a later period, it is determined by the weight of the limb, by the necessity of maintaining the joint in a fixed position and of preserving it from the pressure of external objects, and lastly by the neighboring muscles becoming fixed in the positions which they have been permitted to assume. When synovitis ends in resolution, or subsides into a chronic state, the symptoms which have been described gradually pass away, the in- 572 DISEASES OF JOINTS. fiammatory fever (which runs high in the acute stage) diminishing, and the part gradually returning, more or less completely, to its normal condition. The swelling may, however, as already mentioned, persist in chronic synovitis, constituting hydrarthrosis; while in some cases a peculiar crepitation or crackling may be developed by moving the part, due apparently to the rubbing together of bands and adhesions which have resulted from the organization of inflammatory lymph. The occurrence of suppuration in a joint (pyarthrosis) is marked by an increase of all the symptoms, and by the occurrence of rigors—while the accompanying inflammatory fever assumes a somewhat typhoid type. Abscesses form in the surrounding soft parts, the articular cap- sule gives way, and the contents of the joint are evacuated; recovery, if obtained at all, is effected by the obliteration of the articular cavity by a process of granulation and cicatrization, partial or complete stiffness or anchylosis resulting. When the disease invades the articular cartilages and bones, passing in fact into what will be presently described as Arthritis, the pain be- comes much aggravated, assuming a peculiar "jumping" or "starting" character (usually worst at night), and often accompanied by a distinct grating, on rubbing the articulating surfaces together. Treatment.—The Constitutional Treatment of synovitis presents no peculiarities requiring special comment, being essentially that directed in Chapter II., for any case of severe inflammation. Rheumatic, gonorrhoeal, or syphilitic complications require various modifications, according to the circumstances of the case. In the Local Treatment of synovitis (during the acute stage), great benefit will often be de- rived from the application of dry cold, in the form of Esmarch's ice- bag, or by the method of mediate irrigation (page 56). In other cases, it may be better to surround the joint with a warm poultice, medicated with laudanum or hops; that application should be preferred which is most agreeable to the patient. In every case, the joint should be placed at complete rest, and in such a position as will secure the greatest use- fulness should anchylosis occur. For this purpose the limb should be fixed upon a well-padded splint, or in a suitable fracture-box, the mechani- cal support being so arranged as to prevent even the slightest motion of the affected joint. When the acute symptoms have subsided, absorption of effusion and restoration of function may be promoted, by the repeated application of blisters or tincture of iodine, together with douches, frictions with stimulating embrocations, moderate pressure by means of a soap plaster and bandage, and the cautious employment of passive motion, if any tendency to stiffness be observed. If the joint be left in a relaxed con- dition, the patient should continue to wear an elastic support for some time after recovery. Hydrarthrosis or Hydrops Articuli (Dropsy of a Joint) is almost invariably a result of chronic synovitis; it would appear, however, from the observations of Richet and others, that it may occasionally occur a3 a primary affection. Hydrarthrosis is most common in the knee, and is occasionally seen in the elbow, but very rarely in any other joint. The effused fluid differs from ordinary synovia, resembling more the contents of a hydrocele, or the fluid met with in ascites. This affection is often associated with a gouty or rheumatic diathesis, and is apt to recur from very slight causes. The treatment (in the event of the failure of the ARTHRITIS. 573 ordinary remedies for chronic synovitis) consists in the injection of the tincture of iodine, either pure or diluted. A portion of the effused liquid should be first evacuated by means of a small trocar and canula, intro- duced through a valvular incision; the iodine is then injected (not more than a fluiclrachm of the tincture being used at once), and after remain- ing for a few minutes is again withdrawn, precautions being taken against the admission of air, and the wound being immediately sealed with collodion. Any inflammation which may result should be treated in the way already described. This mode of treatment has been used with great success by several French and German surgeons, and is favorably spoken of by Mr. Erichsen; as, however, the plan is necessarily attended with some risk, it should not be employed except in very chronic cases which have resisted other modes of treatment, and in which the distension of the joint is productive of great inconvenience. Pyarthrosis or Abscess of a Joint may, as has been mentioned, result from acute synovitis—or may accompany a more serious condi- tion, such as arthritis, subperiosteal abscess, or osteo-myelitis—or may be a mere incident in the course of pyaemia. If the diagnosis of intra- articular abscess be not clear, the surgeon may, in the case of the super- ficial joints, satisfy himself as to the nature of the case by the use of an exploring or suction trocar. The treatment consists in evacuating the pus by means of a free incision, drainage being secured by position, or by the use of Chassaignac's tubes or Ellis's wire coil (see p. 381). In some cases, advantage may be derived from washing out the joint by injecting diluted tincture of iodine, or a weak solution of carbolic acid. In favorable cases, especially in children, recovery by anchylosis may be obtained; but should the strength of the patient begin to flag, no time should be lost in resorting to excision or amputation—the former opera- tion being, under these circumstances, as a rule, applicable to the upper, and the latter to the lower extremity. Death after pyarthrosis may result from simple exhaustion, or from the development of pyaemia. Arthritis. By Arthritis is meant inflammation of a joint as a whole; whichever tissue may have been first attacked, the remainder are sooner or later implicated. Arthritis usually begins with inflammation of the synovial membrane, or of the articulating extremities of the bones; more rarely the ligaments, and surrounding soft parts, are first involved, but it is doubtful whether the articular cartilages are ever affected, except sec- ondarily. Gelatinous Arthritis.—The origin of arthritis in ordinary Syno- vitis, has already been considered; there is, however, a form of chronic synovitis, called by Barwell strumous, and by Athol Johnson scrofu- lous—but which, as justly remarked by Swain, may exist without any evidences of a scrofulous diathesis—in which the synovial membrane is found in a pulpy or gelatinous condition, and which almost invariably ends in destructive disorganization of the joint. This condition of the synovial membrane is described by Brodie and Swain as a peculiar form of degeneration, called by the former pulpy, and by the latter gelatini- form degeneration; Barwell, on the other hand, regards it as essentially the same as the granulation change referred to in speaking of the pa- thology of synovitis in general, the difference being, that in ordiuary 574 DISEASES OF JOINTS. synovitis this granulation tissue undergoes further development, while in the cases now under consideration it remains in a rudimentary state. As the disease progresses, the articular cartilages undergo a somewhat analogous change, to which Erichsen gives the name of fibro-cellular de- generation, the disease finally reaching the bones, which become softened and carious. The symptoms of this peculiar form of disease, which might be appropriately called Gelatinous Arthritis, and which is rarely Fig. 279. Gelatinous arthritis of elbow. seen, except in the knee and elbow, and in adults, differ from those of ordinary synovitis in several particulars. Thus the swelling is more diffused, and comparatively unattended with fluctuation, being of a doughy and somewhat elastic type—this elasticity, as pointed out by Fergusson, causing the bones, if pressed together, to resume their former position when the pressure is removed. The swelling is often accom- panied, and partially masked, by general oedema of the limb. The p)ain is less marked than in synovitis, and of a dull, gnawing character, dif- fering both from the acute pain of ordinary synovitis, and from the "jumping" pain which attends exposure of the bone by ulcerating car- tilage. There is little or no heat, and if the part be at first red, the sur- face soon loses its color, often becoming eventually positively blanched— SYMPTOMS OF ARTHRITIS. 575 an appearance so characteristic as almost to justify the name of white sir citing formerly given to these cases. Another point, to which Swain calls attention, is that considerable mobility of the joint often remains, even when the disease has reached an advanced stage. Arthritis from Bone Disease, etc.—Arthritis begins, in many cases, with a morbid condition of the bones, which enter into the formation of the joint—this condition consisting of diffuse periostitis (subperi- osteal abscess), osteo-myelitis, necrosis, caries, tuberculous deposit, or (which is probably the most common) a low form of osteitis of the arti- culating extremities, which is often described as strumous, but which has no necessary connection with the scrofulous diathesis (see page 414). Arthritis may likewise begin with inflammation of the Ligaments and other peri-articular structures (as after sprains), and it may possibly (in cases of wound, for instance) originate in primary inflammation of the Articular Cartilage. Causes of Arthritis.—Among the causes of arthritis may be enu- merated wounds (see page 210), sprains, contusions, exposure to cold and moisture, pyaemia, the puerperal state, scarlet fever, the deposit of tubercle, the scrofulous diathesis, etc. Symptoms.—The symptoms of arthritis are those of deep-seated inflammation ; they often begin very insidiously, but when fully estab- lished are easily recognized. The swelling is more uniform than in syno- vitis, and doughy rather than fluctuating to the touch; the pain, which is specially referred in the case of the knee to the inside of that joint, and in the case of the hip to a point above and behind the great tro- chanter, is excessive, worst at night, aggravated by the slightest touch, or by motion of the part, and accompanied (when the disease is fully developed) by spasmodic contractions of the adjoining muscles, giving it the peculiar "jumping" or "starting" character which has been already referred to. These spasms occur particularly at night, coming on when the muscular system is relaxed by sleep, and often causing the patient to wake with a scream. These "jumping" pains have long been associated with ulceration of the articular cartilages, and were formerly supposed to be due to the condition of those structures; it is now, how- ever, generally acknowledged that inflammation and ulceration of carti- lage is not, in itself, attended with pain (cartilage containing no nerves), and that the peculiar starting pains of arthritis are really due to the condition of the plate of bone immediately beneath the seat of ulcer- ation. When the cartilaginous disintegration has gone so far as to lay bare opposing surfaces of bone, they will rub together when the joint is moved, and distinct grating may thus be produced. The position as- sumed by the patient, in a case of arthritis, is quite characteristic: the affected joint is so placed as to enable it to be kept fixed, and to be most thoroughly relaxed; thus, in the case of the knee, the patient lies on the affected side, with the outside of the joint resting on the bed, the leg flexed on the thigh, and the thigh on the pelvis—the opposite knee drawn up so as to serve as a guard, and to keep off the weight of the bed- clothes—and the whole attention apparently concentrated and directed to shield the diseased part from injury. The inflammatory fever is severe, assuming a typhoid type if suppuration occurs, and perhaps yield- ing to hectic in the advanced stages of the disease. 576 DISEASES OF JOINTS. Fig. 280. The symptoms which accompany the occurrence of suppuration in cases of arthritis, are very much the same as were described in speaking of pyarthrosis from synovitis. Pointing sometimes takes place at a comparatively early period, but in other cases the pus, after escaping from the cavity of the joint, dissects up the muscular interspaces of the limb for some distance before making its appearance on the surface. Occasionally all the evidences of suppuration may have been present, including even relaxation of the articular ligaments (as shown by un- natural mobility, or the occurrence of dislocation) and distinct grating on motion, and yet recovery may ensue under judicious treatment, with- out any discharge of pus, though with more or less complete anchylosis. In these cases the pus, or at least its fluid portion, has probably been ab- sorbed, the pus corpuscles undergoing fatty or calcareous degeneration. It is in such cases as these that residual abscesses are sometimes observed after considerable in- tervals of time (see p. 382). When arthritis of a large joint, as the hip or knee, has advanced to the stage of abscess, the pros- pects of spontaneous recovery are usually very limited. In some cases, particularly among those whose social condition secures to them careful nursing, abundant nutri- ment, opportunity for change of air, and other favoring circumstances, a cure by anchylosis may be obtained, the opposing joint surfaces becoming united by granula- tions which are subsequently organized into a fibrous or imperfect bony tissue; but in most instances, and as a rule with hospital patients, unless rescued by opera- tion, such cases eventually terminate in death, from exhaustion, diarrhoea, or pyae- mia, or from phthisis or other disease of internal viscera. Arthritis of the smaller joints offers a much more favorable prognosis. Treatment. — The Constitutional Treatment of arthritis consists pretty much in the administration of anodyne diaphoretics, with occa- sional mild laxatives, during the acute stage—followed by tonics, especially iron and cod-liver oil, at a later period. Mercurials, which may be proper in traumatic arthritis, should be used, if at all, with great caution in these cases—medicines of any form being, indeed, of less im- portance than nutriment, which should be given abundantly and in an easily assimilable form. The most important part of the Local Treatment is to place the joint in a state of complete and long-continued rest, and in a favorable posi- tion. If the shoulder be affected, the arm should be kept to the side, and directed somewhat forwards, while the elbow, if diseased, should be maintained in a flexed, and the wrist, hip, or knee in a straight or ex- tended position. In all cases in which the lower extremity is involved, the foot should be properly supported, so that when recovery is obtained the patient may not be left with apes equinus. It is recommended by many excellent authorities, that if the limb be found in a vicious posi- tion, it should be forcibly placed right, while the patient is under the influence of an anaesthetic, any resisting muscles or tendons being sub- Arthritis of knee-joint, in an. ad- vanced stage. (From a patient in the Children's Hospital.) TREATMENT OF ARTHRITIS. 577 Fig. 281. cutaneously divided if necessary. I think, however, that the object may be, in many cases, quite as well and more safely accomplished by the use of continuous extension, applied by means of elastic bands, or, which is more convenient, by means of the ordinary weight-extension apparatus (see Fig. 125). When the limb has been brought into the proper position, it should be fixed, with well-padded splints or fracture-boxes, or, if the sur- geon prefer, with some form of immovable apparatus, an aperture being cut so as to allow of inspection and topical medication of the joint. In many cases of arthritis, particularly if affecting the knee or hip, the greatest advantage may be derived from the use of continuous extension, which may be applied with Barwell's splint, in which the extension is effected by an India-rubber accumulator, or (which I prefer) with the ordinary weight-extension apparatus—a mode of treatment which was used by Brodie, and which has been since successfully resorted to by numerous surgeons. The efficacy of this simple ap- paratus may be still further increased by the appli- cation of lateral long splints or sand-bags. The relief from pain afforded by continuous extension in cases of joint disease is very marked. It appears to act by counteracting the tendency to muscular spasm, and thus preventing the inflamed ends of bone from being pressed together. With regard to topical medication in cases of ar- thritis, the best application during the acute stage is, I think, usually a warm poultice, though in some instances, dry cold appears to afford more relief. Leeches may be required in some cases. When the first acute symptoms have subsided, benefit may often be derived from counter-irritation in the form of blisters, or the actual cautery. The cautery should be applied before the occurrence of suppuration (the patient being anaesthetized), by drawing the iron, heated to a black heat only, rapidly across the joint, in lines at least an inch apart; it is not neces- sary to produce a slough, and the surrounding parts may be protected (as recommended by Yoillemier) by coating the whole with collodion, the cautery thus only affecting the part which it absolutely touches. Nelaton suggests the use of a metal ruler, as a guide to the lines in which the cautery is to be applied. The hot iron, though doubtless an efficient remedy, is one to which all patients have a feeling of repulsion, and should, therefore, I think, be reserved for very urgent cases. Blis- tering I have usually found quite satisfactory; the blister should be placed over the seat of greatest pain, and it is better to use a small than a large blister, repeating it if necessary. In the chronic stages, great advantage may be derived from painting the part with iodine, and from the use of pressure applied by means of a soap plaster and firm bandage. If suppuration occur, the case must be treated by free incisions, etc., as directed in speaking of pyarthrosis; if the bones be but slightly involved, recovery may still be sometimes obtained by perseverance in conserva- tive treatment, but under opposite circumstances, excision or amputa- tion will usually be indicated, if the joint be so situated as to admit of 37 Barwell's splint for making continuous ex- tension. 578 DISEASES OF JOINTS. operative interference. In cases of gelatinous arthritis, the chances of spontaneous recovery are so slight, that excision is indicated at a com- paratively early period. The account which has been given above of arthritis in general, will suffice for a description of the affection as met with in most of the articu- lations, as the shoulder, elbow, wrist, knee, ankle, tarsal joints, etc. There are, however, two situations in which arthritis occurs, which impress certain peculiarities on the disease, requiring more detailed con- sideration; these are the hip, and the sacro-iliac articulation. Arthritis of the Hip-joint, Morbus Coxarius, Coxalgia, or Hip Disease, is an affection of early life (more than two-thirds of all cases occurring in persons under fifteen years of age), and is much com- moner in boys than in girls.1 Three varieties of the disease are recog- nized by Erichsen, according as it begins in the head of the femur, the acetabulum, or the proper structures of the joint (especially the synovial membrane); and this division being, in some respects, convenient, I shall follow that author in speaking of femoral, acetabular, and arthritic coxalgia. Nature.—The nature of hip disease has been a matter of much dispute, many distinguished surgeons looking upon it as almost always, if not invariably, a constitutional affection, depending upon a tuberculous or scrofulous diathesis. The remarks made in a previous chapter upon struma, are particularly applicable here; while it is probable that, in a few cases at least, a deposit of tubercle does lead to hip disease, and while there can be no doubt that the scrofulous diathesis does act as a predisposing cause of the affection, there can be as little doubt, I think, in the light of modern pathology, that many if not most cases are simply of an inflammatory nature; and that, in a majority of instances, the dis- ease is to be looked upon as having a local origin, and (which is of the highest importance, in a practical point of view) -as specially demanding local treatment. Causes. — The exciting causes of hip disease are usually of an ap- parently trivial character, such as slight blows or falls, sprains, over- exertion in walking, or sitting on cold steps, or in wet grass. Symptoms.—The symptoms of the affection vary in its different stages, three of which are commonly described by surgical writers. Hip disease usually begins very insidiously, obscure pains, which are probably con- sidered rheumatic, and a limping or shuffling gait, often existing for some time before any deformity is discovered. (1.) Pain is felt in the affected joint and in the corresponding knee, the latter symptom being most marked in the femoral form of the disease, and apparently due to irritation of branches of the anterior crural and obturator nerves. The pain in the hip is constant in the arthritic form, of a very acute type, and accompanied with a feeling of tension, and with tenderness above the great trochanter. It is increased by-motion or ex- ercise, and is, therefore, worse in the evening, but the "starting" pains caused by muscular spasm do not come on until a comparatively late period. In the femoral and acetabular varieties, the hip pain is of a dull gnawing character, worse at night, often intermittent, and specially 1 Of 100 consecutive admissions for hip disease into the Children's Hospital of this city, 61 were of boys and 39 of girls. Again, of 208 cases of excision for hip disease in which the sex of the patient was ascertained, 142 were in males, and 66 in females {Penna. Hosp. Reports, vol. ii., p. 148). HIP DISEASE. 579 elicited by striking on the knee or heel, and thus pressing the joint sur- faces together; starting of the limb is developed at an early period. Of course, as the disease advances, in whatever form it may have originated, the different symptoms become merged together, so that these distinctions are only available in the earliest stage of the affection. (2.) Swelling is most marked in the arthritic variety, which may be looked upon as the acute form of the disease. Redness and Heat are rarely observed in any case, on account of the deep situation of the joint. (3.) Deformity.—In the first stage of hip disease, the knee is slightly flexed, and the limb usually but not always abducted—this position being involuntarily assumed, as most easy to the patient. Slight limping accompanies this stage of the disease. The second stage is marked by flattening of the buttock, the fold of the nates on the affected side be- coming almost if not quite obliterated; with this, there is elongation of the limb, which in the large majority of cases is apparent merely, being due to a twist of the pelvis, though in the arthritic form of the disease there may possibly be in some instances true elongation, from distension of the synovial capsule. When in this stage the patient stands, the whole weight is borne by the sound limb, that which is diseased being carried forward, flexed, and abducted. If now he be placed in the recumbent posture, the limbs may be brought to the same level, the deformity ap- parently disappearing; but by careful examination it will be found that Fig. 282. • Fig. 283. Hip disease in second stage; showing flatten- Hip disease in third stage; showing shortening ing of huttock, with apparent elongation. and adduction, with obliquity of pelvis. (From a patient in the Children's Hospital.) the relative position of the thigh and pelvis is the same as in the standing posture, the lumbar spine being unduly arched, and the pelvis distorted into an abnormally vertical position. In this stage there is marked lameness, and it is to this stage also that the pain in the knee particu- 737 580 DISEASES OF JOINTS. larly belongs. In the acetabular variety of the disease there is compara- tively little deformity, while in the femoral, there may be, as long as the patient is going about, apparent shortening (due to distortion of the pelvis), which, however yields to apparent lengthening, after a few days' rest in bed. The deformity of the third stage (between which and the second there may be an interval of comparative comfort) consists in adduction of the limb (Fig. 283), leading to shortening which is greater in appearance than in reality, with undue prominence of the buttock on Fig. 285. Perforation of the pelvic bones in acetabular coxalgia. Excised head and neck of femur ; showing change in shape of bone in third stage of hip disease (see Tig. 2S3). (The specimen is in the Mutter Museum of the College of Physicians of Phila- delphia.) the affected side, marked obliquity of the pelvis, and a compensatory double lateral cur- vature of the spine. The rima natium, which in the second stage inclined towards the affected side (Fig. 282), is now directed away from it. The shortening of the third stage of hip disease, is, at the beginning of that stage, merely apparent; as the malady progresses, however, actual shortening occurs, from alteration in the shape of the bones which enter into the formation of the joint (Fig. 284), and in some cases, though in fewer than was formerly supposed, from positive dislocation taking place. (4.) Dislocation is chiefly confined to the femoral variety of the disease, and its occurrence is often attended with marked relief from pain; if, as sometimes happens, it takes place without the previous formation of abscess, a new socket may be developed upon the dorsum ilii, the aceta- bulum becoming gradually filled up and obliterated. In the acetabular form of the affection the cotyloid cavity may become perforated (Fig. 285), the head of the femur perhaps slipping through into the cavity of the pelvis. (5.) Suppuration may or may not occur in the arthritic form of hip disease, but is almost inevitable in the other varieties. It occurs earlier in the acetabular, than in the femoral form of the affection. The spot at which pointing occurs is often significant; thus an abscess opening on the outer part of the thigh, below the trochanter, indicates disease of the caput femoris, while abscesses opening in the pubic region denote disease of the acetabulum—the abscess being intra- or extra-pelvic ac- cording as it opens above or below Poupart's ligament. Abscess opening in the gluteal region may indicate either form of the affection. Terminations of Hip Disease___The arthritic and occasionally the other forms of the disease, if submitted to judicious treatment at an DIAGNOSIS AND PROGNOSIS OF HIP DISEASE. 581 Fig. 286. Deformity resulting from double hip dis- ease. (From a patient under the care of Dr. Hodge, in the Children's Hospital.) early period, may terminate favorably, though in many cases the best that can be hoped for, is a cure by anchylosis. Even if the joint be anchylosed, provided that the limb have been kept in a straight position, the result will be quite satisfactory, the mobility of the pelvis compensating in a great degree for the stiffness of the joint; but unless precautions have been taken with regard to position, anchy- losis with great deformity will ensue, such distortion as is exhibited in the accompanying cut, being by no means unfrequently met with. If suppuration have occurred, and therefore we may say as a rule in cases of acetabular or femoral coxalgia (particularly if fol- lowed by consecutive dislocation), the utmost that can usually be attained by conservative measures is recovery with a shortened, deformed, atrophied, and often useless limb. Death may occur from simple exhaustion, diarrhoea, tuber- culosis, amyloid degeneration, or pyaemia, or from some intercurrent affection which would have been successfully re- sisted but for the constantly depressing influence of the joint affection. Diagnosis.—Hip disease may be distinguished from rheumatism, by observing the limitation of the affection to one joint, and by noting the characteristic deformity. From lateral curvature of the spine with neu- ralgic tenderness, it may be distinguished by the pain being increased by pressing together the joint surfaces, and by the existence of painful nocturnal spasms, while the diagnosis from antero-posterior curvature of the spine, may be made by observing the mobility of the hip in that disease, and the different seat of pain—though if the abscess in spinal disease point on the outer side of the thigh, pressing on filaments of the obturator nerve, there will be pain referred to the knee, just as in hip disease. Morbus coxarius could only be mistaken for abscess external to the joint, for disease of the knee, or for caries of the great trochanter, by neglect of careful examination. From sacro-iliac disease, the diagnosis may be made by observing that in that affection the seat of greatest tenderness is different, that there is no shortening, and no pain on moving the hip if the pelvis be fixed, and that the pelvic distortion is permanent and absolute, not, as in hip disease, temporary and relative. The diagnosis from separation of the upper epiphysis of the femur with abscess, is difficult, if not impossible—a matter which, fortunately, is of no practical moment, as excision would be equally indicated in either affection. Prognosis.—Statistics are wanting to show the mortality of hip disease, it being but seldom, from the chronic nature of the affection, that the surgeon has the opportunity of watching a case to its termina- tion. My own impression is very decided, that, when suppuration has occurred, the bones being involved, recovery without operation is an extremely rare occurrence: this impression is confirmed by the results of 9 terminated cases observed by Gibert, which gave 8 deaths and but 1 582 DISEASES OF JOINTS. recovery. It is true that hip disease does not appear very frequently in our mortuary records, but this is owing to the fact that the patients are carried off by secondary complications or intercurrent affections, to which the death is attributed—no reference being made to the chronic condition, without which those affections would not have occurred, or would not have proved fatal. Femoral, and still more acetabular coxalgia, may be therefore looked upon as extremely grave diseases; the arthritic form of the affection, however, offers, as already mentioned, a much more favor- able prognosis. Treatment.—It is very important that early treatment should be adopted in every case of hip disease, and accordingly a rigid examina- tion of the case should be instituted on the slightest suspicion of the existence of this serious affection. During the first stage of the disease, the patient should be put to bed, and the joint kept in a state of com- plete rest by the adaptation of a suitable splint. I myself employ an ordinary long thigh-splint, well padded; but the surgeon may use with equally good results the carved splint of Dr. Physick, or one moulded from gutta-percha, leather, or pasteboard, or splints made from wire gauze, as recommended by Barwell and Bauer, or finally any of the forms of immovable apparatus which were described at page 83. The particular form of splint used is a matter of indifference, provided the limb be kept in a proper position, and the joint in a state of absolute rest. To relieve pain, especially the starting pain which is one of the most distressing symptoms of the affection, continuous extension is a most valuable adjuvant to rest. The ordinary weight-extension appa- ratus may be used, as in cases of fractured thigh, or Barwell's elastic "accumulator" may be employed instead. The simple weight is the most convenient means, and is, according to my experience, very efficient. I have not, myself, found it necessary to resort to subcutaneous division of the tendons or spasmodically contracted muscles, an operation which has, however, been successfully employed by Bonnet, Bauer, Sayre, and other surgeons. If the affection have run onto the second stage, the same treatment is to be employed, together with counter-irritation by blisters or the cautery, applied to the seat of greatest pain, usually a little above and behind the great trochanter; the general condition of the patient must at the same time receive attention, the state of the digestive organs being looked to, and the strength maintained by the administration of food and tonics, especially iron and cod-liver oil. In most cases of arthritic coxalgia, and in some at least of the femoral variety, if the treatment above described be early adopted and strictly carried out, a marked improvement will soon be manifested, the pain and tenderness gradually disappearing, till at length motion of the joint is no longer productive of suffering, and the patient feels and considers himself well. The time required for this favorable evolution of events, is of course variable, six or eight weeks being probably a minimum period. If now all further treatment be neglected, the disease will in a short time almost inevitably recur, and probably in an aggravated form; and yet it is very important that the patient should be no longer con- fined to bed, but should be enabled to take exercise in the open air. It is in these circumstances, I think, that the ingenious forms of apparatus devised by Davis, Sayre, Andrews, Agnew, Taylor, and other American surgeons, are particularly serviceable: they act by keeping up extension and counter-extension, while the patient is enabled to walk about and lead a comparatively active life. Fig. 287. TREATMENT OF HIP DISEASE, Fig. 288. 583 Fig. 289. £&) ]^ Davis's splint applied. Sayre's apparatus applied. Agnew's apparatus for coxalgia. In the'.third stage of the disease, the treatment already advised is still applicable, extension being here particularly indicated inorde to prevent or counteract the tendency to shortening. I abc*s form nowT'J1"11 rj ^ be tinned, counter-irritation beh,^howev^ capsule^^Itendin?86 WH "♦ ^ ab8C6SS °ri°inate with™ & ^7Z KciSSfbtl *hre+aten«g to rupture the latter, the pus may the eXn^ of T^ ° 5 V°c/™nicaimla' with precautions against ine entranCe 0f air, as advised by Dr. Bauer. Under other circum- stances, the abscess should, I think, be treated on the genera princiZ f pusTdS ffi£ o82' Ut " nUfy P°SSible t0 effe^ the aC^ion will ocZtLu cirou,m8ta^s, but the attempt is worth making, and will occasionally succeed—as in a case mentioned by Barwell and as 584 DISEASES OF JOINTS. After abscesses have opened in cases of hip disease, leaving sinuses which lead down to carious bone, it is still possible in some instances to obtain a cure by anchylosis, and, in cases not admitting of operation, this is the best termination that can be hoped for. Little can be done, under these circumstances, beyond keeping the limb straight, moderately extended, and with the foot well supported, while the strength of the patient is maintained by appropriate constitutional and hygienic treat- ment. In many of the cases, however, which reach this condition (at least among the class of children that comes into our city hospitals), excision, or possibly amputation, may afford a better chance of life than perseverance in expectant treatment. Arthritis of the Sacro-iliac Joint (Sacro-iliac Disease)— This affection, which is extremely fatal, is fortunately rare, though pro- bably not quite so rare as is commonly supposed—being sometimes not recognized by practitioners, as indeed it has, until comparatively recently, been commonly ignored by systematic writers. It has been particularly studied by Ne'laton and Erichsen. Sacro-iliac disease is an affection of early adult life, and usually begins with a condition analogous to, if not identical with, that form of arthritis which has been called gelatinous, though, in other instances, the bones appear to be first affected. The disease can seldom be traced to any definite exciting cause. The Symptoms consist of pain and tenderness, with swelling over the line of the sacro-iliac junction, the pain being aggravated by motion, laughing, coughing, straining at stool, etc., and accompanied by a pecu- liar sensation, as if the body was falling apart. Pain is elicited also by pressing the sides of the pelvis together. The patient is lame from the beginning; and, as the disease advances, becomes completely bedridden, usually lying on the unaffected side. The limb on the diseased side is commonly extended, elongated from downward displacement of the os in- nominatum, and wasted from atrophyof its muscles. It is sometimes mark- edly oedematous from obstruction of the iliac vein. The hip is deformed, from the side of the pelvis being tilted forwards and rotated downwards. Suppuration occurs at a rather late period of the disease, abscesses pointing, according to Erichsen, over the joint, in the gluteal or lumbar regions, within the pelvis, or in connection with the rectum. In a case which was under my care at the Episcopal Hospital, abscesses pointed in the groin, in the gluteal region, and on the inside of the thigh. The Diagnosis of sacro-iliac disease can usually be made without much difficulty, the affection with which it is most likely to be confounded being hip disease, the diagnostic marks of which have already been pointed out. Disease of the spine may be distinguished, even if there be no posterior curvature, by the presence of tenderness in the region of the affected vertebrae, and of stiffness of the whole spinal column, with absence of any elongation of the limb, or sign of disease about the sacro-iliac joint. Neuralgia of the hip may be distinguished by the diffused and superficial character of the pain, and by the absence of any real displacement of the os innominatum ; while sciatica may be recog- nized by the seat of pain being below the sacro-iliac joint and extending down the limb, and by the absence of elongation or other signs of articular disease. The Prognosis of sacro-iliac disease is always unfavorable; Erichsen, who has devoted special attention to the subject, says that he has never seen recovery in any case in which the disease was fully developed, and in which suppuration had occurred. RHEUMATOID ARTHRITIS. 585 The Treatment consists in endeavoring to prevent suppuration, by placing the joint at rest by means of a leather or pasteboard splint, moulded to embrace the pelvis, hip, and thigh, by counter-irritation in the early stage, and by the administration of cod-liver oil and other tonics. The patient should of course stay in bed, and preferably in the prone position. No operation is, for obvious reasons, admissible in this errave affection. Rheumatoid Arthritis. Rheumatoid Arthritis is the name proposed by Dr. Grarrod for a pecu- liar form of inflammation of the joints, which was described by Adams, R. W. Smith, and Canton, as Chronic Rheumatic Arthritis, and which, in the case of the hip, is sometimes known as Morbus Coxae Senilis. The pathology of this disease is involved in much obscurity; rheumatoid ar- thritis resembles both gout and rheumatism, and yet does not appear to partake of the nature of either of those affections. It probably begins with hy- Fig. 290. peraemia of the synovial membrane and increased synovial secretion, followed by thickening, and sometimes elongation, of the ligaments, gradual absorption or ossi- fication of the inter-articular cartilages, and finally porcelanous induration and eburnation of the bony extremities. Bar- well, however, believes that osteitis is the primary condition, and that the synovial change is entirely secondary. In the case of the hip, which is the joint most com- monly affected, the round ligament disap- pears, and] the head of the bone becomes irregularly enlarged, flattened, sometimes elongated, and placed at a right angle with the shaft. The cervix femoris be- comes shortened, apparently by intersti- tial absorption, and is often surrounded by vascular fringe-like projections of the synovial membrane. The acetabulum becomes enlarged, and sometimes flattened, but in other cases deepened, so as to surround the head of the femur as with a cup. Extensive stalactitic bony outgrowths often ap- pear about the base of the great trochanter, and especially along the inter-trochanteric line, while similar osteitic formations are developed in the ligamentous and other soft tissues. On section, the bone is found to be rarefied, with an excess of oily matter—in a state, indeed, of osteo- porosis with eburnation. All the joints of the skeleton may be involved, but those in which the disease is most commonly observed, are the arti- culations of the hip, shoulder, and lower jaw. Rheumatoid arthritis of the shoulder is, according to Canton, the true pathological condition in those cases described by Soden and others as displacement of the long head of the biceps. The joints on either side are often symmetrically affected. Rheumatoid arthritis usually occurs in the male sex, and in per- sons who have passed the middle period of life; when met with at an earlier age, the patients are generally females; the disease appears in most cases to result from the action of cold in persons of debilitated Appearance of the head of the femur in rheumatoid arthritis. 586 DISEASES OF JOINTS. constitution, the development of the affection in any particular joint being sometimes hastened by traumatic causes. Symptoms.—The disease begins with pain of a rheumatic character, increased, in the case of the hip, by standing or walking, and followed by impaired power of motion, preventing the patient from either standing erect, stooping, or sitting in the ordinary posture. The limb may at first appear lengthened, but subsequently becomes shortened from changes in the shape of the bones, the apparent shortening being still further in- creased by obliquity of the pelvis. The limb is somewhat flexed and everted, the buttock becoming flattened, while the trochanter is unduly prominent and thickened. Crackling, or grating, may be elicited by rotating the limb, being evidently produced by the stalactitic formations already referred to, and by the rubbing together of the eburnated sur- faces of bone. The muscles of the thigh waste, but those of the calf of the leg maintain their nutrition; the loss of motion in the hip is in some degree compensated for, by increased mobility of the lumbar verte- brae. Suppuration occasionally, but very rarely occurs, nor, according to Barwell, is there any tendency to the production of anchylosis. Diagnosis.—Rheumatoid arthritis is chiefly interesting to the sur- geon in a diagnostic point of view, being frequently mistaken for frac- ture in the neighborhood of the affected articulation. The diagnosis can usually be made by inquiring into the history of the case, and by observing that the affection is not limited to a single joint. Prognosis.—The disease is very seldom fatal, but, on the other hand, is extremely chronic and intractable, and productive of a great deal of pain and discomfort. Treatment.—But little can be done in the way of treatment, beyond the employment of ordinary hygienic means and the administration of tonics, especially cod-liver oil, iron, and quinia, the affected joint being, during the acute stage, kept at rest, and occasionally blistered. Iodide of potassium may be sometimes used with advantage, as may be arsenic and guaiacum. R. W. Smith speaks highly of the latter drug, in combination with sulphur, rhubarb, alkalies, and aromatics. Change of air, and a resort to various mineral springs, may be properly advised in some cases. With regard to motion of the diseased joints (in the chronic stage), it may be said that the patient may take as much exercise as can be done without inducing an aggravation of pain. Erichsen recom- mends, in the case of the hip, external support by means of lateral irons, jointed opposite the articulations, with a pelvic band and leather socket for the thigh and leg. Excision of the hip has been resorted to in this affection, but is not to be recommended; the prospective benefits of the operation, under these circumstances, are not sufficient to compensate for the risk which would necessarily attend its performance. Anchylosis. Frequent reference has been made in the preceding pages to the cure of joint-diseases by anchylosis, a word which, as used by surgeons, is equivalent to stiff-joint. Anchylosis, or ankylosis (the latter is etymolo- gically the more correct spelling), may be incomplete or complete. In incomplete, or fibrous anchylosis, the stiffness is due to thickening of the ANCHYLOSIS. 587 Fig. 291. joint capsule, with the development of bands of fibro-cellular material which cross from one articular surface to the other, and which result from the organization of inflammatory lymph, or of the granulation structure which in joint-diseases replaces the synovial membrane and articular cartilages. The stiffness of the part is further promoted by contraction and adhesion of the neighboring muscles and tendons, the latter being almost exclusively concerned in the production of the so- called false anchylosis, which results from mere disuse. In complete or bony anchylosis the joint may be entirely obliterated, the articulating surfaces being united throughout by bone (synostosis), or (which is pro- bably the more common condition) there may be fibrous anchylosis, with the superaddition of osseous arches or bands, which cross from side to side externally to the joint, and which may be new formations, of the nature of exostoses, or may result from the deposit of ossific matter in ligaments or other pre-existing soft structures. Bony anchylosis is rarely met with except as the result of traumatic arthritis, fibrous anchy- losis being more common in the ordi- nary forms of the disease, particularly in patients of a strumous diathesis. It not unfrequently happens, indeed, under the latter circumstances, that, while more or less perfect anchylosis is taking place in one part of a joint, caries or necrosis is in exist- ence at another. In bony anchylosis there is absolutely no motion of the joint, while in the fibrous variety slight motion may always be elicited by careful examination, particularly if the patient be in a state of anaes- thesia. Treatment.—The treatment of anchylosis varies according as it is complete or incomplete, and according to the position in which the joint has become stiff. 1. Fibrous Anchylosis in a Good Position—No treatment should be adopted under these circumstances until all acute inflammatory symp- toms have subsided; when the dis- ease has become chronic, passive motion may be cautiously employed, being aided by frictions, the salt douche, etc. In fibrous anchylosis of the elbow, the patient may himself practise passive motion by swinging a flat-iron or other weight, as advised at page 227. Advantage is occasionally derived from the use of well-padded splints, the angle of which may be varied by means of a Stromeyer's screw or other similar contrivance, or from the use of continuous extension by elastic bands or by a weight. It may be, in some rare cases, justifiable to attempt subcutaneous division of the restraining intra-articular bands, but the operation is not very promising, and is necessarily attended with some risk. 2. Fibrous Anchylosis in a Bad Position.—If the elbow be anchylosed Synostosis of hip-joint. 588 DISEASES OF JOINTS. in an extended position, or the shoulder, knee, or hip at a right angle, it becomes important to adopt more active treatment, though no operation should be performed until acute symptoms have passed away. In many cases, it is possible at once to restore the limb to a position in which it will be useful, by forcibly flexing and extending the joint, and thus rupturing the intra-articular adhesions, while the patient is in a state of anaesthesia. In other instances, continuous extension, by means of elastic bands (Fig. 294) or a weight, will be safer1 and equally efficient. If resist- ance be made by contracted tendons in the neighborhood of the joint, these should be subcutaneously divided, a few days being then allowed to elapse before the employment of extension. Any inflammation which follows these manoeuvres must be treated upon general principles. The deformity met with in anchylosis following arthritis of the knee-joint, Fig. 292. Fig. 293. Anchylosis of knee-joint in position of over-extension. Chronic arthritis of knee-joint, with (From a patient in the Episcopal Hospital.) partial anchylosis in had position. (From a patient in the Episcopal Hospital.) usually consists in flexion, backward displacement of the tibia upon the condyles of the femur, and outward rotation of the leg and foot. In these cases, simple extension, even with division of the hamstring tendons, is not sufficient, the backward displacement persisting, and rendering the limb weak and comparatively useless; under such circumstances, the ingenious apparatus of Mr. Bigg (Fig. 295) may be employed, which acts by means of springs, drawing the head of the tibia downwards and forwards, while the condyles of the femur are at the same time pressed upwards and backwards. Anchylosis of the knee in a position of over- extension is extremely rare; it is well seen in the accompanying illustra- tion (Fig. 292), from a patient under my care in the Episcopal Hospital. The displacement in these cases is an exaggeration of that which is com- 1 The humerus has been fractured in attempting forcibly to rupture adhesions of the elbow-joint. / TREATMENT OF ANCHYLOSIS. 589 monly observed, the head of the tibia slipping entirely behind the femur and projecting in the popliteal space. In cases of partial fibrous anchy- losis, complicated by frequently recurring inflammation of the joint (Fig. 293), excision or amputation will not unfrequently be required. Fig. 294. Fig. 295. Barwell's splint for making continuous extension in Bigg's apparatus for contraction of the knee, cases of anchylosis of knee. 3. Bony Anchylosis in a Good Position.—If a joint be affected with bony anchylosis, and in such a position as to retain the usefulness of the limb, prudent surgery would dictate that no operation should be resorted to; an exception may be occasionally made in the case of the elbow, which may be in some instances advantageously excised under these circumstances. 4. Bony Anchylosis in a Bad Position.—Yarious operations have been employed to remedy bony anchylosis under these circumstances. Hip.—Dr. J. Rhea Barton, of this city, in the year 1826, treated a case of osseous anchylosis of the hip, by sawing through the femur between the trochanters, thus allowing the limb to be brought into a straight position; the patient recovered, as was anticipated, with an artificial joint, which remained movable for several years. This operation is often said to have consisted in the excision of a wedge-shaped piece of bone, but a reference to the original account of the case shows clearly that 590 DISEASES OF JOINTS. but one section was made with the saw. In 1830, Dr. J. Kearney Rodgers, of New York, improved upon Barton's operation by removing a disc of bone from between the trochanters, the portion exsected beincr half an inch thick at its outer, and three-quarters of an inch thick at its inner side; the operation proved successful, the mobility of the new joint persisting after two and a half years. In 1862, Dr. Sayre, of New York, still further improved upon Rodgers's procedure, by removing a segment of bone from between the trochanters, the upper section being semicircular, with its concavity downwards, and the upper end of the lower fragment being rounded off, so as to imitate as closely as possible the natural form of a ball-and-socket joint. Dr. H. Leisrink has tabulated twelve cases, in which one or other of these operations was resorted to, which, with Barton's original case, and others in the hands of Berend, Textor, Warren, of Boston, and Peters, of New York, give seventeen operations, of which seven are known to have proved fatal—a mortality which, though large, is less than has fol- lowed excision of the head of the femur for anchylosis, two out of four cases of the latter operation having terminated in death. W. Adams has recently suggested a return to Barton's method, the operation being, however, made subcutaneous, and no attempt being made to secure a movable joint; the operation thus modified has been per- formed six times, once by Adams himself, twice by Jessop, and once each by Jowers, Jordan, and J. Croft—the case of the last-named sur- geon, which was one of fibrous anchylosis, being the only one of the six which terminated unfavorably. Hence this procedure, though inferior to Sayre's as regards the ultimate result, when that is successful, seems to be less dangerous than any of the other methods which have been proposed, and should, therefore, be preferred in most cases, particularly as the mobility of the pelvis compensates in a great degree for the loss of a movable articulation. Barton's operation has been, according to Chelius successfully employed (by Yan Wattman) in a case of bony anchylosis of the elbow, and a similar procedure might be properly re- sorted to, if it should be necessary to interfere in a like condition of the shoulder. Knee—Barwell recommends (in case of bony anchylosis of the knee), that in persons under fourteen years of age, advantage should be taken of the'fact that the upper epiphysis of the tibia is, at this time of life, not yet united to the shaft, to straighten the limb by producing an epiphyseal fracture—the upper truncated end of the diaphysis then rest- ing against the angular edge of the epiphyseal end, and the limb being shortened by little more than an inch. This mode of treatment is, accord- ing to Barwell, quite satisfactory and entirely free from risk. In a case of bony anchylosis of the knee, in a bent position, Dr. J. Rhea Barton, in 1835, removed a wedge-shaped piece of bone from the front of the femur, immediately above the condyles; the portion of bone did not 'involve the entire thickness of the shaft, the posterior shell of bone which was left, slowly yielding as the limb was, subsequently, gradually brought into an almost straight line. The result was entirely satisfactory, the thigh becoming firmly united in its new position. In 1844, Dr. Gurdon Buck, of New York, modified this procedure by exsecting a wedge-shaped mass embracing the entire thickness of the bone, and containing the con- dyles of the femur, head of the tibia and patella, performing, in fact, what has since been called "excision in a block." In 1853, the same surgeon, in a case of fibrous anchylosis, substituted for the removal of a wedge- shaped mass, an ordinary excision of the knee-joint, the parts being sub- LOOSE CARTILAGES IN JOINTS. 591 sequently held together with silver wire. S. W. Gross1 has collected thirteen cases of Barton's operation, to which should be added another (successful) by Blackman, of Ohio, making in all fourteen cases with two deaths, while one or other of Buck's methods appears to have been em- ployed' thirty-three times with five deaths—the mortality of the former operation being thus about fourteen, and that of the latter about fifteen per cent. A safer method consists in subcutaneously perforating the anchylosed joint in various directions by means of a suitable drill (Fig. 108), the remaining bony adhesions being then forcibly ruptured, and the limb being, after a few days, gradually brought into a straight position by an extending apparatus. This operation appears to have been first sug- gested by Malgaigne, who proposed to use a chisel and mallet (as has since been done by L. S. Little), though Dieffenbach had previously sug- gested separation of the united joint by means of a chisel and saw—not, however, used subcutaneously. Brainard, of Chicago, in 1854, proposed to apply the drill to the bone immediately above the joint, and the first opera- tion upon this plan was performed by Pancoast, of this city, in 1859. Brainard subsequently applied the drill to the knee-joint itself, and the operation has since been repeated upon several occasions by Prof. Gross and others. Nine cases, collected by S. "\V. Gross in 1868, had proved uniformly successful. This procedure is certainly preferable to any other that has, as yet, been proposed, being not only attended with less risk to life, but having the great advantage of not shortening the limb by the removal of any portion of bone. Loose Cartilages in Joints. The name " loose cartilage" is given to certain bodies which are met with in joints, and which are very analogous to the rice-like bodies de- scribed as occurring in compound ganglia, and in diseases of synovial bursae. These loose cartilages have, according to Rainey, as quoted by Bar- Fig. 296. well, a distinct investing membrane of a fibro-cellular character, and are found on section to consist of two layers, one fibre-cartilaginous and the other resem- bling bone. They appear, in most in- stances, to originate in a transforma- tion of the villous or fringe-like pro- cesses of the synovial membrane, being thus at first attached by narrow pedi- cles to the parietes of the joint, but, subsequently, often becoming isolated. They are, according to R.Adams, espe- cially met with in cases of rheumatoid arthritis, and are most common in the knee, though occasionally seen in other joints. Usually quite small and round, they are sometimes found as large as a chestnut, and flattened 1 Am. Journ. of Med. Sciences, April, 1868, p. 361. 2 L. Penieres {Des Resections du Genou, Paris, 1869, p. 84) tabulates thirty-two cases of resection for anchylosis, of which eight appear to have been cases of Bar- ton's^ operation, while one (Swain's) was really an excision for arthritis ; to the remaining twenty-three may be added seven additional cases collected by Swain, and others operated on by Warren, of Boston, and by Mutter and Morton, of this city, thus giving, as stated in the text, thirty-three operations with five deaths. Trochlea of humerus ; showing formation and connection of loose cartilaginous bodies. 592 DISEASES of joints. or elongated. They may be single, or may coexist in large numbers. According to Teale and Paget, these bodies are in some cases actually fragments of articular cartilage, which are separated by a slow process of exfoliation following necrosis, the result of injury. Symptoms.—If closely attached, these bodies may give rise merely to weakness of the joint, with a tendency to intra-articular effusion, but if floating or loose, they are apt to be caught between the opposing joint surfaces—this occurrence causing intense pain, sometimes accompanied with nausea or syncope, and the patient being unable to move the joint, and sometimes falling, while rapid synovial effusion commonly supervenes. These symptoms, it will be seen, closely resemble those of dislocation of the semilunar cartilages (see page 295). Treatment.—This may be palliative or radical. The palliative treat- ment consists in supporting the joint by means of an elastic bandage, so as to restrain its motions, and lessen the risk of the loose body becoming caught between the articulating surfaces. Hilton advises that the loose cartilage should be fixed in contact with the synovial membrane, by means of adhesive strips applied externally, when absorption of the foreign body may often be obtained. The radical treatment, which con- sists in removing the foreign body, either by direct or by subcutaneous incision, is attended with considerable risk to life, the mortality of the direct operation being, according to H. Larrey's statistics, 22, and of the subcutaneous procedure 13 per cent. Hence neither should be em- ployed, unless the disease is attended with so much suffering as to make interference absolutely necessary. The direct operation consists in making a sufficiently free incision over the loose cartilage, which is firmly fixed between the surgeon's finger and thumb, the skin being drawn to one side so as to make a valvular opening, as recommended by B. Bell. The loose cartilage is then squeezed out through the cut, which is immediately closed, while the limb is kept at rest upon a splint. Any inflammation which may follow is to be treated upon the principles already laid down. The subcutaneous operation, which, though much safer, is more difficult and more likely to result in failure, consists in fixing the loose cartilage as before, and dividing the synovial membrane over it with a long tenotome passed subcutaneously beneath the skin; the foreign body is then squeezed into the periarticular areolar tissue, where it may be left to be absorbed, or from whence it may be removed by direct incision, after some days' interval, as advised by Goyrancl. Another plan, introduced by Square, of Plymouth, is to squeeze the loose cartilage into, but not through, the subcutaneous opening in the synovial membrane, fixing the foreign body in that position by means of a compress and adhesive strips. The point at which the incision is to be made, in the case of the knee, which is the joint usually affected, is to the inner side of, and a little below, the patella. If there be more than one foreign body, it may be necessary to repeat the operation at a subsequent period. Articular Neuralgia. (Hysterical Joints.) Intense pain in a joint may arise from various causes unconnected with disease of the articulation itself. Thus, pain in the knee is, as we have seen, a common accompaniment of hip disease, and the same EXCISION IN GENERAL. 593 symptom may arise from other circumstances, as the pressure of a tumor or an aneurism. Occasionally, however, intense neuralgic pain is felt in a joint, accompanied perhaps with slight swelling and redness, and attended with spasmodic action, or more often, rigid contraction of the neighboring muscles, and yet not dependent upon any perceptible organic change. These cases are chiefly, though not exclusively, met with in women, and usually in those who present other evidences of hysteria. The credit of first forcibly directing the attention of surgeons to the true nature of these cases, is undoubtedly due to the late Sir Benjamin C. Brodie. The joints most often affected are the knee, hip, and ankle, though a similar condition is occasionally seen in the elbow and shoulder. Diagnosis.—The diagnosis from arthritis may be made by observing the diffused and superficial character of the pain and tenderness, which are not increased by pressing together the joint surfaces (as would be the case in arthritis), and are not attended with the other signs of in- flammation, and with the constitutional disturbance, which would be pre- sent in an ordinary case of joint-disease. The rigid contraction will often disappear, if the patient's attention be suddenly called away, and if an anaesthetic be given, the motions of the limb will be found to be unim- paired. Treatment.—This consists in the adoption of measures to improve the state of the patient's general health, particularly by attention to the digestive functions, and by the use of tonics and antispasmodics, with the cold douche and frictions to the affected joint. If contraction exist, the limb may be straightened while the patient is in a state of anaesthesia, and may be kept for a few days subsequently upon a suitable splint. Moral treatment is quite as important as physical, and the patient should, if possible, be induced to co-opexate with the surgeon in the adoption of the means employed to promote recovery. In the belief that the disease is mental, it is sometimes advised to work upon the patient's imagination by pretending to perform an operation for her relief; though such a course may occasionally succeed, I believe the surgeon will do better, in the end, by dealing perfectly honestly with his patient, and avoiding even the appearance of deception. It is almost needless to say that such heroic measures as amputation or excision, or even the application of the actual cautery, would be totally unjustifiable in the cases under consideration. CHAPTEE XXXII. EXCISIONS. Excision in General. The operation of resection, in cases of compound fracture and dis- location, appears to have been known to the ancients, but subsequently was entirely forgotten, until revived in the first half of the last century by Cooper, of Bungay, who removed the lower ends of both tibia and 38 594 EXCISIONS. fibula for compound dislocation of the ankle. The first excision for disease of a joint, appears to have been that performed by Filkin, of Norwich, in 1762, in a case of arthritis of the knee. The history of the introduction of the operation of excision into the practice of surgery, is a subject of much interest, but cannot be entered upon within the limits of this work; the reader is respectfully referred, for information upon this matter, to the able monograph of 0. Heyfelder, and to that of Hodges, of Boston. The applicability of excision to the various traumatic lesions of bones and joints, and to deformity resulting from anchylosis, has already been considered in previous chapters (see pp. 164, 211, 589); and I shall therefore, in the following pages, confine myself to a description of the operative procedure in the different regions of the body, and to a consideration of the applicability of excision to diseases of bones and joints, especially to caries and arthritis. Indications for, and Contra-indications to, Excision in Gene- ral.—1. Excision is indicated (1) in case a bone or joint is so exten- sively diseased that its removal is imperative; here the question is be- tween amputation and excision, and the latter operation should always be preferred, provided that the circumstances of the particular case admit of a choice. (2) Excision is sometimes justifiable, where the amount of disease is not sufficient to warrant amputation, and yet where the time which would be required for a spontaneous cure would be so long as to render opera- tive interference proper, or where the utility of the limb would be less after a spontaneous cure than it would be after removal of the joint; as in the elbow, where a cure by anchylosis would be particularly unde- sirable. 2. Excision is, on the other hand, contra-indicated by (1) the extent of diseased bone being so great that its removal would render the limb an encumbrance, and less useful than a well-formed stump; this is particu- larly the case in the lower extremity, but in the arm, provided that the hand be preserved, very considerable portions of bone may often be properly removed. (2) Excision should not as a rule be practised in cases of acute disease, experience showing that amputation is under such circumstances better tolerated. Hence, if operative interference be necessaiy to preserve life, in a case of acute bone or joint disease, amputation will usually be in- dicated: excision of the shaft of a bone may, however, be occasionally proper in cases of acute necrosis from subperiosteal abscess (see page 565). (3) If the soft tissues around a diseased bone or joint be extensively diseased, infiltrated with lowly organized lymph, and riddled with sinuses, the result of an excision is less apt to be satisfactory than under op- posite circumstances, though the operation is not absolutely contra- indicated by such a condition. (4) Either extreme of life is considered unfavorable to excision, on account of the long period required for recovery after the operation, and, in the case of early childhood, on account of the risk of interfering with the growth of the limb, which is chiefly dependent upon the integrity of the epiphyseal cartilages. Boeckel, of Strasburg, however, from an exami- nation of over twenty cases of arrested development, concludes that the shortening is less due to injury of the epiphyseal cartilages than to disuse of the limb owing to pain or to muscular atrophy—causes which would be equally active if excision were not performed. PROCESS OF REPAIR AFTER EXCISION. 595 (5) A bad state of the general health, particularly if dependent upon organic visceral disease, as of the lungs, liver, or kidney, must always be considered a contra-indication to excision. The long confinement which usually follows the operation, with perhaps long-continued and ex- hausting suppuration, will seriously complicate the chances of recovery in such a case. Hence, if any operation at all be required in a patient suffering from advanced phthisis, or from Bright's disease, amputation will usually be the preferable procedure. From the above remarks, it will be seen that, while excision is, in suit- able cases, an admirable and truly conservative operation, and in every way superior to amputation, yet it is, after all, only applicable in selected cases; hence it is obviously unfair to attempt, as has been sometimes done, to prove that excision is a less fatal operation than amputation, by a comparison of the statistical results of the two procedures—one being habitually reserved for favorable cases, while the other is indiscriminately applied to all the remainder: greatly as I admire the operation of ex- cision, I cannot but believe that, casteris paiHbus, it is, in every region of the body, at least as fatal as the corresponding amputation. Process of Repair after Excision.—The growth of the long bones in thickness is accomplished by means of the periosteum, and in length by means of the epiphyseal cartilages. Hence, in excising por- tions of the shafts of bones, it is of the utmost importance to preserve the periosteum, by the osteo-genetic power of which it may be hoped that the excised portion will be reproduced: another advantage of subperios- teal excision, is that, by preserving the membrane in question, the attach- ments of the various muscles are not disturbed. If the periosteum can- not be preserved—and this can rarely be done in excisions of the short bones, as of the calcaneum—repair is effected by the wound filling with granulations, which are subsequently transformed into a dense, fibrous, cicatricial mass. In excisions of the joints (particularly among patients who have not attained their full height), it is important not to remove the entire epiphysis, nor even encroach upon the epiphyseal line; for, if this be done, the subsequent growth of the limb will be deficient. This is especially important in the case of the knee, the lower epiphysis of the femur and the upper of the tibia being chiefly concerned in the growth of the lower extremity. An attempt should, as a rule, be made to pre- serve the periosteum, in articular resections, particularly when, as in the case of the shoulder, elbow, or hip, a movable joint is desired—the effect of retaining the periosteum in these cases being, as shown by Oilier, to improve the shape of the new articulating surfaces, which measurably approach the form of those which were removed ; in the knee, where the great object is to obtain firm bony union, the subperiosteal character of the operation is not so essential, though still desirable, as tending to diminish the amount of consecutive shortening. Operation of Excision in General.—The knives ordinarily required for the operation of excision, are scalpels and straight bistou- ries, which should be pretty thick at the back, and set in strong handles; a strong probe-pointed knife, with a limited cutting edge, will also be found useful for clearing the soft parts from the bones in the deeper por- tions of the wound. Bone forceps of various sizes and shapes will be the required, the most important being a pair of strong cutting pliers, and lion-jawed forceps designed by Fergusson (Fig. 297). Gouges and gouge- 596 excisions. forceps will also be found useful for dealing with carious bone. The saw which I prefer, in most cases, is that designed by Butcher, of Dublin, Fig. 29 Fergusson's lion-jawed forceps. which has the great merit of allowing the blade to be fixed at any angle, or even completely reversed, so as to cut from below upwards, and thus Butcher's saw. preserve the soft parts from injury. In certain cases (as in excisions of the hip), the chain saw is more convenient than any other instrument. If an ordinary saw be employed, a spatula or retractor must be slipped beneath the bone, in order to guard the soft parts; a good instrument for the purpose is the " resection sound" of Blandin, or the probe-pointed grooved retractor described by Dr. D. Prince, of Jacksonville, Illinois; or, which in some cases will prove as satisfactory, an ordinary broad lithotomy staff grooved on the back, which may be readily slipped around the bone and then turned with its convexity upwards. An- other instrument which I have found of value, is the knife-bladed forceps of Mr. Butcher (Fig. 300). This cuts like a pair of scissors, and is very efficient in removing the thickened and degenerated synovial tissues, which, if allowed to remain, are apt to slough and impede the progress of cure. The particular operative procedures required for excisions in various regions of the body, differ of course according to the parts to be removed; it may be stated, however,in general terms, that the external incisions should be sufficiently free, and as much as possible in the direc- Chain saw, special excisions. 597 tion of the muscular interspaces, so as to avoid unnecessary destruction of tissue. The incisions should, if practicable, include any sinuses that may be present, and should be made so as to avoid injury to the principal ves- Fig. 300. Butcher's knife-hladed forceps for excisions. sels and nerves. The periosteum should be preserved, if possible, and the amount of bone removed should be as small as may be consistent with the thorough extirpation of the diseased structure. It is a good plan in excising joints, to remove but a thin layer with the saw, and then to attack any necrosed or carious spots with the gouge or trephine. The epiphy- seal line should never be encroached upon in children, and, even in adults, it is important not to lay open the medullary canal. Care must be taken not to mistake bone which is merely inflamed and softened (medullized), for that which is carious, nor bone thickened and rough- ened by inflammation, for that which is necrosed. The skin and other soft tissues, no matter how much altered in appearance, should be as a rule preserved entire—the flaps, though at first redundant, ultimately shrinking and resuming their natural condition. The degenerated syno- vial lining of the joint may, however, be advantageously cut away with the knife-bladed forceps. All bleeding should be checked, by ligature or otherwise, before the wound is closed, as it is very important that when the limb is once adjusted, it should not be disturbed for several days. The dressings should be light and simple, and precautions must be adopted to secure free drainage, by the arrangement of the incisions, or by the use of Chassaignac's tubes, etc. Concentrated food, with tonics and stimulants, will usually be required in pretty large quantities during convalescence. Finally, although the case should not progress as favorably as may be wished, the surgeon must not hastily conclude that the operation has failed, and that amputation is necessary ; even if caries or necrosis should recur in the sawn bony extremities, a re-excision may often be attended with a satisfactory result. Special Excisions. Scapula.—Excision of the scapula, complete or partial, may be re- quired for various causes, as caries, necrosis, tumors, and some forms of injury, though in traumatic cases it is often necessary to remove the whole upper extremity as well (see page 119). The operation may be done with a crucial incision, or, which is probably better in most cases, a-T-shaped incision, as recommended by Syme, the transverse branch of the cut running from the acromion to the posterior edge of the bone, and the other passing downwards, at a right angle from the centre of the former. If the operation be for tumor, the incisions should be merely skin-deep, the flaps being dissected off without cutting into the growth, which may, probably, be very vascular. It is advised by Fergusson and Pollock to liberate the posterior border of the scapula first, and then the inferior, turning up the bone from below upwards as the operation proceeds. By this plan the subscapular artery can be controlled by 598 EXCISIONS. the finger before division, and the risk of hemorrhage is thus consider- ably lessened. The subclavian artery should be compressed by an assist- ant throughout the whole procedure. In cases of malignant disease, the whole scapula should be excised, but under other circumstances a partial operation may suffice, there being certainly an advantage in retaining the head of the bone, acromion, and coracoid, when there is no reason for their removal. The clavicle should not be interfered with unless itself diseased. After the operation, the arm should be supported in a sling, and an axillary pad may be sometimes advantageously employed for a few days. The history and statistics of this operation have been particularly investigated by Dr. Stephen Rogers,1 of New York, from whose valuable paper the following facts are mainly derived. The first surgeon who extirpated the scapula was dimming, who, in 1808, successfully re- moved this bone, together with the upper extremity, for gunshot injury. Liston, in. 1819, excised a large portion—about three-fourths—of the scapula for cancer, the patient dying a year later from a recurrence of the disease. The first case in which the entire scapula was removed, the arm being preserved, was that of Langenbeck, who, in 1855, excised the whole scapula, with three inches of the clavicle. Since then, complete excision of the scapula, with or without interference with the clavicle and head of the humerus (the arm being preserved), has been done by Syme (twice), Heyfelder, Jones, Hammer, Schuh, Michaux, Hamilton, Rogers, Pollock, and Steele—the twelve cases giving eight recoveries and four deaths; while of eight similar operations (subsequent to previous amputation at the shoulder), by Crosby, Mussey, Rigaud, Fergusson, Buck, Langenbeck, Busch, and Krakowizer, six recovered and two died. Total is thus quite as successful as partial excision, 30 terminated cases of the latter operation, collected by Rogers, having given 16 recoveries and 14 deaths. The patient in one case died during the operation, while in another (fatal) case the operation was abandoned unfinished. Clavicle and Ribs.—The clavicle may require partial or, in rare instances, complete excision, on account of caries, necrosis, tumor, or compound fracture. The inner extremity of the bone may also require resection, if it be so displaced as to produce dangerous compression of the oesophagus or trachea. In cases of necrosis, the operation may be made subperiosteal, and presents no particular difficulties, a simple incision following the course of the bone being sufficient for the pur- pose. In cases of tumor, the operation is both difficult and dangerous, the principal risks being from hemorrhage and the entrance of air into the veins. The entire clavicle has been extirpated about a dozen times, and of eleven terminated cases which are on record, only three proved fatal. Portions of the ribs have been frequently excised, in cases of caries, necrosis, compound fracture, wound of an intercostal artery, etc. The operation is not particularly difficult, but, except in case of necrosis, when the periosteum can be detached, is attended with considerable risk of injury to the pleura or even the peritoneum. Thirty-seven cases mentioned by Heyfelder gave eight deaths. Shoulder-joint.—Excision of the scapulo-humeral articulation, or of the head of the humerus, may be required in cases of arthritis, caries or necrosis, compound fracture or dislocation, or non-malignant tumor. 1 Am. Joum. of Med. Sciences, Oct. 1868, and N. Y. Med. Journal, Jan. 1869. HUMERUS. 599 Fig. 301. For malignant disease the operation would be manifestly improper, as exposing the patient to an almost inevitable recurrence of the affection. The operation may be conveniently performed by making a single longi- tudinal incision, beginning somewhat to the outside of the coracoid process, and carried downwards and slightly outwards—passing between the fibres of the deltoid muscle, in the line of the bicipital groove, for about five inches. The long head of the biceps being held to one side, the cap- sule is divided, and the tuberosities of the humerus freed by the use of the probe-pointed knife, when the head of the bone may be thrust through the wound and removed with a chain saw, or, in young children, with strong cutting- forceps. If the glenoid cavity be diseased, it may then be attacked with the gouge-forceps, or may, if necessary, be exposed for the ap- plication of the saw by a transverse cut, as directed for excision of the scapula. Hemor- rhage having been arrested, the wound may be closed with a few points of suture, a space being left for drainage (and perhaps a tube introduced), and the arm then supported with a sling and axillary pad. In some cases, as of tumor, the longitudinal incision may not suffice to give access to the part, and the surgeon may then raise a flap by means of a V_snaPecl cu% or °ne in the form of a ^ , X, or [J, as may be thought most convenient. These all have the common disad- vantage of involving a transverse division of the fibres of the deltoid, and of therefore protracting the healing process, as well as of entailing subsequent weakness of the limb. The first excision of the head of the humerus for disease, appears to have been performed by Bent, of New Castle (England), in 1771, while the first complete excision of the shoulder-joint was performed by the elder Moreau, in 1786. The operation is quite a successful one, consider- ing its magnitude, 169 cases of excision for all causes having given, according to Heyfelder, but 30 deaths, a mortality of less than 18 per cent. If excisions for disease alone be considered, the statistics show a still more*favorable result, 50 cases tabulated by Hodges giving 42 recoveries, and but 8 deaths. The preserved arm is known to have been useful in more than three-fourths of the successful cases. The risk which attends this procedure, therefore, is so moderate as to render shoulder- joint excision one of the most satisfactory of surgical operations. Excision of shoulder-joint; lon- gitudinal incision. Humerus.—Excision of the shaft of humerus may be occasionally required in cases of compound fracture, especially as the result of gun- shot injury {see page 167), or may sometimes be necessary in cases of caries or necrosis. Resection is also not unfrequently called for in the treatment of ununited fracture, and when performed with the precautions recommended by Oilier, of Lyons, and by Bigelow, of Boston, is quite a successful procedure (see page 236). The operation consists in making a single longitudinal incision on the outer side of the arm, between the muscular interspaces, and, after carefully dividing and stripping off the periosteum (which should always be preserved), removing as great an extent of bone as may be thought necessary with a chain saw; the 600 EXCISIONS. resected bony extremities should then be^ipproximated and held together by means of a strong metallic suture, and the limb placed at rest on a suitable splint. Elbow-joint.—Excision of this articulation may be required for chronic disease of the joint, for bony anchylosis, or for compound frac- Fig.302. Excised extremities of humerus and ulna. (From a specimen in the museum of the Episcopal Hospital.) ture or luxation. The lower end of the humerus was resected by Wain- man (in 1758 or 1759), and by Tyre, while the olecranon and upper part of the ulna were removed by F[S- 304- Justamond, in 1775, but the first complete excision of the elbow- joint was performed by the elder Moreau, in 1794, in a case of chronic disease of the articula- tion. The operation may be con- veniently done by means of a single longitudinal incision, be- ginnino- two inches above the olecranon and carried about three inches below it, the line of the in- Excision of eibow-joint by longitudinal incision. cision being parallel to the course of the ulnar nerve, and a few lines to its radial side. The only point requiring special attention in this procedure is to avoid injuring the ulnar nerve, which must be carefully dissected from its position behind the inner condyle (the edge of the RADIUS AND ULNA. 601 knife being kept close to the bone), and then held out of the way with a blunt hook or spatula. The back of the articulation being thus ex- posed, the olecranon should be cleared and cut off with strong cutting pliers. In order to preserve the function of the triceps muscle, Spence divides its tendon by an inverted A/shaped incision, while Maunder takes care not to cut the tendinous fibres which are inserted into the fascia of the forearm. The joint being forcibly flexed, and the forearm thrust backwards, the lateral ligaments may now be carefully divided with the probe-pointed knife. The operation is completed by removing the con- dyles and the articulating surfaces of the radius and ulna, with Butcher's saw. The tubercle of the radius should, if healthy, be left undisturbed, so as to preserve the attachment of the biceps tendon. Some surgeons employ a transverse incision in addition to that which has been de- scribed, making a wound of this form j—, while others (as Mr. Butcher, and the late Mr. Syme) add also a second longitudinal incision on the outside of the joint—H, thus forming two rectangular flaps. The simple longitudinal incision is, however, perfectly satisfactory,in the majority of cases, and is better adapted for rapid healing than either of the others, having no tendency to gape. As soon as the bleeding has been checked, the wound should be lightly dressed, and the limb laid upon a pillow, or well-padded splint, in a nearly straight position ; after a week or two, when consolidation has begun, an obtuse-angled splint may be employed, and this angle thenceforward occasionally varied, so as to prevent the occurrence of anchylosis. The results of elbow-joint excision, when performed for chronic joint- disease, are commonly very satisfactory, Erichsen having lost but one case out of 18, and Bickersteth 2 out of 19. Heyfelder and Fig. 305. Boeckel have tabulated 145 cases of this operation (for disease), with but 20 deaths and 7 conse- cutive amputations, giving thus a mortality of 13.8 per cent. Hodges's tables embrace 119 cases,with 15 deaths and 15 subse- quent amputations, giving thus a mortality Of 12.6 per Cent., Or, if Arm after excision of elbow-joint. two deaths after amputation be counted, 14.3 per cent. With regard to the condition of the limb after excision, the statistical results are equally satisfactory: thus, according to Hodges, 77 out of 89 patients who recovered had useful arms, while in 94 out of 118 successful cases tabulated by Heyfelder and Boeckel, the patients could make good use of their preserved limbs. Partial excieion of the elbow-joint appears to be a less successful operation than total excision, which should therefore be preferred, even though all the articular extremities be not diseased. Twenty-one cases of partial ex- cision embraced in Hodges's tables, gave five deaths, three subsequent amputations, and only nine recoveries with a useful limb. Radius and Ulna.—Dr. Compton, of New Orleans, in 1853, excised the whole ulna and greater part of the radius, while the whole radius has been excised by Carnochan of New York, and the whole ulna by the same surgeon, and by Jones, of Jersey. Erichsen in one case excised the elbow-joint, together with the greater portion of the radius, while Williamson made a still more extensive resection, embracing the elbow- joint and the entire ulna. The result in all of these cases appears to 602 EXCISIONS. have been satisfactory, the patients recovering with useful limbs. Partial excisions of one or both bones have been frequently performed, and usually with very good results. The operation consists in making a longitudinal incision on the back of the forearm, in the line of the bone to be resected, the periosteum being if possible preserved, and the bone divided with chain saw or cutting pliers. Wrist.__The lower extremity of the radius was excised by Cooper, of Bungay, in 1758, but complete excision of the wrist-joint seems to have been first performed by the elder Moreau, in 1794. The articulation may be excised by means of one or two longitudinal incisions, on the dorsum of the wrist, the carpal bones being removed piecemeal, or by Lister's operation, which is thus performed: A radial incision begins about the middle of the dorsal aspect of the radius, on a level with the styloid process and passes downwards and outwards towards the inner side of the metacarpophalangeal articulation of the thumb, but, on reaching the line of the radial border of the meta- carpal bone of the index finger, di- verges at an obtuse angle (Fig. 306), and passes downwards longitudinally for half the length of that bone ; an ulnar incision begins two inches above the end of the ulna and imme- diately in front of that bone, passes downwards between the flexor carpi ulnaris and the ulna, and terminates at the middle of the palmar aspect of the fifth metacarpal. The only ten- dons necessarily divided by this me- thod are the extensors of the wrist. The trapezium is to be separated from the rest of the carpus by cutting with the bone forceps before the ulnar in- cision is made, but is not to be re- moved till a later stage of the opera- tion ; similarly the pisiform bone is to be separated and left attached to the flexor carpi ulnaris, while the hook of the unciform bone is also severed and left attached to the annu- lar ligament. The tendons being then raised both before and behind the wrist, the anterior ligaments of the joint may be divided, and the cutting pliers introduced first between the carpus and radius, and afterwards between the carpus and meta- carpus. Its connections being thus divided, the whole carpus (except the trapezium and pisiform) may be pulled out with a pair of strong forceps. The articulating extremities of the radius and ulna can now be made to protrude through the ulnar incision, and can be retrenched as much as may be thought desirable, the ulna being sawn obliquely so as to retain its styloid process and thus lessen the tendency to subsequent displacement. The articulating ends of the metacarpal bones are then protruded and excised, and the operation completed by dissecting out the trapezium, and by removing the articulating surface of the thumb, and A.. Radial artery. B. Tendon of extensor secundi internodii pollicis. C Indicator. D. Extensor communis digitorum. E. Extensor minimi digiti. F. Extensor primi interuodii pollicis. G. Extensor ossis metacarpi pollicis. H. Extensor carpi radialislongior. I. Extensor carpi radialis brevior. K. Extensor carpi ulnaris. L L. Line of radial incision. HIP-JOINT. 603 as much of the pisiform and hook-like process of the unciform as may be found necessary. A portion of the ulnar-wound is left unclosed for drainage, and the hand is kept during the after-treatment upon a splint fitted with cork supports for the palm and thumb, as seen in Fig. 307. The statistics of wrist-joint excision are not very favorable, thirty-one terminated cases tabulated by Hodges giving six deaths, eight subse- quent amputations, and only fourteen really good results. By the recent introduction of Lister's method of operation, the chances of success Fig. 307. Hand after excision of wrist, laid on splint. seem, however, to have been considerably improved, though the mor- tality remains about the same—twelve terminated cases reported by Prof. Lister in 1865, giving ten satisfactory recoveries and two deaths. Hand.—The metacarpal bones or metacarpo-phalangeal joints maybe" excised by simple longitudinal incisions on the back of the hand, the extensor tendons being held to one side, and the bone sections made with strong cutting pliers. A similar procedure is required for excision of the inter-phalangeal joints, except that in this case the articulation should be approached from the side. Hip.—Excision of the hip-joint may be required in cases of injury (especially from gunshot wound), of hip disease, and possibly of necrosis, though, in cases of the latter affection, it would usually be proper to wait for the spontaneous separation of the femoral epiphysis, which could then be extracted with comparatively little risk. Hip-joint excision has likewise been performed for malignant disease, for anchylosis, and for rheumatoid arthritis, but is not, in my opinion, a suitable operation in any of those conditions. Excision of the hip-joint was suggested by Charles White, of Manchester, in 1769, but was first practised by An- thony White, of London, in 1822. The first operation in this country was performed by Bigelow, of Boston, in 1852. A simple longitudinal incision on the outside of the limb will usually give ready access to the joint, but may be supplemented, if necessary, by a transverse cut form- ing a ^—. The incision which I myself prefer, is that recommended by 0. Heyfelder, which begins a little above and behind the great tro- chanter, towards which it passes in the line of the fibres of the gluteus maximus, and then, curving around and behind the trochanter, passes downwards and slightly backwards, ending on the linea aspera between the insertions of the gluteus and. vastus externus (Fig. 308). This incision forms two irregular flaps, the loosening of which affords abun- dant room for the subsequent steps of the operation, while no muscular fibres are divided transversely. If spontaneous dislocation has occurred, the head of the bone may be at once protruded through the wound, hut under other circumstances the capsule must be opened, and the liga- mentous structures cautiously divided with the probe-pointed knife. 604 EXCISIONS. The femur may be divided with the chain saw (or in young children with cutting pliers) immediately below the great trochanter, it being always advisable to remove this portion of bone, even if not diseased, as it is apt to become so subsequently, and to interfere with union by protruding through the wound. The acetabulum should then be carefully examined; if healthy, it may be left untouched, but if carious or necrosed, it should be freely dealt with, loose pieces being extracted, and any part that is diseased but not loose, removed with the gouge-forceps, trephine, or Fig. 308. Fig. 309. AB. Line of incision for excision of hip-joint Heyfelder.) (After Head and neck of femur, removed by excision. (From a specimen in the museum of the Episcopal Hospital.) Hey's saw. It was formerly taught that interference with the acetabulum was unjustifiable, and that extensive disease of the pel- vis therefore forbade the hope of successful excision; it is now, how- ever, well established, through the labors of Hancock, Erichsen, and others, that the acetabular form of the disease is almost equally amenable to operative treatment as the femoral, and the entire bony floor of the acetabulum, and even large portions of the ischium and pubis, have, accordingly, been safely removed. There is, as shown by Hancock, no risk of opening the cavity of the pelvis in these operations, for its inner wall, composed of fasciae and muscles which are thickened and infiltrated with lymph, forms an effect- ual barrier to prevent the possibility of such an occurrence. The after-treatment of hip-joint excision is very simple: free drainage must be secured for the wound, which should be lightly dressed—the patient being kept in bed, with the limb slightly abducted, so as to pre- vent any tendency to projection of the sawn extremity of the femur. Moderate extension may be made by means of a weight, while the limb is kept in place by the apposition of sand-bags. As soon as the wound is sufficiently consolidated, the patient should be allowed to get about with crutches, or with a well-fitting Davis's, or Sayre's splint, or with that devised by Andrews, of Chicago, which acts by supporting the perineum upon a crutch-piece extending down the limb and riveted to the heel of HIP-JOINT. 605 the shoe. Re-excision has been occasionally practised with advantage, while amputation, subsequent to excision, has resulted favorably in three out of six cases in which it has been done. Elaborate statistics of hip-joint excision have been published by Fock, Sayre, Heyfelder, Hodges, Eulenberg, Good, Leisrink, Lyster, and others, the largest number of cases yet tabulated being, I believe, embraced in a paper contributed by myself to the second volume of the Pennsylvania Hospital Reports. To the 242 cases there collected, I have been enabled to add 56 from the tables of Dr. R. Good,1 which con- tain many French and recent English cases; 46 from the tables of Dr. H. Leisrink2 (containing principally German cases); 7 from the last edition of Mr. Erichsen's Surgery; 8 from Dr. Cheever's paper in the Medical and Surgical Report of the Boston City Hospital; and 17 from the excellent report of Dr. H. Lyster, in the Transactions of the Michigan State Medical Society for 1870. This gives a total of 376 cases, of which the results are known in all but 49. The total number of recoveries is 164, and of deaths 163, giving the large mortality of almost 50 per cent. of terminated cases. The following tables exhibit, in a form easy for reference, the statistics of the operation, as performed at different periods of life, and the com- parative results, according as the acetabulum was or was not interfered with, or, in other words, of complete as compared with partial excision. Results of Hip-joint Excision at Different Ages. Total. Recovered. Died. Result undeter-mined. Mortality per cent. Age. Of termi-nated cases. Of whole Xo. of cases. Under 5 years............ 22 115 97 41 37 18 46 11 63 47 16 11 2 14 10 34 36 24 23 15 21 1 18 14 1 3 1 11 47.62 35.05 43.37 60.00 67.65 88.24 60.00 45.45 Between 5 and 10 years... " 10 " 15 " " 15 " 20 " " 20 " 30 " Over 30 years............ 29.57 36.91 58.54 62.16 83.33 Age not stated............ 45.65 Aggregate.......... 37G ! 164 163 49 49.85 43.35 Comparative Results of Complete and Partial Excision. Total. Recovered. Died. Result undeter-mined. Mortality PER CENT. Form of Excision. Of termi-nated cases. Of whole No. of cases. Partial " ........ Form not stated.......... 133 48 195 65 25 74 58 22 83 10 1 38 47.15 46.81 52.87 43.61 45.83 42.56 376 164 163 49 49.85 43.35 1 De la Resection Coxo-femorale pour Carie; These. Paris, 1869. * Archiv fur Klinische Chirurgie (Langenbeck), xii. band, 1 heft, s. 134. Berlin, 606 EXCISIONS. Fig. 310. With regard to the utility of the limb after excision of the hip-joint, it may be said in general terms that a favorable result will be secured in two-thirds of the instances of recovery, the limb being reported as useful in one hundred and ten out of the above one hundred and sixty-four successful cases. From the first of the preceding tables, it is seen that the most favorable age for the operation is from five to ten years, the mortality increasing after puberty, and in adult life being so large as to be almost prohibitory. Even at the most favorable period, the death-rate is more than one in three, the operation being thus as often followed by death as ligation of the third part of the subclavian or of the external iliac, and almost as often as amputation at the shoulder, for all ages. The second table shows that complete is, upon the whole, quite as successful as partial exci- sion—more so if those operations are con- sidered as partial, in which this point is not definitely stated—and that hence the acetabulum should be freely gouged, in any case in which it is found to be diseased. The results of hip-joint excision, it will therefore be seen, are not very brilliant— one out of three dying under the most favorable circumstances, and but two out of seven recovering with useful limbs. Ought we, then, to abandon the operation? I answer, certainly not. The question is not so much, what does excision promise? as, does any other mode of treatment promise as well ? What, in fact, can the opponents of hip- joint excision offer instead? The operation is indeed such a grave one, that I have never felt that it was justifiable to resort to it, in any case in which it was not evident that life would be endangered by persistence in expectant measures. But in cases of hip disease in which suppuration has occurred, there usually, sooner or later, comes a time when the only alternatives are excision, amputation, or a prolonged and painful illness, terminated by death. These cases very rarely—in the class of patients which we see in hospital practice we might say almost never—recover under expectant treatment; they are carried from one hospital to another, and at last die worn out by suppuration or visceral disease, or are carried off from a life of pain and weariness by some intercurrent affection. No one, probably, at the present day, would think of amputating, in any case of hip disease to which excision was at all applicable; and, indeed, apart from the mutilation necessarily entailed, the chances of life are little better after removal of the limb than after excision—four out of eight cases amputated for hip disease having terminated fatally; so that excision is, in a good many instances, the surgeon's only available re- source, and, as such, should be employed without hesitation. In this respect, excision of the hip-joint differs from that of any other articu- lation of the body, and, as justly remarked by Mr. Holmes, "in cases Result of hip-joint excision. (From patient in the Episcopal Hospital.) KNEE-JOINT. 607 which show a decided tendency to get worse, we may pretty confidently reckon all the recoveries after the operation as a clear gain." Cases of Primary Amputation at the Hip-joint for Hip Disease. No. Result. Surgeon. Date. Reference. 1 Died........ Henry Thompson. Dr. John Thomson, Report on Belgian Hospitals, Edinburgh, 1816, p. 264. 2 Died, 18 days. William Kerr___ 1778 Med. and Philosoph. Commentaries, vol. vi., p. 337. 3 Died, 3 mos.. 1812 Richerand, Nosographie Chirurgicale, t. iv., p. 518. 4 Recovered... TV". J. Duffee..... 1840 Am. Journ. of Med. Sci., July, 1857, p. 283, and July, 1866, p. 22. 5 Died, 2 mos.. 1861 Jamain et Wahu, Annuaire, 1862, p. 221. Trans. Penna. State Med. Society, 3d fi Recovered... Allen........... 1862 s., Part II. (1862), p. 209. 7 Recovered... H. Lee.......... 1865 St. George's Hospital Reports, vol. i., p. 147. 8 Recovered... 1866 ^London Hospital Reports, vol. iii., p. 214, and vol. iv., p. 518. Knee-Joint.—Excision of the knee-joint may be required in cases of chronic disease of that articulation, and may be occasionally justi- fiable in cases of compound fracture or dislocation, or of angular anchylosis. This operation appears to have been first performed by Fil- kin, of Norwich, in 1762 (the case terminating in recovery), and was again successfully done by Park, in 1781. So little favor, however, did the procedure meet with in the eyes of surgeons generally, that thirty years ago it had been performed in all but twenty times. Revived by Textor, in Germany, and by Fergus- son, in England (the last- named surgeon operating for the first time in 1850), it has since been resorted to so frequently, that its statistics are now more ex- tensive than those of any other excision. The operation may be performed in several ways, the methods most deserv- Figs. 311, 312. Extremities of femur and tibia removed by excision of knee- joint. (From a specimen in the museum of the Episcopal Hos- pital.) ing attention being by the H, the U, and the simple transverse incision. The H incision was first employed by Moreau, and consists of two longi- udinal incisions, one on either side of the joint, with a transverse cut 608 EXCISIONS. Fie. 313. passing immediately below the patella. The lateral incisions should be placed far back, so as to give ready access to the femoral condyles, and to insure free drainage subsequently. This method, which is preferred by Butcher, greatly facilitates the subsequent steps of the operation, but has the disadvantage of making an unnecessarily large wound. The U, horseshoe, or semilunar incision was first practised by Mac- kenzie, and is probably that now generally preferred by surgeons. This method consists in raising an anterior flap containing the patella, the base of the flap reaching to above the condyles, as seen in Fig. 313. The liga- mentum patellae is divided in the first incision, when, the crucial and lateral ligaments being cut, the articulating ex- tremity of the femur can be readily excised with a Butch- er's saw. The limb being then flexed and forcibly thrust up- wards, the extremity of the tibia can be made to protrude, and may be removed with the same instrument. The simple transverse in- cision across the front of the joint, was suggested by Park, but appears to have been first employed by Textor, Kempe, of Exeter, and Fergusson. It makes a smaller wound than either of the other methods, and is prefer- able when the thickening of parts is not so great as to require a more extensive exposure. It is to be observed, however, that an incision which is transverse to the axis of the tibia, when the limb is flexed to a right angle (as it frequently is in these cases), will, when the excision is completed and the limb extended, form an obliquely curved wound, with its convexity downwards, so that this is in many cases really a flap- operation. The incision should reach on either side to the posterior edge of the base of the condyles (so as to secure drainage), and should at it8 centre come far enough forward to pass below the patella, which is turned ' upwards in the flap thus formed. In sawing through the articulating extremity of the femur, the natural obliquity of this bone should be borne in mind, and the section made in a line parallel to that of the free surface of the condyles; if this is neglected, and the section made transverse to the axis of the femur, the limb after adjustment will be found to be markedly bowed outwards. It should also be remembered that the situation of the epiphyseal line, is somewhat higher on the anterior, than on the posterior surface of the thigh-bone—so that it may be given as a safe rule, that the section of the condyles should be in a plane which, as regards the axis of the femur,is oblique from behind forwards, from below upwards, and from within outwards. The section of the tibia should be in a plane transverse to the long axis of the bone, with a slight antero-posterior obliquity so as to correspond with that of the section of the condyles. The epiphyseal cartilage of the tibia is less important for growth than that of the femur, Semilunar incision in excision of the knee-joint. KNEE-JOINT. 609 and need not therefore be so scrupulously respected. The patella should be dissected out, whether it be or be not diseased; it is shown by Penieres's researches that, while its excision diminishes the risk of death by nearly one-third, its retention more than doubles the probability of subsequent amputation becoming necessary. The bone sections being made, and the patella removed, the operation is completed by clipping away with scis- sors curved on the flat, or with Butcher's knife-bladecl forceps, all the fungous and degenerated synovial lining of the joint, taking care, how- ever, not to sacrifice the posterior ligament, which serves a useful pur- pose in preventing displacement, and in protecting the important struc- tures in the popliteal space. The limb should be dressed while the patient is yet in a state of anaesthesia: for this purpose, the leg is brought into the extended posi- tion, the bone sections accurately adjusted, and the whole limb securely fixed upon the splint on which it is to be kept. It may occasionally happen that the limb cannot be brought into the straight position by the application of any justifiable amount of force: under such circumstances the hamstring tendons may be carefully divided, this procedure, though in itself undesirable, being preferable to the removal of an additional segment of bone. The chief difficulty to be contended with, during the after-treatment, is to prevent the anterior projection of the cut extremity of the femur, and hence, the surgeon may, if he think proper, fix the bones in apposition by means of a strong metallic suture, as originally employed by Gurdon Buck, of Xew York, and since resorted to by many other surgeons. In most instances, however, this will not, I think, be found necessary, particularly if the bone sections be made, as above recommended, in a plane slightly oblique from behind forwards and from below upwards—a suggestion which appears to have originated with Billroth, and which is readily carried out with the aid of Butcher's saw. The best splint for the after-treatment of knee-joint excision is, I think, that known as Price's (Fig. 314), though excellent cures may be doubt- less obtained with Butcher's box splint, or, as recommended by Watson, Fig. 314. Price's apparatus for after-treatment in excision of the knee. of Edinburgh, with a posterior moulded splint and an anterior wire rod to enable the limb to be suspended. The essential points to be secured are absolute immobility of the limb, and ready access to the wound; hence, in default of other apparatus, an ordinary bracketed posterior wooden splint (Fig. 315), with a movable foot-piece and a slide, will prove satisfactory, the splint being, of course, well padded, and the thigh, leg, and foot firmly fixed with bandages or broad strips of adhe- sive plaster. Any tendency to anterior projection of the femur may be counteracted, as advised by Butcher, by using in addition a short anterior splint, while the risk of outward bowing may be prevented by using an external splint, or a metal spring and truss-pad, as ingeniously suggested 610 EXCISIONS. Fig. 315. Packard's bracketed splint for excision of knee-joint (modified). by Swain. The object being to obtain firm bony union, the splint should be removed as seldom as possible, and the first application should suffice, if possible, for at least a fortnight. The statistics of excision of the knee-joint have been investigated by a number of writers, and elaborate tables have been published by Butcher, Heyfelder, Hodges, and many others. The most recent re- searches upon this subject are those of L. Penieres,1 who has analyzed Fie. 316. Fig. 317. Excision of knee-joint for recurrent arthritis with partial anchylosis in bad position. in the Episcopal Hospital.) (From a patient nearly 600 operations, of which no less than 431 were for chronic disease of the articulation. These 431 cases gave 300 recoveries and 131 deaths, a total mortality therefore of 30.4 per cent. The following table will exhibit the results more in detail:— Recovered without further operation . " with useful limbs .... Re-excised (of which 6 recovered and 4 died) Amputated subsequently (47 recovered and 14 died) Died after first excision 247 or 57.3 per cent. 166 or 38.5 10 or 2.3 61 or 14.2 113 or 26.2 Death-rate of cases in which no further operation was performed 31.5 1 Des Resections du Genou. Paris, 1869. ANKLE-JOINT. 611 It is thus seen that, while a re-excision is, as might be anticipated, more fatal than the first operation, consecutive amputation is attended with comparatively little risk, less indeed than thigh amputation for disease in general. The following table shows in a very satisfactory manner the mortality of knee-joint excision at different ages: it is corrected from that given by Penieres, which contains a number of misprints. Result of Knee-joint Excision at Different Ages. Age. Total. a Recovered. Died. Mortality per cent. 6 to 10 " ........... 18 84 73 61 57 49 42 14 33 11 71 59 41 38 . 30 22 8 20 7 13 14 20 19 19 20 6 13 38.88 15 48 11 to 15 "........... 19 18 16 to 20 " ........... 32 79 21 to 25 " ........... 33.33 26 to 30 " ........... 38 78 31 to 40 " ........... 47 62 Over 40 " ........... 42.86 Not stated.............. 39.39 431 300 131 30.39 It thus appears that the operation of knee-joint excision, which is quite fatal in very early childhood, is not attended with much risk from the age of six up to the period of puberty; while from that time the danger steadily increases, till in adult life the operation is again one of a very serious nature. We may, therefore, probably say, with Holmes, that fourteen is, all things being considered, about the most favorable age—there being then comparatively little danger of consecutive short- ening, while the operation is at the same time not attended with any particular risk to life. Excision of the knee-joint should not as a rule be performed during the first five years of life, while it must be deemed an extremely grave procedure in persons past the age of thirty. Bones of the Leg.—Excision of the tibia is rarely justifiable, but may occasionally be proper in cases of acute necrosis from subperiosteal abscess (see p. 565). The operation requires a single longitudinal in- cision, the bone being then divided with a chain saw, and wrenched from its epiphyseal attachments with the lion-jawed forceps. .Excision of the fibula, which may be required for compound fracture or for necrosis, may be effected by a similar operation, care being taken to prevent sub- sequent eversion of the foot, by the use of a suitable splint. Ankle.—Excision of the ankle-joint may be required for compound fracture or dislocation, or for disease of the articulation. The operation may be performed by means of two lateral incisions, one behind either malleolus, or, which is probably better, by means of a semilunar incision passing around the lower border of the external malleolus and continued in a longitudinal direction along the line of the fibula. The anterior portion of the incision should not extend so far as to endanger either the extensor tendons or the dorsal artery of the «foot. Having divided the peroneal tendons, the surgeon may remove the lower end of the fibula, when the astragalus will come into view. If this bone be very slightly affected, it may be sufficient to gouge away such parts as are 612 EXCISIONS. diseased, but under ordinary circumstances it should be removed entire. The foot being then inverted, the lower end of the tibia is to be cau- tiously cleared with the probe-pointed knife, the inner malleolus being cut away with strong forceps, and as much of the articulating extremity of the tibia as may be thought necessary, removed with the chain saw. The limb should be kept during the after-treatment in a fracture-box, or on a posterior carved splint provided with a foot-piece. The foot must be well sujDported, lest anchylosis with a "pointed toe" ensue. The statistics of excision of the ankle-joint have been particularly investigated by E. Spillman,1 who has collected 73 cases, in 22 of which the fibula alone was involved, while in the other 51 the tibia was like- wise implicated. The disease, in most instances, was caries or arthritis, but occasionally necrosis, bony tumor, etc. The results may be seen in the following table:— Nature of operation. Total. Recovered. Died. t Not termi-nated. Subse-quent am-putation. Mortality per cent, of termi-nated cases. Excision of outer malleolus Excision of ankle......... 22 51 15 35 4 10= 1 2 1 1 5 20 pr. et. 20 pr. ct. 73 i 50 14 1 3 6 20 pr. ct. The condition of the preserved limb, in most of the cases of recovery, is said to have been quite satisfactory. Mr. Hancock, who has devoted special attention to the surgery of the foot and ankle, has collected3 32 cases of this operation performed by British surgeons, to which may be added five others since reported by Erichsen, Mulvany, Holmes, and Murney, of Belfast. Of the 37 patients, 25 recovered with useful limbs, 7 died, and 2 submitted to amputation, while the result of 3 cases is not known. In every instance, the operation was a complete excision, the mortality of terminated cases being 20.6 per cent. Foot.—The only excisions of tarsal bones which require special notice are those of the astragalus and of the calcaneum. Excision of the Astragalus may be required in cases of compound fracture or dislocation (or even simple dislocation, if irreducible), caries, necrosis, etc. The operation requires a semilunar incision on the ante- rior and outer aspect of the joint. The removal of the bone may often be facilitated by cutting across its neck with strong pliers, when the fragments may be successively dislodged with elevator and forceps, the probe-pointed knife being cautiously used in the deep portions of the wound—but in other cases it may be necessary to remove the bone piece- meal, by means of the gouge. The statistics of this operation (which was first performed by Hildanus, in 1670) have been investigated by Hancock,4 who finds that of 109 patients, 76 recovered with useful limbs, 2 were cured by amputation, and 17 died, while in 14 cases, the result was not ascertained. The mor- tality of terminated cases was thus nearly 18 per cent. 1 Archives Generales de Medecine, Fev. 1869. 2 Two of these after amputation. 3 New Syd. {Society's Biennial Retrospect, 1867-8, p. 251. 1 Ibid., 1865-6, p. 281. BONES OF FOOT. 613 Fig. 318. Excision of the Os Calcis is occasionally required incases of caries or necrosis of that bone, though in the majority of instances, free gouging, or the extraction of sequestra will suffice. The operation of excision of the calcaneum, may be done by raising a heel flap, as in Syme's ampu- tation, or (as recommended by Erichsen) by turning down an elliptic flap constituted of the tissues of the sole, and then making two lateral triangular flaps, by carrying a longitu- dinal cut through the tendo Achillis to meet the former incision, as shown in Fig. 318. A still better method, probably, is that of Holmes, in which an incision is made on the level of the upper part of the bone, beginning at the inner border of the tendo Achillis (which it divides), and passing around the back and outer surface of the foot as far forward as the mid-point between the heel and the base of the fifth metatarsal bone, a second incision passing at a right angle from near the anterior end of the former, downwards to the commencement of the grooved internal surface of the os calcis. The flap thus formed, which includes the cut peronei tendons, is then reflected from the bone, when, the ligaments of the calcaneo- cuboid joint being divided, the calcaneum itself can be slightly displaced inwards, so as to facilitate the division of the various ligaments between that bone and the astragalus. This being done, the calcaneum is twisted outwards, and carefully separated from the soft parts on its inner side. The operation is completed by stuffing the cavity with a strip of oiled lint, and. by fixing the foot at a right angle with the leg, by means of an anterior moulded splint. The statistics of excision of the os calcis, which appears to have been first performed by Monteggia, in 1814, have been studied by Burrall,1 of New York, and by Polaillon,2 of Paris. The last-named writer has col- lected 64 cases, which resulted as follows: 39 patients recovered with useful limbs, 6 recovered, but without much use of the preserved mem- ber, 7 submitted to subsequent amputation, and 3 died, while the result in 9 cases was not ascertained. If we add 3 successful cases recently reported by McGuire, of Richmond, Ta., we shall have a total of 58 ter- minated cases, giving 42 recoveries with useful limbs, and but 3 deaths, a mortality of but a little over 5 per cent. The other tarsal bones, or those of the metatarsus or toes, rarely admit of excision, the disease, when too extensive for successful gouging, usu- ally requiring amputation. Should the operation of excision be in any case resorted to, the lines of incision should be regulated by the position of external sinuses; no rules can be given which in such cases would admit of general application. Excision of the os calcis. 1 Bellevue and Charity Hosp. Reports, 1870, p. 91. 2 Archives Generales de Medecine, Sept. et Oct. 1869. 614 ORTHOPEDIC SURGERY. CHAPTEE XXXIII. ORTHOPEDIC SURGERY. Orthopaedic1 surgery is that branch of surgical science which treats of the means of remedying deformities, congenital or acquired. Etymo- logically, the term should be used only with reference to the deformities of childhood, and might be taken to embrace a great variety of subjects, such as the removal of tumors, the reduction of dislocations, etc. In practice, however, the application of the term is limited to a few particu- lar kinds of deformity, as wry-neck, lateral curvature of the spine, club- hand or club-foot, and contractions of joints not due to articular disease, while, on the other hand, no reference is intended to the age of the patient in whom these deformities occur. Wry-neck. This affection, which is also known as Torticollis, or Caput Obstipum, is occasionally congenital, but more often originates in children from three to ten years old. It consists in a contraction of the cervical muscles, particularly the sterno-cleido-mastoid and trapezius, usually on one side only, but sometimes on both. The head is drawn downwards and in- clined to the affected side, being at the same time rotated in the opposite direction. In the congenital form of the disease, and in that which is acquired (if long continued), the deformity is increased by defective development of the corresponding side of the face and head. The cervi- cal vertebrae undergo rotation on their axis, becoming twisted, and serv- ing to maintain the deformity, and ultimately compensatory lateral curvature is developed in the rest of the spinal column. Wry-neck is more common in girls than in boys; it is apparently due to irritation of the spinal accessory nerve—the non-congenital variety coming on after the eruptive fevers, or as the result of glandular inflam- mation or ordinary muscular rheumatism. It sometimes occurs as a reflex phenomenon, depending on the irritation of teething, or of intes- tinal parasites. Many of the cases Avhich are considered congenital are, according to Little, due to injuries received during birth. When both sterno-cleido-mastoid muscles are involved, the affection will usually be found to have a rheumatic origin. Symptoms and Diagnosis.—The symptoms are easily recognized, the contracted muscles being tense and well defined; frequently both portions of the sterno-cleido-mastoid seem equally rigid, but often the sternal portion is alone or principally involved. The diagnosis is usually easy; the deformity may be closely simulated by the contrac- tion of a cicatrix after a burn, or by disease of the cervical vertebrae; in the former event, the nature of the case will be evident upon careful examination, while, if spinal disease be present, the fact can be ascer- From offlof (straight), and »■*»; (child). WRY-NECK. 615 tained by observing the localized tenderness on pressure, and the pain produced by moving the spine or by pressing the head downwards, with perhaps the existence of inflammatory thickening and of partial motor paralysis. Treatment.—In the milder form of the affection, especially when of a rheumatic origin, a cure may be sometimes effected by the use of ano- dyne and stimulating embrocations, or, as successfully practised by Dr. J. M. Da Costa, of this city, by the hypodermic use of atropia; in some cases, in which the disease would appear to consist not so much in spas- modic contraction of the muscles on one side as of paralysis of those on the other, benefit may be derived from the employment of electricity, or from the endermic application of strychnia. In severer and more obstinate cases, it will usually be necessary to resort to an operation, though, if the degree of contraction be not very great, mechanical ex- tension, by means of a suitable instrument, will occasionally suffice. The Operative Treatment of wry-neck consists in the subcutaneous division of one or both of the lower attachments of the affected sterno- cleido-mastoid muscle: the sternal portion may be divided by intro- ducing an ordinary tenotome in front of the upper margin of the sternum, and about half an inch above the line of the clavicle, and, having passed Fig. 319. Tenotome. the knife behind the tendon, with its flat surface towards the latter, turning the edge forwards, and cutting the muscle, which is previously rendered tense, with a slight sawing motion from behind forwards. The clavicular attachment may be divided by a similar operation, through a puncture made at its posterior edge; or, which is perhaps safer, a small incision may be made clown to the clavicle, between the two portions of the muscle, and the clavicular attachment then cut from behind forwards, with a delicate probe-pointed tenotome which is cau- tiously insinuated between the muscle and the bone. As soon as the tendons have been divided, the punctures should be closed with a little dry lint and an adhesive strip, the patient being then placed in bed with the head well supported; after a few days an apparatus may be applied to effect mechanical extension, while the cure is further promoted by the systematic employment of friction and passive motion. The operation for wry-neck is one of much delicacy, and not free from risk, the princi- pal danger being from the possibility of wounding the external or in- ternal jugular vein, or the carotid artery; that this risk is not merely imaginary is shown by the fact that, in more than one case, the operation has been followed by fatal hemorrhage. Yarious forms of mechanical apparatus are employed in the after- treatment of wry-neck; in young subjects, it may sometimes be sufficient to apply a broad adhesive strip around the forehead and occiput, and another around the waist, fastening the two together by means of a handage carried from above the ear of the unaffected side across the chest to the opposite side of the trunk, thus reinforcing the healthy sterno-cleido-mastoid muscle, and so causing the disappearance of the wry-neck. A more elegant appliance is that of Jorg, which consists of a 616 ORTHOPEDIC SURGERY. leather corset and firm head-band, connected by a steel rod worked by a ratchet-wheel and key. Other efficient forms of apparatus act by means of two levers, one pressing on the side of the chin, and the other on the opposite temple. Wry-neck accompanied with Painful Convulsive Spasm of the Af- fected Muscles is a very intractable form of the disease, and occurs chiefly in female adults. Here division of the sterno-mastoid muscle affords, usually, only temporary relief. Dr. Little has several times obtained a cure by the administration of the bromide of potassium, or of the corrosive chloride of mercury, with attention to the digestive functions; and in one case a portion of the spinal accessory nerve was excised with benefit by Mr. Cambell De Morgan. Lateral Curvature op the Spine. This affection, which appears, in the majority of cases, to depend simply upon relaxation and debility of the spinal ligaments and mus- cles, is most common in young girls of from twelve to eighteen years of age. There are usually two curves, one occupying the dorsal region, and in most instances presenting its convexity to the right side, and the other or compensatory curve in the lumbar region, and convex to the left. More rarely there are four curves, an upper and a lower dorsal, and an upper and lower lumbar. Together with the lateral curvature, there is always, probably, a rotation of the bodies of the vertebrae on their axis, this rotation or twisting taking place in the direction of the convexity at each portion of the curve. The bodies of the vertebrae are thus more displaced than the spinous processes, the latter, indeed, sometimes appearing, even in advanced cases, to occupy almost their natural lines. The disease affects at first only the ligaments and mus- cles of the spine, but, in long-continued cases, may give rise to com- pression or partial absorption of the intervertebral cartilages, or even of the bones themselves. As the result of the twisting of the vertebrae which accompanies the lateral displacement, a certain degree of antero- posterior curvature is sometimes superadded—a rounded or hump-like projection occurring in the dorsal region, with a corresponding incurva- tion of the lumbar spine, the former constituting the condition known as cyphosis, and the latter that called lordosis. These are indeed but exaggerations of the natural curves met with in every adult spine. In some cases, especially among rachitic persons, they may exist without lateral displacement. Causes.—The common cause of lateral curvature is, as already men- tioned, simply debility of the ligamentous and muscular structures which normally support the vertebral column, thus allowing, as it were, the head and upper part of the body to settle downwards, and necessarily forcing the relaxed and weakened spine to yield at its least-resisting point. The physiological changes which occur in the female at the age of puberty, and the customary relinquishment, at that period of life, of the out-door sports of childhood, appear to act as powerful predisposing causes of the spinal relaxation referred to. The very constant character of the displacement—to the right in the dorsal, and to the left in the lumbar region—is doubtless due to certain vicious habits and postures, such as supporting the whole weight on the right leg ("standing at ease," in the language of the drill-master), whereby the pelvis is ren- LATERAL CURVATURE OF THE SPINE. 617 dered oblique, and the lumbar spine necessarily distorted to the left side; to sitting habitually at a desk with the left shoulder depressed and the right elevated; to over-exertion of the right arm in sewing, etc. Though the dorsal curve is usually most apparent, it is really, according to Shaw, preceded in time of formation by the lumbar. The latter, how- ever, does not become so quickly permanent, on account of the greater flexibility and elasticity of the part, which enable it to resist longer the occurrence of absorption of the articular processes and other secondary changes than can be done by the dorsal spine, fixed as that is by its connections with the thoracic walls. According to Willett, both curves are developed simultaneously. Among the rarer causes of lateral spinal curvature maybe mentioned obliquity of the pelvis from any circumstance, as from anchylosis of the hip-joint after hip disease (here the deformity is principally of the variety called lordosis), and distortion resulting from contraction of one side of the chest after empyema or chronic pleurisy. Inequality in the length of the lower limbs is, according to Barwell, a frequent cause of lateral curvature. Fie. 320. Symptoms.—The symptom of lateral curvature which first attracts attention, is commonly a projection or "growing out" of the right sca- pula, often attended with pain in the shoulder and back; this is usually worse while sitting, or upon first lying down, so that a patient, who has made no complaint during the day, may lie awake in pain for several hours upon going to bed at night. Upon making an examination, the sur- geon will readily perceive the wing-like projection of the scapula, and may, even at this early stage, recognize a slight deviation in the line of the vertebrae, by tracing down the spinous processes and marking each with pen and ink. It must be, moreover, remembered that the devi- ation of these processes by no means represents the degree of distortion of the bodies of the bones, the displace- ment of the latter being usually greater than that of the former. In the early stages of the affection,the deformity can be made to disappear by laying the pa- tient on a bed in the prone position and making slight extension on the spine; but in advanced cases, the deformity will persist in all positions, while the whole chest and the pelvis may be likewise markedly distorted, and serious functional disturbance, or even organic disease, may result from the consequent compression of the thoracic, abdominal, or pelvic viscera. Diagnosis.—Lateral curvature may be distinguished from the graver condition known as antero-posterior curvature, or Pott's disease of the spine (which will be described hereafter), by the fact that in the latter affection the displacement is commonly angular, rarely lateral, and Lateral curvature of spine. 618 ORTHOPEDIC SURGERY. unattended with axial rotation of the vertebrae. There are besides, usually, marked immobility, thickening, and tenderness of the affected portion of the spine. From the spinal distortion of rickets lateral curvature may be distinguished by observing the different ages at which the diseases respectively occur, and by noting that in rachitis the primary displace- ment is antero-posterior, the lateral deformity, if there be any, being a mere coincidence; while in the true lateral curvature the fact is exactly the reverse, cyphosis and lordosis being in these cases secondary phe- nomena. Treatment.—No matter how slight the deformity in any case may appear to be, it should not be neglected: in the early stages, before any structural alteration has occurred, it may be possible to effect a com- plete cure; but at a later period, the most that can be done is to prevent further increase of the deformity. The treatment consists in the adop- tion of measures to improve the general health, the administration of tonics, especially iron and quinia, and the abandonment of amy injurious habit or occupation. The patient should take exercise in the open air, and may often derive great advantage from gymnastics, swinging by the hands from bars placed above the head, the use of light dumb-bells, etc. The object is to put in motion and thus to strengthen the various mus- cles attached to the spinal column, and much ingenuity may be exerted in devising various modes of accomplishing this purpose. None of these exercises should, however, be persevered in to the extent of producing fatigue. During the intervals of exercise the patient should be encou- raged to keep the recumbent posture, lying upon a firm mattress or sofa with a single pillow, so as to relieve the vertebral column from pressure. If the curvature persist while lying down, a cushion maybe placed under the projecting portion of the spine, so as gradually to press the bones into their normal position. Friction of the muscles on either side of the spine, either with the hand alone or with stimulating liniments, will often be of service, as will also the daily use of the cold salt douche. In severer cases, it will probably be necessary to afford mechanical support by means of some form of apparatus. A great many instruments have been devised for this purpose, the general principle of action being to elevate the shoulders by means of crutch-heads under the axillae (con- nected with a well-padded pelvic collar), with side-pieces to support and gradually replace the projecting vertebrae by applying pressure to the corresponding portions of the chest-walls. Such an apparatus may be at first applied during the clay only, but when the patient has become used to it, both day and night, and may be continuously worn for an indefi- nite period of time. If a case of lateral curvature be recognized at an early period, and promptly and judiciously treated, it may be, if not cured, at least kept in check until the critical period of adolescence has passed by, when there will be comparatively little tendency to increase of the deformity. It thus happens that while a very large number of young girls suffer from incipient lateral curvature, its advanced stages are comparatively seldom seen—the disease being, as it were, " outgrown" in a great many instances. Myotomy, or subcutaneous division of the spinal muscles and aponeu- roses, is now almost entirely abandoned in the treatment of lateral curva- ture ; indeed, as the disease is dependent upon ligamentous and muscular relaxation, not contraction, it is difficult to understand why such an operation should be expected to prove beneficial. DEFORMITIES OF THE UPPER EXTREMITY. 619 Deformities of the Upper Extremity. Contraction of the Arm may be owing to disease of the elbow, to the retraction of the cicatrix of a burn, or to a contracted state of the biceps muscle—which latter condition may itself be variously due to hysteria, to rheumatism,ov to constitutional syphilis (see pp. 449, 502). In hysterical cases, the proper constitutional treatment for that condition should be employed, the arm being, if necessary, extended while the patient is in a state of anaesthesia, and then kept in a straight position for a few days. In the rheumatic form, when the contraction is perma- nent and accompanied with organic change, tenotomy may be required. The operation is performed by slipping a tenotome flatwise beneath the tendon of the biceps from within outwards, so as to avoid the artery, and then, turning the edge of the knife forwards and upwards, effecting the section by cutting with a slight sawing motion while the arm is forcibly extended. The wound should then be closed and the arm placed in a sling, extension being applied after a few days by means of a screw- splint or weight. Contraction of the Forearm and Hand is occasionally met with, as the result of excessive use of certain muscles, with disuse of others: the treatment consists in a change of occupation, with the employment of a straight splint, friction, galvanism, etc. Club-hand is a rare affection, analogous to club-foot. It is usually complicated with a deformed condition of the lower end of the radius, and sometimes of the carpal bones. Two forms of club-hand are met with, in one of which the part is in a state of extreme flexion, and in the other of extension. The affection is sometimes congenital, but usually results from infantile paralysis, and is, according to Holmes, always ac- companied by other deformities. The treatment consists in supplement- ing the action of the paralyzed muscles by means of India-rubber bands, attached to a light metal frame, and passing beneath a ring at the wrist. In inveterate cases, tenotomy may be required, followed, after the healing of the wound, by passive motion, aided by the use of friction and gal- vanism. Contraction of the Fingers into the palm of the hand is not unfre- quently met with, usually in old persons, as the result of an indurated state of the palmar and digital fascia, due apparently to a constitutional condition analogous to that of rheumatoid arthritis. The exciting cause of the affection is often the habitual pressure of the head of a cane, or of the handles of various kinds of tools. A similar contraction may be due to burns or other traumatic causes (in which case a scar would be perceptible), or to certain forms of eczema—an important point to be remembered, as the operation about to be described would not of course be applicable to that affection. The treatment of the deformity now under consideration consists in the cautious subcutaneous division of the contracted tendons, which may be effected by slipping a small tenotome beneath the tendon in the palm and cutting forwards, the cure being completed by passive motion (after a few days), with frictions, bandaging, or the use of a screw-splint. Under this treatment, tfie fascial induration gradually yields, the ridges and furrows disappearing, and the part slowly returning to its normal state. Relapse is, however, 620 ORTHOPAEDIC SURGERY. not infrequent (owing to the constitutional nature of the affection), and a repetition of the operation may therefore become necessary. Deformities of the Lower Extremity. Contraction of the Hip.—Contraction of the muscles surrounding the hip may occasionally require tenotomy or myotomy, in cases of spasmodic rigidity of the lower extremities, of congenital luxation, or of chronic hip disease. The tendon which most often requires division is that of the adductor longus, though the operation is also sometimes performed upon the adductor brevis, pectineus, tensor vaginae femoris, and rectus. Division of these muscles is performed in accordance with the principles of tenotomy in general, the knife being introduced behind the part to be divided, and the section then cautiously effected by cut- ting from behind forwards. Knock-knee or Genu-Valgum is a not uncommon deformity, consisting of a relaxation of the ligamentous and muscular structures of the knee-joint, allowing the articulation to yield in a direction inwards and backwards. The internal lateral liga- Fig. 321. ment is elongated, while the external lateral ligament is rendered tense, together with the vastus externus and outer ham- string tendon. The inner condyle of the femur is, as compared with the outer, dis- proportionately large and prominent, while thepopliteal space is somewhat obliterated. The affection is probably never congenital, but comes on during childhood, and is apparently connected in many instances with a rachitic tendency. Both knees are usually simultaneously affected, though the disease may be more marked in one than in the other. The treatment consists in the adaptation of an apparatus such as is shown in Fig. 321. An iron rod, hinged at the hip, knee, and ankle, extends from a pelvic band to the sole of the shoe, and is provided with pads, straps, and buckles, by which the knee may be drawn out- wards : in severe cases, motion should be Apparatus for knock-knee. permitted at the hip and ankle only, fhe knee being fixed, and its displacement gradually rectified by means of the adjusting straps or a ratchet-screw. Division of the external hamstring tendon is occasionally resorted to as a preliminary measure, but, according to Little, does not appreciably hasten recovery, and is therefore not to be recommended. Outward Bowing of the Knee or Genu-Extrorsum is a con- dition which is the reverse of Genu-Valgum: the external lateral liga- ments are relaxed, and the tibiae themselves are commonly curved, giving tHe appearance known as " bow-legs." This deformity is sometimes traceable to premature attempts at walking, and is usually connected with a rachitic vice of constitution. The treatment consists in the applica- tion of padded splints, so as to overcome the outward bending of the CLUB-FOOT. 621 limbs, and, at a later period, in the adaptation of suitable supports, so as to prevent a recurrence of the deformity. Mr. Marsh recommends forcible straightening of the curved tibiae, even at the risk of producing fracture, this lesion being, as he justly remarks, easily repaired in rickety bones. Contraction of the Knee, dependent upon shortening of the ham- strings, may occur in connection with anchylosis of the joint, or inde- pendently: the treatment consists in division of the hamstring tendons, followed by gradual extension, with passive motion, friction, etc. Division of the Hamstring Tendons is thus performed: the patient being in the prone position, an assistant renders the parts tense, by fully extend- ing the limb, and the surgeon then introduces the tenotome flatwise on the inner side of the outer hamstring, or biceps tendon (which is to be first divided), through a puncture which in the adult should be an inch above the point at which the tendon joins the fibula. By keeping the knife close to the tendon, the risk of wounding the peroneal nerve is avoided, and the section is then effected by cautiously cutting towards the skin. The semi-tendinosus, being superficial and prominent, is readily divided, but the semi-membranosus requires a freer use of the knife: it, however, comparatively seldom needs to be cut. In operating on the inner hamstrings, the tenotome should be introduced close to the outer (popliteal) side of the semi-tendinosus, as there is thus less risk of wounding the important structures in the popliteal space After the operation, the wounds should be instantly closed with a firm compress (to prevent extravasation, or the entrance of air), and no attempt at extension should be made until the parts are entirely healed, which usually requires a delay of four or five days. Neglect of this precaution may give rise to wide-spread suppuration in the tissues of the ham. When cicatrization has occurred, gradual extension may be made by means of a weight, elastic bands, or screw apparatus, or in some few cases forcible extension maybe preferably employed, the patient being of course in a state of anaesthesia. Recovery may be further promoted by the assiduous practice of passive motion, aided by friction, douches, etc. Club-Foot.— Talipes or Club-foot is a common deformity, which may affect one or both extremities, and may occur in either sex, though more frequently in boys than in girls. It may be congenital or acquired. There are four primary and as many secondary varieties of the deformity. The primary forms of club-foot are Talipes Equinus, Talipes Calcaneus, Talipes Varus, and Talipes Valgus, while the secondary forms are com- binations of these, receiving the names of Equino- Varus, Equino-Valgus, Calcaneo-Varus, and Calcaneo-Valgus. All forms of club-foot depend upon contraction of various muscles and tendons, which may result from spasm of the contracted parts themselves, or from paralysis of the antagonistic muscles; in most cases, the bones of the foot are not altered in structure, but in inveterate cases of varus (which is the most common form of congenital talipes), the astragalus, scaphoid, and cuboid will all be found more or less atrophied and twisted, the ligaments cor- respondingly altered in length, the tendons distorted, and the muscles of the whole limb wasted. Adams indeed maintains that, in cases of varus, the astragalus is malformed from the moment of birth, the malformation probably being due to the pressure of the adjacent bones during intra-uterine life. In non-congenital club-foot, the muscles 622 ORTHOPEDIC SURGERY. commonly undergo fatty degeneration, rendering the prognosis in these cases less favorable than in those which are congenital. The first application of tenotomy to the cure of club-foot was an operation performed by Lorenz, in 1784, on the recommendation of Thilenius, of Frankfort. The operation consisted in a simple incision, involving the skin and subjacent tissues as well as the contracted tendon, and a perfect cure is said to have been obtained. Delpech, in 1816, transfixed the limb beneath the tendo Achillis, and cut towards the skin which was, however, carefully protected from injury. To Stromeyer, of Hanover, in 1831, is due the credit of first resorting to subcutaneous tenotomy as it is now practised, while to Grue'rin and Bonnet, in France, to Little, Tamplin, and Adams, in England, and to Detmold and Mutter, in this country, are in a great measure owing the general introduction and perfection of the procedure. The process of repair after division of tendons consists, as shown by Adams, in the development, between the retracted ends, of a new material, which does not, as was formerly supposed, subsequently contract and bring down the shortened muscle, but remains permanently, though gradually assimilating itself in structure and appearance to the original tendon. 1. Talipes Equinus.—This is very seldom, if ever, a congenital affec- tion, but is, on the other hand, the most common non-congenital form of club-foot, occurring, according to Tamplin, in forty per cent, of cases ori- ginating after birth, and in twenty-two and a half per cent, (or, according to Lonsdale and Adams, thirty-four per cent.) Fig. 322. 0f a\\ cases taken indiscriminately. The defor- mity in talipes equinus consists simply in an elevation of the heel, which may be so slight as merely to prevent the foot from being flexed beyond a right angle, or may be so marked as to force the patient to walk upon the toes and extremities of the metatarsal bones, as seen in Fig. 322. The cause of this deformity (in children) is very often disturbance of the nervous system during dentition, or from the irri- tation of intestinal worms, though some cases depend upon general infantile paraly- sis ; in adults, this form of club-foot may result from paralysis, from abscess or injury of the calf of the leg, or from habitually keeping the foot in a bad position (during the treatment of fractures, etc.), by which the patient acquires a " pointed toe." The treatment consists in the subcuta- neous division of the tendo Achillis, about an inch above its point of insertion. The patient being prone, and the tendon rendered tense by depressing the foot, the tenotome is introduced flatwise (on either side, as most convenient) and carried across in close contact with the tendon, so as to avoid wounding the posterior tibial artery: the edge of the knife being then turned back- wards, the tendon is forcibly brought against it by still further depress- ing the foot, while the blade is given a slight sawing motion. An audible snap usually marks the completion of the operation, when the heel can be immediately brought clown an inch or two further than before. CLUB-FOOT. 623 Prof. Pancoast has in some cases advantageously substituted division of the lower portion of the soleus muscle for that of the tendo Achillis. In very severe cases of talipes equinus, it may be necessary to divide the plantar fascia, or even some of the tendons of the toes as well: when the plantar fascia is to be divided, this should be done as a preliminary operation, the tendo Achillis being for the time untouched, so that its tense condition may fix the heel and facilitate the " unfolding" of the arch of the foot. After the operation, the punctures made by the teno- tome should be immediately closed with a piece of lint and adhesive strip. Mechanical extension may be begun from the third to the fifth day (not before the former), and may be conveniently effected by Adams's modification of Scarpa's shoe, which differs from those in ordinary use, chiefly in having a transverse division of the sole-plate, corresponding to the transverse tarsal joint. In using this, as with all other forms of orthopaedic apparatus, care must be taken to guard against excoriation, by frequently removing the instrument and bathing the skin with some stimulating lotion. The extension must be effected very gradually, the maxim "festina lente" being in no cases more important than in these. 2. Talipes Varus is the most frequent variety of congenital club-foot, being met with, according to Tamplin, in ninety per cent, of such cases. The deformity of varus is twofold, consisting in an inversion of the Fig. 323. anterior two-thirds of the foot, which rotate upon a centre of motion consti- tuted by the astragalo-scaphoid and calcaneo-cuboid joints, with an eleva- tion of the posterior third by the con- traction of the muscles of the calf. When the latter displacement is par- ticularly marked, the affection receives the name of equino-varus. The inver- sion of the front part of the foot is due to contraction of the tibialis anticus, tibialis posticus, flexor longus digito- rum, and occasionally the flexor and Talipes varus extensor longus pollicis, the plantar fascia and flexor brevis digitorum being also sometimes more tense than in the normal state. The treatment of this form of club-foot is best divided into two stages, the inversion of the front of the foot being remedied during the first^ and the elevation of the heel during the second stage; in other words, the case is first to be converted into one of simple talipes equinus, and then treated as was directed in speaking of that form of the affection. In some very slight cases of congenital varus, the deformity can be remedied by simple manipulation and friction repeated several times a day, but in cases of ordinary severity, tenotomy should be resorted to, the best age for the operation being probably between the second and third month of life. 1 he tendons to be divided in the first stage of treatment, are those of the tibialis anticus, and posticus, with sometimes that of the flexor longus digitorum, and the plantar fascia. The tibialis anticus tendon deviates from its normal direction, curving downwards and backwards across the mner malleolus, while the posterior tibial tendon passes from behind the inner ankle directly downwards, or even with a slight backward obliquity. In dividing the latter tendon there is some risk of wounding the posterior tibial artery; hence it is well to adopt Tamplin's suggestion of making 624 ORTHOPEDIC SURGERY. Fig. 324. a preliminary puncture, and then using a blunt-pointed tenotome. Should the vessel be wounded, it should be cut completely across, and a firm compress and bandage then instantly ap- plied. If a traumatic aneurism form, it may be treated by compression, by injec- tion of the perchloride of iron, or by the " old operation." Similar treatment would be required if the internal plantar artery should be wounded in dividing the plantar fascia. After tenotomy, the inversion of varus may be slowly overcome by banda- ging the limb to a straight external splint, or by the use of a " varus shoe," provided with a joint in the sole-plate for effecting eversion (Fig. 324). The second stage of treatment consists in dividing the tendo Achillis, and in subsequently bringing clown the heel, as in a case of simple talipes equinus. The time required for the cure of talipes varus varies from two months to a year, according to the age of the pa- tient, anel the severity of the affection. 3. Talipes Calcaneus is very rare as a congenital affection, though as a non-con- genital disease, resulting from infantile paralysis (particularly in combination with talipes valgus), it is, according to Adams, comparatively common. This form of club-foot depends upon contraction of the muscles of the front and outer part of the leg, the deformity, which is the reverse of talipes equinus, causing the patient to walk on the heel. In slight Varus shoe, with jointed sole-plate. Fif Fi<* 326. Talipes calcaneus. Talipes valgus. cases of the congenital variety, a spontaneous cure maybe effected by the simple process of walking, but in most instances, tenotomy will he required, the tendons to be divided being those of the tibialis anticus, extensor communis digitorum, extensor proprius pollicis, and peroneus CONTRACTION OF TOES. 625 tertius. The after-treatment consists in the application of an apparatus provided with an elastic spiral spring at the heel, to supplement the action of the tendo Achillis. This form of talipes is occasionally com- bined with varus, constituting calcaneo-varus. 4. Talipes Valgus, or flat, or splay-foot, is rare as a congenital, but sufficiently common as an acquired affection. The deformity is here the reverse of that seen in varus, the sole being flattened, the arch of the instep obliterated, and the foot everted. In severe cases, the heel is com- monly depressed as well, constituting calcaneo-valgus; or, on the other hand, the heel may be elevated, constituting equino-valgus. Congenital cases of talipes valgus may often be cured by simple manipulation, or by bandaging the foot to an inside splint, with a wedge-shaped pad, as in Dupuytren's mode of treating fractured fibula. In other instances, tenotomy will be required, the parts to be divided being the tendons of the peroneus longus and brevis, and extensor communis digitorum, with sometimes the tendo Achillis, or even the tendons of the tibialis anticus and extensor pollicis. The after-treatment consists in applying an appa- ratus to produce gradual inversion, with a pad to restore the arch of the foot. Weak Ankles, which often precede the development of acquired talipes valgus, should be treated by attentio'n to the hygienic surroundings of the patient, and by the use of friction and the salt douche, with, if neces- sary, an elastic bandage, or light metallic lateral supports. On the Treatment of Club-foot without Dividing Tendons.—Mr. Bar- well opposes the practice of tenotomy, in the treatment of talipes, on the ground' that the affection is always the result of paralysis, and that divided tendons seldom reunite. He recommends instead, the employ- ment of an apparatus, in which elastic cords supplement the paralyzed muscles, and counteract the action of those which are contracted. With- out entering into any discussion of Mr. Barwell's theoretic views (which are opposed to those of the leading authorities on the subject of club-foot), it will be sufficient to say, that while the ingenious mode of treatment which he advocates may undoubtedly effect a cure in mild cases, it will, as undoubtedly, fail in many of those which are more severe; and even in the slight cases, tenotomy (which has not been proved to do any harm), certainly abbreviates the time required for treatment. Indeed, we may safely say, in the words of Mr. Adams, that the successful treatment of club-foot demands, inmost cases, "a judicious combination of operative,. mechanical, and physiological means." Contraction of a Toe, usually the second, is commonly due to a tense state of the digital prolongation of the plantar fascia, and requires division of the offending structure; the operation should be done sub- cutaneously, opposite the base of the second phalanx, the toe being then straightened, and secured to a small pasteboard or wooden splint. 40 626 DISEASES OF THE HEAD AND SPINE. CHAPTER XXXIY. DISEASES OF THE HEAD AND SPINE. Diseases of the Head. Tumors of the Scalp.—The most common forms of tumor met with in the scalp, are the cutaneous proliferous cyst, and the vascular or erectile tumor, though fatty and fibrous growths have also been occa- sionally seen in this situation. The treatment of these affections has been sufficiently discussed in other parts of the volume. Tumors of the Skull. — Bony, cartilaginous, myeloid, and can- cerous growths are met with in the cranial walls, the latter form of dis- ease constituting the affection sometimes described as Fungus of the Skull. Surgical interference is rarely admissible in this serious con- dition, though a case is referred to byErichsen, in which such a growth was successfully removed by B. Phillips. Fungus of the Dura Mater.—Under this name is commonly de- scribed a tumor which, beginning without any obvious cause, makes its appearance on the top or side of the head, or in the temporal region, forming a semi-fluctuating mass, sometimes crackling on pressure, pulsa- ting, attended with much pain, and accompanied by various cerebral symptoms, such as double-vision, deafness, convulsions, and, in the latter stages, coma and paralysis. The tumor, as it increases, becomes softer and more prominent, a distinct margin of bone being often felt surround- ing the morbid growth, indicating the occurrence of erosion of the skull. The pathology of this serious affection, which was first clearly described by Louis, has been recently investigated by Mr. Lawson Tait, who con- cludes, from the dissection of a case which came under his own observa- tion, as well as from the recorded histories of other instances of the disease, that the so-called fungus of the dura mater is really an affec- tion of the skull, originating in the layers of osteal cells, and, clinically speaking, of a malignant character. The disease may originate either beneath the pericranium (outside the skull), or between the cranial wall and the dura mater, or, as happened in Mr. Tait's own case, in both situ- ations simultaneously, the skull thus undergoing erosion on both sides, until the masses meet and amalgamate, when pulsation is developed. The Diagnosis from vascular tumor of the scalp, which is the only disease with which the affection is likely to be confounded, may be made by observing that the growth cannot be moved laterally upon the skull, and (in cases in which the bone is perforated) can be often partially re- duced within the cranial cavity. A fungus of the dura mater has been punctured under the impression that it was an abscess, but such a mis- take could scarcely arise except through carelessness. The Treatment of this affection is extremely unsatisfactory: Louis recommends that the growth should be excised, or otherwise extirpated, after removing as much of the skull as may be necessary with the tre- phine; but the case which he gives of recovery after this severe treatment, seems, as justly remarked by Holmes, to have been really one of simple ENCEPHALOCELE AND MENINGOCELE. 627 caries with underlying exuberant granulations. Any partial operation, in view of the malignant character of the affection, would be worse than useless, while complete extirpation would, in all probability, but hasten the fatal issue. Fungus of the Brain, or Hernia Cerebri, has been sufficiently alluded to in a previous portion of the work. (See page 316.) Encephalocele and Meningocele.—These are the names given to congenital tumors, consisting of a protrusion through a suture, or part of the skull which in foetal life is membranous, of portions of the cranial contents. The meningocele contains merely a bag of cerebral membranes with sub-arachnoid fluid, while the encephalocele contains a portion of brain-substance as well. These malformations usually, but not invariably, occupy the occipital region, protruding a little behind the situation of the foramen magnum; they are usually solitary, but occasionally multiple, varying in size from that of a pea to that of the liead itself, and complicated with internal hydrocephalus. The sac of a meningocele may be single or multilocular, and the contained fluid may be clear like that of a hydrocele, or ma}- be dark from the admixture of blood. If the tumor be sessile, it may be wholly or partially reducible by pressure, such reduction being followed by symptoms of cerebral compression; the tumor swells up, and becomes tense when the child cries, and sometimes partakes of the motions of the brain. The affec- tion is occasionally complicated with naevus, and not unfrequently with other congenital malformations. The Diagnosis from congenital cystic tumor, when the meningocele is sessile, is sometimes very difficult; but in most cases may be made by observing the situation of the malformation, its variations of tension, and the fact that it is not movable upon the skull; if, however, the com- munication with the cranial cavity be very small, the diagnosis may be quite impossible. The affection is also liable to be confounded with erectile tumors of the scalp, and indeed, as already mentioned, the two diseases may coexist. The Prognosis is unfavorable, the large majority of these cases termi- nating fatally during infancy, though occasionally patients thus affected have survived to adult life. Death is usually preceded by convulsions, due to cerebral pressure, but in some cases ulceration or rupture occurs, when inflammation of the sac and general spinal meningitis are the im- mediate precursors of the fatal issue. The Treatment in most cases should (according to Holmes, who has devoted special attention to the subject) be limited to affording support and making gentle pressure, by means of a gutta-percha cap lined with cotton wadding; and in cases evidently complicated with general hydro- cephalus, nothing further is admissible. If the tumor be rapidly increas- ing, without general symptoms, repeated tappings may be resorted to, with precautions against the entrance of air. In cases of meningocele, if pedunculated, iodine injections may be tried with some hope of benefit. Finally, if there be reason to believe that, as sometimes happens, the communication with the cranial cavity has become obliterated, the tumor may be excised; or even if a communication persist, the operation might be occasionally justifiable, the pedicle of the tumor in such a case being first compressed by means of a clamp, which should be allowed to remain for twenty-four hours. A very remarkable case has been re- cently reported by Dr. Daniel Leasure, of Alleghany City, Pa., in which a meningocele (or, as the author terms it, hydrencephalocele) is said to f 628 DISEASES OF THE HEAD AND SPINE, have been radically and permanently cured by evacuating the contents of the sac, and invaginating its integuments so as to plug the cranial aperture—very much as is done with the scrotal tissues, in Wutzer's operation for the radical cure of hernia. Paracentesis Capitis.—The operation of tapping the head is occa- sionally required in cases of acute, or even of chronic hydrocephalus, when death seems imminent from the intra-cranial pressure exercised by the accumulated fluid. The relief afforded by paracentesis, under these circumstances, can scarcely be expected to be permanent, particularly in congenital cases, in which there is usually malformation of the brain. Still the operation is not, even in these instances, likely to add much to the gravity of the situation, while in the non-congenital cases it has unques- tionably been occasionally productive of much benefit. A very delicate trocar is to be employed, being introduced through the anterior fonta- nelle, as far as possible from the median line (so as to avoid wounding the longitudinal sinus), or, in cases of internal hydrocephalus, through the coronal suture on either side, midway between the anterior aud sphenoid fontanelles, the point being then directed inwards and back- wards so as to penetrate the lateral ventricle. A small quantity only (about two fluidounces) of fluid should be evacuated, the sides of the skull being compressed during the operation by the hands of an assist- ant. As soon as the instrument has been withdrawn, the puncture should be closed with an adhesive strip, and an elastic, perforated, India- rubber cap (as advised by Holmes) tightly drawn over the head, so as to support the skull and prevent syncope. If no bad results follow the operation, it may be repeated at another point, after a few weeks' interval. Diseases op the Spine. Spina Bifida.—This is a congenital malformation, which consists in a deficiency of the spinous processes and laminae of one or more vertebrae, allowing the protrusion of the spinal mem- Fig. 327. branes, which form a tumor containing cerebro-spinal fluid, and usually some of the spinal nerves or even a part of the spinal cord itself. Spina bifida (or Hydro- rachitis, as it is also called) may occupy any portion of the vertebral column, though most frequent in the lumbar anel sacral regions; maybe single or multiple; is usu- ally of an oval shape; and varies in size from that of a walnut to that of a child's head. It may be sessile or pedunculated, sometimes lobulated, and is usually cover- ed by skin of a more or less normal charac- ter, though in some instances there is no cutaneous investment, the sac-wall being constituted of the spinal dura mater itself, in which case ulceration is apt to occur. The tumor is tense and elastic when the child is in the upright position and during the action of expiration, becoming softer during inspiration and when the child is laid on its face. Fluctuation is sometimes ANTERO-POSTERIOR Ct/RVATURE OF THE SPINE. 629 observed, and partial reduction may be often effected by pressure—the bony aperture through which the protrusion has taken place being then perceptible to the touch. Spina bifida often coexists with other de- formities, and is frequently complicated with hydrocephalus. Death usually occurs within a short time of birth, from convulsions or spinal meningitis, though occasionally life is prolonged to adult age, and in some rare instances it would appear that a spontaneous cure has been effected, by the channel of communication with the cavity of the spinal membranes becoming obliterated. The Treatment of this affection is not very satisfactory; if the tumor be not rapidly increasing in size, the surgeon should content himself with applying equable support, with perhaps slight pressure, by means of a well-padded leather or gutta-percha cap, or an air-pad; if the skin be not irritable, the tumor may be painted with collodion, thus taking advan- tage of the contractile properties of that substance. If the child be otherwise healthy, and life seem to be endangered by the rapid growth of the tumor (threatening ulceration and rupture, or inducing convulsions or paralysis), paracentesis may be tried ; the sac is tapped with a small •trocar at a distance from the median line (in which position the cord is most likely to be placed), an ounce or two of fluid being evacuated, and the wound then instantly closed, and pressure reapplied. If these means fail, and the tumor be pedunculated, a small quantity of a solution of iodine may be cautiously injected, a plan which, with various modifica- tions, has been successfully employed by Brainard, of Chicago, Yelpeau, and other surgeons. Ligation and excision have been occasionally resorted to, and each has proved successful in at least one instance, but, in most cases, has but served to hasten death. False Spina Bifida.—Under this name are included three distinct con- ditions, viz.: (1) a true spina bifida, the connection of which with the spinal membranes has become obliterated; (2) a congenital tumor, cystic or fatty, which originates within the spinal canal and protrudes through an aperture due to a deficiency in the vertebral laminae; and (3) a tumor containing foetal remains, constituting the malformation properly de- scribed as included foetation. If the surgeon can satisfy himself, by care- ful and repeated examination, that, in a case of this kind, there is really no communication with either the cavity of the spinal meninges, or with the pelvic or other internal viscera, an operation for the relief of the de- formity may be properly resorted to; if the tumor be evidently cystic, iodine injection would be the proper remedy, but under other circum- stances excision would be preferable.1 Congenital Cystic Tumors, unconnected with the spine, but occupying the median line of the back, may closely simulate cases of spina bifida, but, as pointed out by T. Smith, can sometimes be distinguished by feel- ing the line of spinous processes beneath the cyst; the diagnosis might further be aided by an analysis of the contained fluid, which in some cases of spina bifida has been found to contain a substance resembling grape-sugar. Antero-posterior Curvature of the Spine (Disease of the Spine, Pott's Disease)—This affection originates in osteitis of the bodies of the vertebrae. In some instances, and in these the prognosis is least 1 See, upon this subject, Holmes's Surgical Treatment of Children's Diseases, pp. 630 DISEASES OF THE HEAD AND SPINE. unfavorable, the case is one of ordinary osteitis; but in most cases there is evidence of the existence of scrofula, or even of the deposit of tubercle. Spine disease occurs chiefly in children and in young adults, and is per- haps rather more frequent in boys than in girls. Occasionally a fall or a blow is referred to as the exciting cause of the affection, but in most instances no explanation of its origin can be given. Any part of the vertebral column may be the seat of the disease, which is, however, most common in the dorsal region. The bodies of several vertebrae are usu- ally simultaneously affected, becoming softened and disintegrated, and leading to disorganization of the intervertebral fibro-cartilages—the su- perincumbent weight of the head and upper part of the body eventually giving rise to the posterior angular deformity,which is characteristic of the fully developed affection. In most cases, the osseous change runs on Fig. 328. Fig. 329. Antero-posterior curvature of spine. Caries of the vertebra. to caries (whence the disease is frequently spoken of as caries of the vertebrae), abscess forming as a consequence, and the pus usually making its way to the surface, either in the loin, or by descending in the course of the psoas muscle; in other cases, however, the pus, for a time at least, becomes concrete and obsolete, rendering the spine a favorite situation of the residual abscess (see p. 382). In a few instances the disease runs its course without any evidence of pus-formation whatever, the patho- logical change in these cases, therefore, being more properly designated as interstitial absorption than as caries (see p. 560). Although, in the course of the disease, the spinal canal may be bent to a right angle, it is very seldom that the spinal cord is pressed upon or otherwise injured. This is evidently owing to the gradual nature of the change, which allows the cord to accommodate itself to its altered circumstances; and to the occurrence of anchylosis, which prevents in- jurious motion. Anchylosis is indeed the process by which nature effects a cure in these cases. It frequently goes on pari passu with the disin- ANTERO-POSTERIOR CURVATURE OF THE SPINE. 681 tegrating changes, arches of new bone being thrown across from one vertebra to another, and the same specimen exhibiting at once, caries, medullization, and eburnation in different parts. In cases in which anchy- losis is deficient (as may happen when the angular projection is not marked, the diseased vertebral bodies being then separated and prevented from coalescing), spinal meningitis may occur, leading to secondary changes in the cord, and to consequent paralysis; while in the cervical region, where the vertebral column has a considerable range of motion, consecutive fracture or dislocation may take place, and, by compressing or bruising the cord, lead to a rapidly fatal issue. Symptoms.—The early symptoms of spine disease, particularly in children, are somewhat equivocal, consisting chiefly in evidences of spinal irritation, such as weakness, numbness, and tingling of the lower extremities, a difficulty in standing or walking, with a tottering gait, and a tendency to fall forwards. The spinal column is somewhat stiffened, the patient moving it as a whole, and thus being unable readily to raise or turn himself in bed without assistance. Examination may reveal an undue prominence of some of the dorsal spines, with perhaps thickening of the surrounding tissues, and tenderness on pressure. Pain may be elicited by pressing on the head, or by making the patient jump from a stool to the floor, thus approximating the extremities of the vertebral column. In adults, pain is a more constant symptom, being usually of a dull rheumatic character. Spasmodic pain in the abdomen is, accord- ing to Dr. B. Lee, an early and characteristic symptom of this affection. As the disease advances, paralysis may be developed, involving the lower or upper extremities, according to the part of the spine affected. Incontinence of feces and retention of urine sometimes form further disagreeable complications. Abscess sometimes occurs quite early in the course of the disease, and not unfrequently before the development of angular deformity. Diagnosis__The diagnosis in the early stages is often very difficult; indeed it is sometimes quite impossible to distinguish spine disease, par- ticularly in children, from inflammation of the surrounding ligamentous structures, until the milder course of the latter affection reveals its true nature. From neuralgia of the spine, an affection analogous to the hys- terical knee-joint, the diagnosis may be made by observing the absence, in the neuralgic affection, of rigidity or other physical evidence of disease, even in cases of long duration. The wincing of the patient, upon the application of a sponge wrung out of hot water to the suspected part of the spine, is looked upon by many surgeons as a sure proof of the ex- istence of caries. According to my experience this test is not to be implicitly relied upon ; at least, I have known it to fail in cases in which the deformity and other symptoms left no doubt as to the nature of the case. The diagnosis from morbus coxarius, and from sacro-iliac disease, has already been referred to. (See pp. 581 and 584.) When the character- istic deformity appears, there is little difficulty in recognizing the nature of the affection. This deformity consists, as already mentioned, in a posterior angular projection of the diseased vertebrae, due to the ab- sorption or disappearance of their bodies, and the consequent subsidence of the upper portion of the column. It is distinguished from the antero- posterior curvature of simple debility, by its persistence in the prone position—and from that of rickets, by its angular character. This angu- lar deformity is accompanied, after the occurrence of anchylosis, with compensatory forward curvatures above and below; the gibbosity of the spine is thus thrown into a plane behind that of the pelvis, while 632 DISEASES OF THE HEAD AND SPINE. the head is directed upwards and backwards, giving the peculiar but involuntary strut and air of pride, which are so often seen in hunch- backs. Occasionally the displacement is at first somewhat lateral, and a hasty examination might then give the impression that the case was one of lateral curvature; the diagnosis may be made by observing that in true spine-disease there is no axial rotation of the vertebrae, such as always exists in the other affection (see p. 617). When the vertebrae in- volved are those of the cervical region, particularly the atlas and axis, the case may be mistaken for one of wry-neck. The sterno-mastoid muscles are, under these circumstances, tense and prominent, and the neck stiff; while the patient often involuntarily supports the head with both hands, so as to guard against sudden movements. The diagnosis from wry-neck may be made by noting the localized tenderness and thickening of the spine, and the increase of pain by tapping or pressing on the head. The diagnosis of Abscess arising from Spine-disease requires some attention. The situation of the abscess, in these cases, varies with the part of the vertebral column which is involved. Thus, in disease of the cervical vertebrae, the pus may present itself at the back of the pharynx, at the side of the neck (beneath the sterno-mastoid muscle), or more rarely in the axilla; it may even pass downwards into the thoracic cavity. Abscess from disease of the upper dorsal vertebrae, commonly makes its way downwards, along the course of the aorta and iliac arteries, presenting itself in the iliac fossa above Poupart's ligament, but may gravitate to the back of the pelvis, passing out through the sacro-sciatic notch into the gluteal region, may pass forwards along the ribs, opening at the side of the trunk, or may go directly backwards, forming a dorsal or lumbar abscess ; finally, it may, in some rare cases, burst into the air-passages or gullet. When the lumbar and lower dorsal vertebrae are affected (the most common situation of the disease), the abscess usually descends in the sheath of the psoas muscle, on one or both sides, constituting the condition known as psoas abscess. This generally points in the front of the thigh beneath Poupart's ligament, but may burrow downwards to the ham or even to the ankle. In other cases the pus may present itself in the lumbar region, in the perineum, on the outer side of the hip, in the iliac fossa, or in the inguinal canal; or it may even burst into the bowel or bladder. By care and attention it is usually possible to determine whether an abscess, oc- curring in any of these situations, be or be not dependent upon disease of the spine. It is, however, sometimes a matter of great difficulty to distinguish between psoas and iliac abscess—the former commonly arising, as we have seen, from caries of the dorsal or lumbar vertebrae, while the latter originates in the areolar tissue of the iliac fossa, and may or may not be connected with disease of the bony pelvis. This difficulty is further increased by the circumstance, that while spinal abscess occasionally presents itself, as we have seen, in the iliac region, an iliac abscess may, on the other hand, make its way into the sheath of the psoas muscle. Psoas abscess is, however, commonly a disease of early life, points below Poupart's ligament, is usually attended with irri- tation and rigidity of the psoas muscle, and often makes its appearance suddenly; while iliac abscess, on the other hand, occurs almost exclu- sively in adults, points above Poupart's ligament, and is gradually developed. Psoas and iliac abscesses must also be distinguished from inguinal aneurism which has become suddenly diffused, from femoral hernia, and from fatty, serous, or hydatid tumors. The diagnosis from aneurism, ANTERO-POSTERIOR CURVATURE OF THE SPINE. 633 may be made by investigating the history of the case, and by observing the presence of fluctuation and the absence of any bruit or other stetho- scopic signs. From hernia, the affection may be distinguished by noting the fluctuating character of the swelling, the absence of gurgling (in both diseases the swelling is reducible, and there may be an impulse trans- mitted by coughing), and the situation of the femoral vessels, which in hernia are to the outside, and in abscess usually to the inside of the tumor. Fatty and other tumors may be recognized' by their not being reducible within the abdomen, and, if necessary, by the use of the explor- ing needle. Prognosis—The prognosis of antero-posterior curvature of the spine is never favorable; the best that can be hoped for is the occurrence of anchylosis, with a permanent angular deformity. If the spine retain its straight position, fatal inflammation of the membranes is apt to occur, while if abscess forms, the patient almost always perishes from exhaus- tion or from secondary visceral disease. In a case at the Episcopal Hospital, some years ago, a psoas abscess caused ulceration of a branch of the internal iliac artery, leading to rapid death from hemorrhage. Treatment.—In the treatment of disease of the spine, rest of the part is of the utmost importance: if the cervical vertebrae be affected, the head must be carefully supported with sand-bags or other mechanical contrivance, so as to prevent any sudden movement which might cause death by producing dislocation. In ordinary cases, the patient may be confined to the horizontal position on a suitable couch, the prone being more desirable than the supine posture. No attempt should be made either to extend the spine or to remove any existing backward projection, for such attempts could only do harm by interfering with the occurrence of anchylosis. The horizontal position must be rigidly maintained for many months, until the surgeon can satisfy himself indeed that bony union of the diseased vertebrae is well advanced. Tonics, especially cod-liver oil, may be exhibited with advantage, and the patient, if a child, should be daily carried into the open air on a couch or in a suitable coach. Counter-irritation (by means of setons, issues, or the actual cautery) was highly commended by Pott, who first accurately investigated the nature of this disease—and is still in much repute with many surgeons. I am not myself very enthusiastic with regard to these severe applica- tions, believing with Shaw and Holmes that, in most cases, the milder remedy of painting the tincture of iodine on either side of the affected vertebrae, will be quite sufficient. If there be much pain, tenderness, and other evidence of inflammation, there can be no better local remedy than dry cold applied in the form of an ice-bag. In some cases, it may be desirable to combine mechanical support with rest in the prone position, and this may be conveniently done by the use of a moulded gutta-percha splint or a corset-like bandage stiffened with whalebones. When anchylosis is well advanced, the patient may be allowed to get up, having been previously provided with a well-fitting apparatus, consisting of a firm pelvic band with crutch-pieces to take off the weight of the upper portion of the trunk, and suitable pads to afford support directly to the affected portion of the spine. If the cervical vertebrae be involved, the apparatus must be provided with an additional piece to fix the neck and support the head. The treatment of spinal abscess is that of cold or chronic abscess in general (see page 382). Every effort should be made, in the first place, to induce absorption of the fluid, it being remembered that, even if a 634 DISEASES OF THE EYE. residual abscess follows at a later period, the prognosis will then, probably, be more favorable than if the collection had been evacuated in the first instance. Even if the opening of a psoas abscess appear inevitable, it is better in most instances to leave the case to nature, rapid sinking not unfrequently following operative interference under these circumstances. If, however, it be determined to use the knife, it should be done under a veil of lint dipped in carbolic oil, with the precautions recommended by Prof. Lister. Arthritis occasionally attacks the articulations of the vertebrae, and, in the case of the occipito-atloid and atlo-axoid joints, is attended with risk of sudden death from the occurrence of dislocation. The most important points in the treatment are to fix the head and neck by suit- able mechanical appliances, so as to prevent injurious movements, and to give free vent to any pus that may be formed, lest suffocation should result from pressure of the abscess upon, or from its bursting into, the air-passages. Necrosis of the bodies of the cervical vertebrae is occasionally seen in cases of syphilitic ulceration, or as the result of gunshot or other injuries; and cases in which recovery has followed the discharge of large sequestra, under these circumstances, have been recorded by Wade,Keate, Syme, Mercogliano, Morehouse, and Bayard. CHAPTER XXXV. DISEASES OF THE EYE. It would be utterly impossible to give, within the narrow limits of this chapter, even a sketch of the present state of ophthalmic surgery, nor indeed would the attempt to do so be worth making, since the dis- eases of the eye have become, of late years, to a great degree an object of special study, and since numerous excellent manuals and treatises on the subject are accessible to any one who may desire to make himself familiar therewith. I shall, therefore, chiefly confine my attention, in the following pages, to a brief reference to those more common affections of the eye which every surgeon may be called upon to treat, and to a short description of the more important operations which are performed upon this organ. Diseases op the Conjunctiva. Acute Conjunctivitis (Catarrhal Ophthalmia).—An inflammation of the conjunctiva, usually caused by cold or other local irritation, but sometimes prevailing epidemically in certain localities, and apparently transmissible by contagion. Symptoms.—A sensation as of dust in the eye, with heat, smarting, and stiffness of the lids. The conjunctiva is brilliantly injected, the redness being quite superficial, and, at first, greatest at the circumference of the globe. Slight photophobia, with increased lachryraation, followed by muco-purulent discharge, which, becoming dry, causes the lids to adhere. OPHTHALMIA NEONATORUM. 635 Treatment.—Astringent lotions of alum, sulphate of zinc, or corrosive sublimate (gr. |- to fjj), with frequent ablutions with cold water, and, in severe cases, the application once or twice daily of a few drops of a solu- tion of nitrate of silver (gr. j-ij to f£j). The lids may be smeared at night with simple ointment, to prevent their adhering together. The constitutional treatment consists in regulating the digestive functions, and in improving the general health by the use of tonics, especially iron and quinia. A shade may be worn if there is much photophobia. Chronic Conjunctivitis, or Chronic Ophthalmia, may occur as a sequel of the affection just described, or may originate from the irritation of inverted lashes, or from reading or sewing with an insufficient light. Treatment.—The cause must, if possible, be removed, by taking away any sources of local irritation, forbidding overuse of the eyes, etc. In addition to the measures above directed for the acute form of the affec- tion, counter-irritation by means of a small blister or the vapor of bro- mine may be advantageously applied to the temples, or behind the ears. If complicated with granular lids, this condition must, of course, be remedied before the conjunctival inflammation can be cured. Phlyctenular Conjunctivitis (Pustular or Papular Ophthalmia). —This is a form of conjunctivitis characterized by the formation of little elevated vesicles, with increased vascularity of the conjunctiva in their immediate vicinity. The treatment, after any acute irritation has been subdued, consists in dusting into the eye with a camel's-hair brush a little finely-powdered calomel, in the application to the inside of the lids of a weak red precipitate ointment (gr. iv-viij to 3j), or in dropping into the eye, thrice daily, a weak solution of the bichloride of mercury.1 Purulent Conjunctivitis, or Purulent Ophthalmia, is a very high grade of conjunctival inflammation, attended with a profuse muco-puru- lent discharge which is fully developed within twenty-four to forty-eight hours after the first onset of the disease. There are three varieties, the purulent ophthalmia of new-born infants, the contagious or Egyptian ophthalmia of adults, and the gonorrhceal ophthalmia, which has already been considered. (See page 427.) Ophthalmia Neonatorum.—This form of the disease usually be- gins a few days after birth, involving both eyes simultaneously or con- secutively, and sometimes ending in total loss of vision. The affection often appears to originate during birth, from direct contact with a puru- lent vaginal discharge in the mother. Symptoms.—A whitish or yellow, muco-purulent or purulent discharge, rapidly increasing in quantity, with swelling of the lids and chemosis of the ocular conjunctiva. If the disease be not checked, opacity, ulcer- ation, or even sloughing of the cornea will probably occur, with, of course, total loss of sight. Treatment.—The discharge should be removed as fast as it accumu- lates, by syringing the eye with a solution of alum (gr. v to f^j) every half hour, day and night, the lids being gently separated with the thumb and finger of the left hand, while the syringe is worked with the right; or, the lids being everted, a five-grain solution of nitrate of silver may be 1 The following formula, which corresponds to the preparation known as Aqua Conradi, will be found satisfactory : ty. Hydrarg. chlorid. corrosiv. gr. |; Mucilag. cydonii f3ss; Vin. opii gtt. v; Aquae destillat. fgij. M. 636 DISEASES OF THE EYE. applied, with a camel's-hair brush, once a day, any excess of the caustic being immediately neutralized with a solution of common salt; the lids should be greased with simple ointment, to prevent their sticking to- gether. If ulceration of the cornea occur, quinia should be given, in doses of about half a grain, three times a day. Purulent Ophthalmia of Adults, Contagious or Egyptian Oph- thalmia (so called from its prevalence as an endemic in Egypt), in its mildest form resembles catarrhal ophthalmia, but often runs a course quite as severe as the affection which results from the contagion of gonorrhoea. Purulent ophthalmia is eminently contagious, and often prevails as an epidemic. It may originate sporadically from various forms of local irritation. Symptoms__A muco-purulent and afterwards purulent discharge, with great chemosis, and inflammation and swelling of the lids, with burning pain, and a good deal of constitutional disturbance. One or both eyes may be attacked. Opacity, ulceration, or sloughing of the cornea may ensue; or the inflammation may spread to the deeper tissues of the eye; or a persistent granular condition of the lids may be developed. Treatment.—If only one eye be affected, the other should be effectually closed by means of a compress of charpie, covered with a disc of adhe- sive plaster, and the whole coated with collodion. This may be removed twice a day, to wash and inspect the organ. In mild cases, astringent and detergent applications, as recommended for catarrhal ophthalmia, will probably prove sufficient; but, if the disease assume a severe type, no time should be lost in adopting those measures which were fully de- tailed in speaking of Ophthalmic Gonorrhcea. (See page 428.) Granular Lids ( Trachoma) is a condition which has been referred to in the preceding pages, and which consists of a rough, villous, granular state of the palpebral conjunctiva, keeping up a chronic muco-purulent dis- charge, causing much pain, and inducing, Fig. 330. by friction, a vascular and hazy condition of the cornea. There are two conditions to which the name of granular lids is commonly applied, one consisting merely in a hypertrophied state of the papillae, and the other in the development of true or vesicular granulations, which are by some authors regarded as new forma- tions, the result of inflammatory action, and by others as enlargements of the closed lymphatic follicles. These vesi- cular granulations appear as little round bodies, like the grains of boiled sago, often occur epidemically, and are trans- missible by contagion. Symptoms.—Heat and a sensation as of sand in the eye, with slight photo- phobia, and enough discharge of muco-pus to glue together the eyelids during the night. The caruncle and tarsal margins of the lids are red- dened, and the upper lid is thickened and droops over the eye. The cornea becomes nebulous, uneven, and extremely vascular (Trachomatous Pannus), and ulceration sometimes occurs. The palpebral conjunctiva may eventually undergo contraction, causing Entropion and Distichiasis. PTERYGIUM. 637 Treatment.—In some cases, counter-irritation to the outside of the lids, as by the application of the tincture of iodine, with the use of tonics, will be sufficient. In other cases, it may be necessary to apply astrin- gents, or caustics, to the granulations themselves. Various articles are employed for this purpose, such as a solution of nitrate of silver, gr. v-xx to fsj (Lawson), the "lapis mitigatus," or nitrate of silver in sub- stance, diluted by fusing with it nitrate of potassa (Wells), the undi- luted Liquor Potassae (Dixon), or, which is a favorite in this country, the blue-stone or crystallized sulphate of copper. These applications may be repeated at intervals of two or three days, the precaution being taken, if nitrate of silver is used, to neutralize it at once by the injec- tion of salt and water. The powdered acetate of lead is another remedy which is occasionally useful. If the cornea be ulcerated, instillations of atropia should be practised, and, in any case, advantage may be de- rived from the use of a compressing bandage. Stokes, of Dublin, has suggested the use of delicate ivory plates, applied within and without the lid, and held together by a spring or screw, so as to maintain con- stant pressure upon the granulations. Inoculation, with the matter from a case of purulent ophthalmia, has been successfully employed in inveterate cases by Bader, Dixon, Lawson, and others. Syndectomy or Peritomy, which is an operation consisting in the excision of a very' narrow band of conjunctiva and subconjunctival tissue from around the cornea, may be practised in cases of pannus which persist after the relief of granular lids. This operation, which was introduced by Furnari, in 1862, is also recommended by Lawson, as a preliminary to purulent inoculation. Pterygium.—This is a peculiar fleshy growth, consisting of a hyper- trophy of the conjunctiva and subconjunctival tissue, which is most com- mon in warm climates. One or both eyes may be affected, the growth almost invariably occupying the inner or nasal part of the eye, arising by a fan-shaped expansion from the semilunar fold and lachrymal Fig. 331. caruncle, and converging as it ap- proaches the cornea, the centre of which it rarely passes. The treat- ment consists in excision, which is performed by seizing the pterygium with toothed forceps, raising it from the surface of the eye, and shaving it off from its corneal at- tachment, then turning it back- wards and carefully dissecting it from its base ; the growth is apt to recur, to prevent which the seat of attachment may be touched every two or three days with a crystal of blue-stone. Another operation, called transplantation, consists in dividing the corneal attachment, turning the pterygium back, and fixing its free extremity in an in- pterygium. cision in the lower part of the con- junctiva, by means of a fine suture; or the growth may be removed by means of a ligature threaded upon two needles, and introduced as seen 638 DISEASES OF THE EYE. in Fig. 331. When the needles are cut off, the pterygium is transfixed by three ligatures, by the tightening of which it is effectually strangu- lated. Fig. 332. Tumors of various kinds grow from the conjunctiva, and may be readily excised with toothed forceps and delicate scissors, curved upon the flat. Diseases of Cornea, Sclerotic, and Ciliary Body. Keratitis (Corneitis, Inflammation of the Cornea).—Essentially a disease of malnutrition, most common in children, sometimes arising from injury, but often from no obvious cause. Both eyes are usually con- secutively affected, the course of the disease extending from six months to two years. The symptoms are pinkness (not the redness of conjunctivitis) in the ciliary region (see page 644), with haziness of the cornea, dimness of vision, photophobia, lachrymation, pain, and a sensa- tion of dust in the eye, with (in the stage of repair) a red ap- pearance of the cornea due to its increased vascularity, the result- ing condition of Pannus some- times involving almost the whole cornea. In favorable cases this increased vascularity gradually fades away,and the part resumes its normal appearance, but in other cases corneal ulcers are developed and retard recovery. panilus. Permanent though slight dim- ness of vision generally remains, due to a general haziness of the cornea, or to the formation of a Nebula in the pupillary region. Treatment.—Internally, attention to the digestive functions, with the administration of tonics, such as iron and quinia, and of opium or bella- donna, if there be much pain and photophobia. Locally, the use of seda- tives, particularly belladonna or atropia, with counter-irritation by means of iodine or the solid stick of nitrate of silver to the brow and upper lid, the eyes being protected from light by a shade or dark-colored glasses. Chronic Interstitial Keratitis is a frequent manifestation of hereditary syphilis (see page 450). Hutchinson recommends the cau- tious use of mercury, applied by inunction behind the ear. Attention to the digestive functions, and the administration of tonics, are also necessary. Strumous Keratitis, in its course and symptoms, resembles the simple form of the affection already described; the photophobia and lachrymation are more marked, and corneal ulceration is apt to occur. The treatment consists in the administration of cod-liver oil and the PARACENTESIS CORNER. 639 syrup of the iodide of iron, and in improving the hygienic surroundings of the patient. Phlyctenular Keratitis.—Closely allied with the preceding, is this affection, which is also known as Phlyctenular or Scrofulous Ophthalmia, and as Herpes Corneae; it frequently accompanies phlyctenulo.r con- junctivitis (p. 635). This disease, which occurs in quite young children, is attended with intense photophobia and spasm of the orbicularis pal- pebrarum (blepharospasm), which often renders the induction of anaes- thesia necessary before a satisfactory examination can be made. The affection receives its name from the existence, usually near the corneal margin, of phlyctenular or herpetic vesicles, which burst, leaving super- ficial but slowly healing ulcers. The treatment is essentially that of keratitis in general; if, as often happens, there is eczema of the lids, advan- tage may be derived from the use of borax lotions. The administration of arsenic is recommended by Wells, in some cases, as is calomel insuf- flation, when the disease has become chronic. The affection is apt to recur, and frequently produces permanent opacity or even perforation of the cornea. Suppurative Keratitis.—This affection may be excited by trau- matic causes, or may be secondary to other inflammatory diseases of the eye. Suppurative keratitis is, as its name implies, attended with the formation of pus between the layers of the cornea, in one part only, or throughout its structure. The resulting Abscess of the Cornea usually bursts exteriorly, leaving an unhealthy-looking ulcer; but occasionally opens into the anterior chamber of the eye, giving rise to the condition known as Hypopyon. A small abscess at the lower part of the cornea, from its fancied resemblance to the lunula of the thumb-nail, is called Onyx. The treatment consists in the use of tonics and anodynes, with good food and stimulants if necessary. Locally, atropia should be freely used, with a compressing bandage, or, in cases unattended with pain or intolerance of light (the non-inflammatory form of Wells), warm chamomile fomentations. Paracentesis of the cornea may be performed once or oftener, serving to relieve intra-ocular tension, and to evacuate the pus if hypopyon be present. If the abscess be central, an iridec- tomy should be performed opposite a clear portion of the cornea. Paracentesis Corneae is performed by puncturing the cornea near its lower mar- gin with a broad needle held flatwise, the point being kept well forward, so as to avoid wounding the lens; by rota- ting the needle slightly on its long axis, the opening is rendered patulous, allowing the slow escape of the aqueous humor, and of any pus that may be present. The operation is completed by restoring the needle to its original position, and quickly withdrawing it. Fig. 333. 640 DISEASES OF THE EYE. This little operation is usually facilitated by separating the lids with a stop speculum, and steadying the eye with suitable fixation forceps. Anaesthesia may be employed if desirable. Ulcers of the Cornea.—These may result from various forms of conjunctivitis and keratitis, or may apparently originate primarily, as the result of depraved health and malnutrition. Several varieties of corneal ulcer are described by systematic writers, as the superficial and deep, the transparent and nebulous, the sloughing, and the crescentic or chiselled ulcer. These names sufficiently explain themselves. The deep and sloughing ulcers are apt to lead to perforation, previous to the occurrence of which, the membrane of Descemet, with, according to Stell- wag, the posterior layer of the cornea, may bulge forwards through the site of the ulcer, forming a transparent vesicle, which is called Keratocele or Hernia of the Cornea. During the stage of repair, in any case of corneal ulcer, enlarged vessels may be seen running from the margin to the ulcerated surface; should these vessels remain permanently after cicatrization, the condition usually known as chronic vascular ulcer results. Treatment.—The treatment of ulcers of the cornea usually requires the administration of tonics and good food, with attention to the diges- tive functions. Locally, soothing applications are commonly indicated, such as lotions of belladonna or poppy-heads, the instillation of atropia, hypodermic injections of morphia, etc. It is only in chronic cases that stimulating applications are ever proper, and even in these they should be used with caution. Syndectomy (see page 63*1) has been occasion- ally employed with advantage in the treatment of the crescentic ulcer, which is a very intractable form of the affection. Paracentesis corneae is often of use in cases of sloughing ulcer. This operation should be performed (through the floor of the ulcer) whenever perforation is threatened, a compressing bandage being subsequently applied. If the intra-ocular tension be very great, iridectomy may be preferable. During the stage of repair, the patient should be encouraged to take exercise in the open air, and if the part fall into the condition of the chronic vascu- lar ulcer, a compressing bandage and a seton in the temporal region will often prove of service. Fistula of the Cornea may result from a wound, or from the im- perfect healing of a perforating ulcer. The treatment consists in the application of a compressing bandage, in touching the edges of the fistu- lous orifice with nitrate of silver, or, if these fail, in the performance of an iridectomy. Sometimes the fistulous condition is maintained by the irritation caused by a wounded lens, which should then be removed. As a last resort, Lawson recommends paring the edges of the fistula, and bringing them together with a fine silk suture. Opacities of the Cornea.—Nebula is the slightest form of opacity, consisting of a mere filmy cloudiness which may be superficial or inter- stitial, and which commonly results from keratitis or superficial ulcera- tion. Albugo or Leucoma, is a dense opacity, due to the cicatrization of a deep ulcer, as of a smallpox pustule. Treatment.—Various remedies are employed for nebula, such as the insufflation of calomel, or the use of lotions containing corrosive subli- mate, oil of turpentine, sulphate or chloride of zinc, iodide of potassium, sulphate of soda, or common salt. A weak ointment of the red or yellow STAPHYLOMA. 641 oxide of mercury, is highly spoken of by Wells. Leucoma, which is usually incurable, may require the formation of an artificial pupil oppo- site a clear portion of the cornea. Opacity resulting from the inju- dicious application of preparations of lead to an ulcerated cornea, may be remedied by shaving off the deposit with a delicate knife, convex on its cutting edge: after the operation, the abraded surface should be pro- tected by applying a drop of olive or castor oil, and by the use of cold water dressing. The same treatment may be required if calcareous de- generation occur in an ordinary leucoma. Conical Cornea.—The cornea retains its transparency, but assumes a conical form, the apex of the projection being commonly central. Vision is interfered with by the development of myopia (short-sighted- ness) and astigmatism, the latter being a general term for want of sym- metry in the state of refraction of different meridians of the eye. In slight cases, vision may be aided by the use of concave glasses, with a diaphragm containing a circular or slit-shaped perforation, but in most instances an iridodesis should be performed, or, if there be much intra- ocular tension, a small upward iridectomy. Another plan, suggested by Yon Graefe, is the formation of an ulcer on the apex of the protrusion, by cutting off a small superficial flap and subsequently cauterizing the sur- face. The contraction which accompanies the cicatrization of the ulcer diminishes the conicity of the cornea. Kerato-globus, Hydrophthalmia, or Buphthalmos, is an af- fection analogous to the preceding, consisting in a uniform spherical bulging of the whole cornea. If the disease be rapidly increasing, a large iridectomy may be performed, while if vision be lost, and the pro- trusion prevent the closure of the eyelids, excision may be indicated. Staphyloma.—When perforation follows an ulcer of the cornea, the iris commonly falls forwards. If the corneal aperture be very small, no protrusion may occur, the iris merely adhering to the inner corneal surface (anterior synechia); under other circumstances prolapse of the ins takes place, the protrusion increases by the distension produced by the pressure of the accumulating aqueous humor, adhesion to the margin of the ulcer follows, and the surface assumes a cicatricial character. The portion of cornea immediately surrounding the protrusion also yields, and a disfiguring projection of the front of the eye results, which is called staphyloma. Yarious forms of staphyloma are described by systematic writers, as staphyloma of the iris, partial or complete staphy- loma of the cornea, and staphyloma racemosum (in which perforation occurs at several points); again, surgeons speak of ciliary staphyloma,. or anterior^ staphyloma of the sclerotic—this condition consisting of a series of bulgings of the weakened sclerotic (through which the dark hue of the ciliary body is perceptible), and resulting from injury of the part, or from chronic irido-choroiditis. When the staphyloma entirely surrounds the cornea, it is said to be annular. 1. Staphyloma of the Iris.—Prolapse of the iris may sometimes be prevented. If the threatened perforation be central, the pupil should < ' Posterior staphyloma is a projection of the posterior half of the eye, met with in severe cases of myopia. 41 642 DISEASES OF THE EYE. Fig. 334. be dilated with atropia so as to keep the iris out of the way, while, on the other hand, if the ulcer be marginal, the Calabar bean should be used to contract the pupil. The alternate use of these substances may also prove useful in break- ing up an anterior synechia. If prolapse of the iris have actually occurred, an attempt may be made to replace the protrusion with a delicate probe, aided by the instillation of atropia. If this fail, the prolapsed iris should be punctured, so as to let it collapse, a compressing bandage being then applied; or the prolapsed or staphy- lomatous iris may be punctured, and then excised close to the cornea with curved scissors, a com- pressing bandage being used as before. Finally, if the prolapse or staphyloma be extensive, a large iridectomy may be performed in an opposite direction, this operation diminishing the intra- ocular tension, and thus lessening, or at least preventing the increase of the projection, while it also affords an artificial pupil if that should be required. Another plan of treating prolapsed iris, consists in touch- ing the protruding portion with a pointed stick of nitrate of silver, as recommended by Dixon. 2. Partial Staphyloma of the Cornea.—This may be considered as an aggravated degree of Staphyloma of the Iris. The treatment con- sists in the formation of an artificial pupil, opposite a healthy part of the cornea, by iridectomy. Prolapse of the iris. 3. Complete Staphyloma of the Cornea signifies a staphyloma- tous condition of the entire corneal surface. Its occurrence may be sometimes prevented by an Fig. 335. early removal of the lens, either immediately after the sloughing of the cornea, or at a later period—when the opera- tion may be performed as di- rected by Bowman, by the use of a broad needle to break up the lens, and a curette to favor the evacuation of any part that is diffluent. Fully formed com- plete staphyloma may be treat- ed by abscission, the seton, strangulation, or excision of the eye. (1.) Abscission may be per- formed by either Beer's, Scar- pa's, or Critchett's method. The first consists in transfix- ing the staphyloma with a Beer's knife (Fig. 335), at the junction of the upper and middle thirds, and cutting downwards. The remaining bridge of tissue is then divided with scissors, and the broad wound left to heal by granulation. Scarpa's plan differs from the above, in that a flap is formed from the upper part of the staphyloma and laid down over the wound. Abscission of staphyloma. SCLEROTITIS AND CYCLITIS. 643 Critchett's method consists in passing four or five curved needles, armed with silk, across the base of the staphyloma, and then removing an elliptical segment with probe-pointed scissors introduced through a puncture made with a Beer's knife. The operation is completed by care- fully tying the sutures, when a linear wound results (Fig. 336). Fig. 336. Critchett's operation for staphjiloma. (2.) A seton may be formed through the base of the staphyloma, as recommended by Yon Graefe, the thread being removed in the course of twenty-four or forty-eight hours. Suppurative choroiditis ensues, Which induces shrinking and atrophy of the globe, allowing the appli- cation of an artificial eye. (3.) The staphyloma may be strangulated, in part or wholly, by Bo- relli's method, which consists in transfixing the prominence with two needles, introduced at right angles to each other, and throwing around them a fine ligature, as in operating for naevus. (4.) Excision of the eye (the mode of performing which will be de- scribed hereafter) is particularly indicated in any case of staphyloma iu which the deep portions of the eye are believed to be diseased. 4. Ciliary Staphyloma, when resulting from irido-choroiditis, may be occasionally arrested in its early stages by iridectomy, but when caused by a rupture of the sclerotic, is probably incurable. If, in such a case, vision be entirely lost, and the staphylomatous globe a source of irritation, excision may be properly resorted to. Sclerotitis and Cyclitis (Inflammation of the Sclerotic and Ciliary Body).—These affections constantly coexist, and are usually secondary to inflammation of the iris or choroid, though they may occur primarily, as the result of traumatic causes. Systematic writers recognize two varieties of cyclitis, the serous and suppurative—the latter being the graver form of the affection. Symptoms.—There are pain and tenderness in the ciliary region, with, photophobia and lachrymation, impairment of vision, increased intra- ocular tension, sub-conjunctival injection (constituting a distinct pink zone around the cornea), cloudiness of the vitreous, dilatation of the veins of the iris, inactivity or distortion of the pupil (from coincident iritis), with, perhaps, turbidity of the aqueous humor, and, in the worst cases, hypopyon. Sclerotitis and cyclitis, in their milder forms, are often seen in rheumatic subjects, constituting what was formerly called 644 DISEASES OF THE EYE. Rheumatic Ophthalmia, and under this head belongs anatomically the eye affection observed in cases of gonorrhoeal rheumatism (see page 430). Treatment.—If the pain be very great, a few leeches may be applied to the temple, followed by warm fomentations and the administration of opium. The state of theprimae viae should be attended to, and the strength of the patient maintained by means of nutritious food, and stimulants if necessary. Quinia may usually be given with advantage, together with the iodide of potassium, and the oil of turpentine (in drachm doses) if the iris be much involved. In a very urgent case it may be proper to administer mercury, either by inunction, or internally in combination with opium. Frequent instillations of atropia should be practised throughout the course of the disease. Iridectomy may occasionally prove beneficial at an early stage of the affection, while, in cases result- ing from injury, excision of the globe should be resorted to without hesitation, if the other eye be threatened with sympathetic implication. Episcleritis is the name given to a small, dusky-red, sub-conjunctival swelling, which usually appears on the temporal side of the cornea, and sometimes causes a good deal of irritation and pain, running a very chronic course, and being prone to recur. The treatment consists in sub- duing irritation by the use pf atropia, and then employing weak collyria of the chloride or sulphate of zinc. Diseases of the Iris. Iritis, or Inflammation of the Iris, may be a primary or a secondary affection. Primary iritis may be due to some systemic disease, such as syphilis or rheumatism, or may result from exposure to cold, from injuries, etc. When secondarily involving the ciliary body or choroid, it receives the names of Irido-cyclitis and Irido-choroiditis. Secondary iritis is caused by the extension of inflammation from neighboring structures, as the cornea, choroid,1 etc. Different classifications of iritis are adopted by authors, the best perhaps being that of Wells, who speaks of the Simple, Serous, Parenchymatous, and Syphilitic varieties. Symptoms.—The following symptoms are common to all forms of iritis: (1.) Marked sub-conjunctival injection, giving rise to the charac- teristic ciliary zone, which is easily recog- Fig. 337. nized by its pink color, its deep, sub- conjunctival character, and the radiating course of the enlarged vessels. It is often accompanied by general suffusion of the conjunctiva, and sometimes by chemosis. (2.) A contracted and sluggish state of the pupil, which, owing to the formation of ad- hesions between the iris and capsule of the iritis: showing"sui>-conjunctivai in- lens (synechia posterior), assumes, when jection forming the ciliary zone. acted upon by atropia, an irregular and distorted outline. If the synechia be complete, the pupil is not at all dilatable, and soon becomes occluded by inflammatory lymph. In serous iritis, however, the pupil is often abnor- mally dilated. (3.) The iris loses its natural lustre, and becomes dis- colored; its striated appearance is obscured, owing to inflammatory 1 Hence, some systematic writers describe choroido-iritis separately from irido- choroiditis. DISEASES OF THE IRIS. 645 swelling; its vessels may become enlarged and varicose; while beads of lymph may perhaps be detected upon its surface. The change of color is even greater apparently, than in reality, owing to the state of the aqueous humor, which is often turbid from the admixture of flocculent lymph or pus. This may accumulate in such quantities as to form a hypopyon. (4.) Vision is impaired, partly by the diminished trans- parency of the aqueous humor, but also in many cases by the coexistence of cyclitis, which alters the accommodation of the eye, and often causes turbidity of the vitreous (p. 643). (5.) Pain is usually a prominent symptom of iritis, though in some cases, particularly of the syphilitic form of the affection, it is almost or altogether absent. The pain is deeply seated in the eyeball, and often extends to the forehead, temple, and nose, assuming a neuralgic character, and being worst at night. Tender- ness in the ciliary region indicates the presence of cyclitis. (6.) Photo- phobia and lachrymation are not usually very intense—much less so, indeed, than in many cases of keratitis. Simple or Idiopathic iritis presents the symptoms above described in a mild, and Parenchymatous iritis in a severe form, the latter variety being that in which suppuration chiefly occurs, leading sometimes to perforation of the cornea and permanent loss of sight. Serous iritis is especially characterized by the absence of lymphy deposits, and by an increase in the amount of aqueous humor, leading to augmented intra- ocular tension, and consequent dilatation of the pupil. Serous iritis often accompanies choroiditis and retinitis, and is the form sometimes assumed by Sympathetic Ophthalmia; it is also seen in connection with hereditary syphilis. The so-called Rheumatic iritis belongs to one or other of the above varieties, and is often associated with sclerotitis in cases of gonorrhceal rheumatism (pp. 430, 644). The true Syphilitic iritis belongs to the parenchymatous variety of the affection, being an accom- paniment of tertiary syphilis, and characterized by a deposit of yellow tubercles which are strictly analogous to gummatous tumors (p. 447); the iritis of secondary syphilis, on the other hand, is an ordinary iritis, simple, serous, or parenchymatous, which is not essentially dependent on syphilitic infection (see page 444). Any form of iritis may be met with as a recurrent affection, particu- larly in rheumatic and syphilitic persons. Treatment—The use of atropia is unquestionably the most important point in the treatment of iritis. A strong solution should be employed (at least gr. iv to f^j), and this may be applied in very urgent cases, as advised by Wells, at intervals of five minutes, for half an hour, three times a day. The advantages gained by the use of atropia are the dilatation of the pupil, thus preventing the occurrence of synechia posterior, the physiological rest secured to the iris by paralyzing its circular fibres, and the diminution of intra-ocular tension. Even if adhesions to the capsule of the lens are already formed, these can often be stretched and even ruptured by the unsparing use of atropia. Hypodermic injections of morphia may be administered to relieve pain, and the same remedy may be employed as an antidote, in the rare event of a poisonous effect being produced by the passage of atropia through the lachrymal puncta into the throat. Leeches to the temple are often serviceable in relieving the intense ciliary neuralgia, and are also of use in lessening intra- ocular tension, and thus preparing the way for the action of atropia. Paracentesis of the cornea may also be employed for the latter purpose, and is particularly indicated if the aqueous humor be cloudy, or if 646 DISEASES OF THE EYE. hypopyon be present. Mercury is certainly a valuable remedy in those cases of iritis in which there is an abundant formation of inflammatory lymph, but is by no means so essential as was formerly supposed. It may be given internally, in combination with opium, or may be employed by inunction. Iodide of potassium and oil of turpentine are particularly useful in cases of syphilitic and rheumatic iritis. Finally, iridectomy may be required, if there be extensive and firm adhesions between the iris and capsule of the lens, or if, as in some cases of serous iritis, there be a marked increase of intra-ocular tension. Tumors of the Iris.—If of a cystic nature, the proper remedy is iridectomy, the cyst being removed with its seat of attachment. Mela- notic cancer of the iris demands excision of the globe, which is the only mode of treatment offering even a hope of benefit. Mydriasis (Dilatation of the Pupil) may result from rheumatism affecting the nerve sheaths, from syphilis, from contusions or other in- juries, from irritation of the sympathetic, from cerebral disease, or from any disease of the eye which produces increased tension of the globe. Paralysis of the ciliary muscle often coexists, producing disturbance of the accommodation. The accompanying impairment of vision, if due to mydriasis alone, may be relieved by the use of a diaphragm with a pin- hole perforation; while the paralysis of accommodation will often yield to the application of a blister behind the ear, and the administration of iodide of potassium. In chronic cases, a weak solution of Calabar bean may be dropped into the eye. Myosis (Contraction of the Pupil) may result from excessive use of the eyes, as in watchmaking or engraving, or may depend upon disease of the cervical portion of the spinal cord, the pressure of an aneurism or tumor on the cervical sympathetic, etc. Little can usually be done in the way of treatment, though temporary relief may sometimes be afforded by the instillation of atropia. Operations on the Iris. Iridectomy.—This operation consists in the excision of a portion of the iris. When done for the relief of intra-ocular tension (as in glau- coma), or as a preliminary to extraction of cataract, the section should, as a rule, be made upwards; though as the outward section is an easier procedure, this may be sometimes preferred by an inexperienced ope- rator. The advantage of an upward iridectomy is that the lid subse- quently covers the seat of operation, thus cutting off the irregularly refracted peripheral rays of light, and at the same time partially hiding the resulting deformity. If, on the other hand, an iridectomy is to be performed as a means of making an artificial pupil, a small inward section is preferable—the visual line cutting the cornea on the inner side of its central point—though, in cases of corneal opacity, the surgeon may be forced to make his section at any point opposite to which the cornea, may happen to be clear. Iridectomy is thus performed: The patient being in the recumbent position, and under the influence of chloroform (which in eye surgery is usually preferable to ether), the surgeon separates the lids by means of OPERATIONS ON THE IRIS. 647 Fig. 338. a spring-stop speculum (see Fig. 336), and, standing behind the patient's head, fixes the eye by seizing with firm catch-forceps the conjunctiva and subjacent fascia, at a point di- rectly opposite to that of the pro- posed section. A lance-shaped kera- tome or iridectomy knife (Fig. 338) —straight for the out ward, but angu- lar for the upward or inward section —is then to be thrust through the sclerotic at about half a line to a line from its junction with the cornea, the handle being well depressed, so as not to wound the iris or lens, while the blade is slowly thrust onwards, until the section is of the desired extent. The knife is then cautiously withdrawn, so as to allow the slow escape of the aqueous humor, when the first stage of the ope- ration is completed. The fixation forceps are now handed to an assist- ant, who may rotate the globe a little downwards, and steady it while Fier. 339. Lance-shaped iridectomy knife. Curved iris forceps. the surgeon excises a portion of the iris; this second stage of the operation is accomplished by introducingcurved iris forceps (Fig. 339), expanding the blades so as to grasp the pupillary margin, cautiously withdrawing the forceps with the included portion of iris, and snipping off the latter close to the wound by one or two cuts with delicate curved scissors. When the object of the operation is to reduce intra- ocular tension, the iris should be excised close up to its ciliary mar- gin. Sometimes, immediately after the withdrawal of the knife, the iris prolapses, when it may be instant- ly seized with forceps and ex- cised. If the anterior chamber be very shallow, it may be safer to substitute, for the lance-shaped in- strument, the knife used by Von Graefe for the modified linear ex- traction of cataract, making a punc- ture and counter-puncture, and then cutting outwards as in the operation referred to. If the section of the iris cause hemorrhage into the an- terior chamber, the escape of blood maybe facilitated by carefully intro- ducing a curette (Fig. 346, b), and making cautious pressure with the fixation forceps. The speculum being removed, the lids are gently closed, and a compressing bandage applied. Fig. 340. Liebreich's bandage. 648 DISEASES OF THE EYE. This is done by covering the closed lids with an oval disc of soft linen, spread with simple ointment or glycerin to prevent its adhering, filling up the inequalities of the orbit by carefully packing the part with fine charpie, and finally securing the whole with a Liebreich's (Fig. 340) or other light bandage. For the first few days, both eyes should be ex- cluded from the light. Iridectomy for Artificial Pupil requires a smaller section, which should be made through the cornea—as in this case it is desirable to leave the ciliary attachment of the iris, so Fig. 341. as to cut off some of the peripheral rays; the ____________ 11 m miMBg- portion of iris which is to be excised may be ^ NdHfiBif' drawn out with forceps, or with a blunt silver Tyneii's hook. or platinum Tyrrell's hook. Iridodesis.—This operation was introduced by Critchett, and is adapted to the formation of an artificial pupil in cases of opaque or conical cornea, lamellar cataract, Fig. 342. etc. It is performed by making an incision, with a broad needle, at the junction of the cornea and sclerotic, a loop of fine black silk (Fig. 342, A) being laid around the wound as soon as the needle is withdrawn. An iris hook is then passed through the loop, and into the anterior chamber, seizing a portion of iris by its pupillary margin, and bringing it out, when the loop is tightened by an assistant drawing with forceps upon its free extremities. The ends of the liga- ture being cut off, the eye is bandaged, the loop coming away in two or Fig. 343. Canula forceps. three days, and leaving the iris adherent to the point of incision. If it be only desired to displace or enlarge the original pupil, the peripheral portion of the iris may be seized with canula forceps (Fig. 343), intro- duced through the loop (instead of the hook), the remainder of the ope- ration being conducted as already described. A double iridodesis (one downwards, and, after several days, another made upwards) has been recommended by Bowman in cases of conical cornea. Artificial Pupil by Incision.—This operation may be practised in cases in which the lens is absent (as after cataract extraction), and in which the pupil is entirely occluded. It is performed by simply splitting the fibres of the iris with a broad needle, the retraction usually affording a sufficient pupil. Under other circumstances, a Tyrrell's hook may be CATARACT. 649 introduced, and the operation converted into a small iridectomy. Bow- man has modified this operation by excising a triangular-shaped piece of iris, with delicate scissors introduced through a corneal wound. (Law- son, Diseases and Injuries of the Eye, page 116.) Corelysis is an operation practised by Streatfeild and Weber, for the detachment of adhesions passing between the pupillary margin of the iris and the capsule of the lens. It consists in making, with a broad needle, a corneal wound at a convenient point, and then with a spatula-hook (Fig. 344) passed Fig. 344. behind the adhesion, drawing forwards and ^y^aggsB-sg* slowly rupturing the latter. ^^^HU!!. Passavant's Operation, for the accomplish- Spatula-hook. ment of the same object, consists in making a small opening at the edge of the cornea, introducing suitable forceps and seizing a fold of the iris in close proximity to the synechia; the latter is then torn loose from its attachment to the lens, and the forceps disengaged and cautiously withdrawn, care being taken to guard against the occurrence of prolapse of the iris. Iridodialysis is an operation employed in cases of extensive central opacity of the cornea; it consists in tearing loose the ciliary attachment of the iris, thus forming a peripheral artificial pupil. Cataract. An opaque condition of the crystalline lens, of its capsule, or of both, is called cataract, the several conditions being distinguished by the names lenticular, capsular, and capsulo-lenticular. A collection of lymph or blood in front of the lens is sometimes called spurious cata- ract. Cataracts are classified according to their mode of origin, as idiopathic, traumatic, or congenital; according to their color, as black, amber, etc.; and according to the consistence of the cataractous lens, as hard or soft. Symptoms.—The first symptom of cataract which attracts the atten- tion of a patient, is dimness of vision, as if from a cloud or mist, which, in idiopathic cases, comes on gradually; the sight is usually best in a somewhat dim light, for the pupil dilates under such circumstances, and allows light to penetrate the periphery of the lens, which is usually less opaque than its centre. The appearance of a cataractous patient differs from that of one who is amaurotic: the former has not the vacant stare of the latter; instead of helplessly rolling up his eyes to the sky, he is able to direct them towards any object with some certainty; and, to a moderate extent, he can find his way about by himself; there is no involuntary oscillation of the eyeball, nor divergent squint, and the pupil reacts normally to the stimulus of light. In a case of uncomplicated cataract, the power of distinguishing day from night is never lost. In a case of advanced cataract, the opacity can be readily recognized by the unaided eye of the surgeon, but in an earlier stage more careful examination may be necessary. The Catoptric Test, which was proposed by Sanson, is now, since the introduction of the ophthalmoscope, seldom employed, but is still worthy of mention: if a lighted candle be moved before a healthy eye, three images of the flame will be seen; two erect, formed by reflection from the convex cornea and anterior surface of the lens, and one inverted, from 650 DISEASES OF THE EYE. the concave posterior surface of the latter. If now the lens be opaque, the inverted image will be wanting, the deeper erect image similarly dis- appearing when the opacity involves the capsule, and the corneal image being then alone perceptible. The diagnosis of cataract may be most satisfactorily made by means of Oblique Illumination and the Ophthalmo- scope. Oblique illumination (Fig. 167) is practised by placing the patient in a darkened room, and, with a convex lens, concentrating the light from a suitably-placed Argand lamp upon the pupil, previously dilated with atropia—when any opacities may be readily recognized by their whitish- gray color. When now the light is reflected by means of the ophthalmo- scopic mirror into the eye, the opacities appear as streaks or spots, which are black from the interference with the return of light from the fundus oculi; or if the opacity be of a diffused character, the ordinary red hue of the fundus may be partially or completely obscured. The most important practical points in the examination of a cataract are to determine—first, whether it be or be not complicated by the pres- ence of some more deeply seated lesion, and secondly, whether xtbehard or soft. In a case of uncomplicated cataract, the patient should be able to distinguish the light of an ordinary Argand burner at a distance of fifteen or twenty feet. Hard cataracts usually occur in persons over fifty years of age, and are probably never met with in those under thirty- five. They are commonly of a smoky ash-color, and frequently present a regularly striated appearance; after extraction, they have an amber tint. Soft cataracts are most frequent in the young, present a bluish- white appearance, and are irregularly if at all striated. Congenital cataracts are always soft. Treatment.—Various operations are practised for the relief of cata- ract—all having for their object the immediate or gradual removal of the opaque lens. In cases of lamellar or zonular cataract, however (a variety of soft cataract, often congenital, in which an opaque lamella or zone intervenes between the nucleus and cortical portion, which are both clear), if the disease be not progressive, an iridodesis may be pre- ferable to any operation upon the lens itself (see p. 648). Before resort- ing to any operation for cataract, the surgeon should test the sensibility of the retina to light, as unless the patient, when placed in a dark room, is able to recognize the presence and general position of the flame of a lamp at a distance of fifteen to twenty feet, the prospect of benefit from an operation will be comparatively slight. With regard to the time for operation, it may be said that congenital cataracts should be operated upon at an early period, as otherwise a disfiguring involuntary habit of oscillation of the eyeballs (nystagmus) is apt to be developed ; in other cases it is better, as a rule, to wait until the cataract is fully ripe or mature, or, in other words, until the whole lens has become opaque. In cases of double cataract, that which is furthest advanced should be first operated upon, so that the patient may continue to use the second eye while the process of cure in the first is going on. Chloroform may be administered in any operation except that of flap extraction; the patient should lie on a table of convenient height, with a good side light, and with the pupil well dilated by atropia. I shall not attempt to describe all the varieties of operation which have been and are practised for the cure of cataract, but shall speak merely of the ordinary flap operation, the traction method, and that of Von Graefe, the needle operation (or that of solution), and the suction method. The first three are adapted for hard, and the last two for soft cataracts. The old operation of Re- OPERATIONS FOR CATARACT. 651 clination, depression, or couching, by which the lens was forcibly thrust down into the vitreous (where it constantly gave rise to destructive inflam- mation), is now happily almost totally abandoned, and is mentioned merely as a matter of historical interest. Operations for Cataract. Extraction by Flap Operation.—In this operation the use of chloroform is not admissible. The surgeon, if able to use the knife with his left as well as with his right hand, may stand behind the patient's head, no matter which eye is to be operated upon; under other circum- stances, he should take this position for the right eye only, standing on the patient's left side and in front, for an operation on the left eye. The peculiarity of this method consists in making a large semicircular flap, involving half the cornea, and the operation may be done either by an Fig. 345. Flap extraction of cataract. upward or downward section, the former being usually preferred. The following description refers to the opera- tion by upward section on the right eye. It is usually best to dispense with specula in this procedure, the eye being fixed by the fingers of the surgeon and his assistant; the former with his left forefinger raises the upper lid, and holds its tarsal edge firmly beneath the upper border of the orbit, while his middle finger is fixed steadily on the in- ner canthus, the assistant in the same way depressing the lower lid, and fixing the outer canthus ; the eye is thus securely held without injurious compression. If, however, the patient be very restless, the surgeon may himself fix the eye with forceps, intrusting the- raising of the upper lid to his assistant (Fig. 345). The surgeon then, standing behind the patient, and hold- ing the triangular extraction knife lightly in his right hand, enters its point half a line within the sclero-corneal junction on the temporal side, at first in the direction of the radius of thecorneal curve, so as not to split the lamellae of the cornea, but keeping the blade subsequently in a plane parallel to that of the iris. The flap is made by simply pushing the blade Fig. 346. i. Cystotome. 6. Curette. 652 DISEASES OF THE EYE. across the anterior chamber, the point of exit being diametrically opposite to that of entrance; the peculiar shape of the blade causes it to constantly fill the wound, and thus prevents the premature escape of the aqueous humor. If fixation forceps are used, they should be disengaged as soon as the counter-puncture is effected. The flap being completed, the eye- lids are allowed to close for a few seconds, when the surgeon proceeds to the second stage of the operation, the laceration of the lens capsule. This is effected by introducing the cystotome (Fig. 346, a), the patient looking downwards, and the upper lid being slightly elevated; when the cystotome has reached the inner side of the pupil, its point is turned downwards, and the capsule freely divided as far as the outer pupil- lary margin; the instrument is then cautiously withdrawn, when the eyelids may again be allowed to close. The third stage of the opera- tion consists in the evacuation of the lens, which is effected by making gentle pressure with the back of the curette (Fig. 346, 6) upon the lower lid, while counter-pressure is made with the forefinger upon the upper portion of the eyeball. The curette should at first press backwards, and then backwards and upwards, so as to cause the lens to present itself edgewise at the corneal wound. The pressure must be very cau- tiously made, lest rupture of the hyaloid membrane and loss of vitreous follow. The operation is now completed, but before applying*the after- dressing the surgeon should again, in a few minutes, separate the lids, to make sure that trfe corneal flap is properly adjusted,and that no pro- lapse of the iris has occurred. The after-treatment consists in closing the eye with a single strip of isinglass plaster, and applying a compress- ing bandage (see p. 647) to both eyes. The patient should be confined to bed for three or four days. Dr. H. W. Williams (Boston City Hospital Reports, 1870, p. 378) recommends the insertion of a delicate suture in the centre of the wound after the operation of flap extraction; his sta- tistics do not, however, show any particular gain by the proceeding—102 cases with suture having given 85 successes, 8 partial successes, and 9 failures, while 104 cases without suture gave 87 successes, 7 partial suc- cesses, and 10 failures. If all goes well, the eye should not as a rule be opened until the end of a week, though the external dressing may be renewed once or even twice a day. Should, however, the occurrence of any unfavorable symptom, such as great pain, swelling, or muco-purulent discharge, lead the surgeon to fear that the case is not progressing satisfactorily, the lids should be gently separated and the eye inspected (by the light of a candle), that the exact condition of things may be recognized, and appropriate treatment resorted to. The chief complications which may arise during the operation, are as follows: (1) the iris may fall in front of the knife—to be remedied by gently disentangling the point of the instrument, and by making cautious pressure through the cornea; if this fail, the section may be completed, the resulting iridectomy not being of any particular disadvantage; (2) the corneal wound may be too small—to be remedied by cautiously enlarging it with blunt-pointed knife or scissors; (3) the lens may drop down into a fluid vitreous—the lens must be instantly extracted with a suitable spoon or hook, and a compressing bandage applied; (4) prolapse of the iris may occur—to be remedied by gently repressing the protrud- ing portion with a fine probe, or by softly rubbing the lids in a circular direction; if this fail, the prolapse should be seized with forceps and ex- cised; (5) portions of the cortical matter of the lens may be detached during its exit—these should, if possible, be removed by very gently von graefe's method of extraction. 653 rubbing the eyelids in a circular direction, so as to bring the fragments into the anterior chamber, whence they may be removed with a scoop or spoon. If, from its transparency, the cortical matter at first escape ob- servation, subsequently swelling and producing irritation, atropia must be freely used; it may even be necessary to make a small corneal incision, facilitating the escape of the remaining lens substance by means of the curette or suction apparatus (see p. 655). The escape of a considerable quantity (more than one-third) of the vitreous humor, is usually followed by loss of the eye, and an equally bad result attends deep intra-ocular hemorrhage, which may occur during the operation, or some hours subsequently. Failure after flap extraction may occur from these causes, or from inflammation attacking the cornea or iris, or even the whole globe; the treatment of these acci- dents must be conducted upon general principles—the application of a few leeches to the temples, and the free use of atropia, are to be re- commended during the early stages, followed by warmth and moisture, and the compressing bandage, if suppuration occur. Traction Method.—In this operation (which originated with Von Graefe and has been modified by Waldau, Critchett, and others), chloro- form may be employed, and the eyelids may be held apart with the stop- speculum. The surgeon, standing behind the patient, fixes the eye with forceps, and makes with an iridectomy knife, or a Graefe's linear extraction knife, an incision in Fig. 347. the upper part of the sclero-corneal junction, in- volving one-third of the corneal circumference; the fixation forceps are then intrusted to an as- sistant, and the surgeon cautiously introducing delicate iris forceps, makes a broad iridectomy as directed at page 647. The capsule of the lens is then freely lacerated with the cystotome, and the lens itself drawn out with a silver spoon (Fig. 347), provided with a barbed or recurrent edge, which allows it to slip easily between the lens and the posterior capsule, and then catches the lower edge of the lens and holds it firmly as it is withdrawn. Care must be taken in the intro- duction of the spoon, not to push the lens before it, and not to rupture the hyaloid membrane, which would allow loss of vitreous. Von Graefe's Method of Modified Linear Extraction, with its lamented author's recent modifications, may, probably, be considered the best operation yet devised for extraction of cataract. The peculiari- ties of this method are that the incision is through the sclerotic, and does not form a flap,1 and that no traction instrument is employed. Fig. 348. Von Graefe's cataract knife. The following description and accompanying wood-cuts are taken from Laurence; the eye operated upon is supposed to be the left. The surgeon ' The incision is usually said to be linear (whence the name of the operation), but this distinction is not mathematically correct, the section in this method no more corresponding to the geometrician's definition of a line, than does that of the ordi- nary flap operation. The curve in Graefe's incision is that of the eye itself. 654 diseases of the eye. Fiff. 349. Fig. 350. opens the extreme periphery of the anterior chamber with a narrow knife, represented at Fig. 348, in its actual size, by an incision A B (4^-4| lines long) through the sclerotic, at the point A (Fig. 349), half a line exter- nal to the margin of the cornea, and two-thirds of a line below the level of its uppermost summit. The point of the knife is, in order to enlarge the internal corneal incision, in the first instance, directed, not to the point of counter-puncture, B, but to about the point C. After the knife has been entered fully three lines into the anterior chamber, its handle is depressed, counter-puncturation at B effected, the knife-edge directed abruptly forwards, and the section completed. In Fig. 350, the uppermost un- dotted line shows the direction of the incision. The next steps of the operation are the same as in the traction method, consisting in an iridectomy and the laceration of the anterior capsule. To remove the lens a spoon of vul- canite or tortoise-shell is employed, not being used as a traction instrument, but simply to exercise pressure from without. The convex back of the instrument is applied to the lower border of the cornea, when, by using a little pres- sure, the wound at its upper part begins to gape. Then the spoon is given a slight turn (so that its upper border buries itself a little in the outer surface of the cornea), at the same time that it is moved a little upwards, in consequence of which the equator of the lens presents itself at the wound. By continuing this manoeuvre and making slight coun- ter-pressure on the scleral border of the wound, the exit of the lens is effected. Any cortical matter which may have become detached, is to be coaxed out by gently stroking the cornea from below upwards with the back of the spoon, as long a time as may be necessary being devoted to the satisfactory accomplishment of this final part of the operation. Diagram of Von Graefe's opera tion for cataract. Fig. 331. Von Graefe's hook. If in any case the evacuation of the lens in the manner described be found impracticable, it may be extracted with a silver spoon, or (which Graefe prefers) a blunt hook (Fig. 351). The after-treatment in this, and in the traction method, is the same as in the flap extraction, except that in these the eye may be safely examined after twenty-four hours, and the patient allowed to leave his bed on the second or third day. Needle Operation, or the Operation for Solution.—This is the method ordinarily to be preferred for the removal of soft cataracts. Chloroform or ether may be indiscriminately Fig. 352. employed, but neither is usually required. The >■■—i pupil being well dilated, and the lids separated ss^b^^J by the stop-speculum, the surgeon fixes the eye Bowman's stop-needie. with forceps, and enters a lance-headed, or, if CAPSULAR AND SECONDARY CATARACT. 655 preferred, a Hays's knife-needle, through the cornea at its outer side and carries it across to the centre of the pupil, when the edge is turned to the lens, and a slight laceration made in the capsule. The operation usually has to be repeated at intervals. Care must be taken not to use so much force as to dislocate the lens, and not to lacerate the capsule too freely in the first operation, lest the lens substance, swelling up from the contact of the aqueous humor, should produce injurious pres- sure on the iris and ciliary body. When the bulging lens matter has disappeared by absorption, the operation may be repeated, the needle Fig. 353. Hays's knife-needle. this time being used more freely. The only after-treatment required is the closure of the eye for twenty-four hours, and the maintenance of pupillary dilatation by means of atropia. If the lens be dislocated, it should, as a rule, be removed by means of a corneal incision and the introduction of a scoop, an iridectomy being at the same time performed; while, if the swelling of the lens be so great as to threaten injurious consequences, a small incision, with a keratome or broad needle, may be made, and the escape of the offending substance aided by the intro- duction of a curette.1 Suction Method.—This operation, which was introduced by Teale, is specially adapted to cases of fluid cataract, such as are frequently met with in diabetic patients. Mr. Teale used a " suction curette," consisting of a curette roofed in to within a line of its extremity, with a handle and a piece of India-rubber tubing furnished with a mouth-piece. The anterior capsule of the lens being lacerated with two needles, the curette is introduced through a small corneal wound into the area of the pupil, and the fluid lens matter sucked out by the application of the operator's mouth. Mr. Bowman has devised a " suction syringe," which is in some respects more convenient than the curette. Treatment of Capsular and Secondary Cataract.—It some- times happens that, after the removal of a cataractous lens, the field of vision is still obscured by an opaque or wrinkled condition of the remaining capsule, containing, perhaps, some portions of lenticular matter inclosed within its layers; the obstruction may be aggravated by the presence of nodules of inflammatory lymph. No operation should be practised for the relief of this condition, until all the irritation caused by the original operation has passed away, an interval of several months heing usually required. The safest mode of treating secondary or capsu- lar opacities, is to tear through the occluding membrane with a Hays's needle, introduced through the cornea. If the capsule be very dense and resisting, two needles, introduced at opposite sides of the cornea, may be used, as advised by Bowman—one serving to fix the membrane while laceration is effected with the other. Another plan is to divide the cap- sule with delicate "canula scissors" (Fig. 354), or, as recommended by Dr. C. R. Agnew, of New York, to perforate and fix the membrane with a 1 The operation is thus essentially converted into the true "linear extraction," which originated in 1811, with Gibson, of Manchester. 656 DISEASES OF THE EYE. needle, and then with a sharp hook, introduced through a small corneal opening, to tear and roll up the membrane, which, if not too closely attached, may be drawn out with the instrument. Fig. 354. Canula scissors. After these, as after other cataract operations, the pupil should be kept for some time well dilated with atropia. Diseases of Vitreous Humor, Choroid, Retina, and Optic Papilla. (Amaurosis and Amblyopia.) Amblyopia and amaurosis are, strictly speaking, symptoms, the former word denoting obscurity, and the latter more or less complete loss of vision.1 These terms are ordinarily applied to all cases of partial or total blindness, which are dependent neither on external obstructions (such as cataract or opaque cornea) nor upon optical defects of the eye, but are limited by Von Graefe and many other modern ophthalmologists, to cases of lost or impaired vision, which are caused by primary atrophy of the optic nerve, or by such irregularities in the circulation of the ner- vous system as may eventually lead to such atrophy. Looking, then, upon these conditions (amblyopia and amaurosis) as symptoms of disease, rather than as definite pathological states which can be referred to any particular cause, I shall first speak of the morbid changes in the deeper structures of the eye, to which their manifesta- tion may be due, and subsequently of those cases of nervous blindness to which alone Von Graefe and his followers would apply the term amaurotic. The Ophthalmoscope.—These cases can only be investigated by the aid of the ophthalmoscope, a brief account of which instrument may, therefore, be appropriately given in this place. The ordinary form of ophthalmoscope consists essentially in a perforated mirror, by which the light from a suitably placed lamp is reflected into the patient's eye, and thence back to that of the surgeon, who looks through the central perforation. Liebreich's portable ophthalmoscope, which is, perhaps, the most convenient for general use, consists of a polished, concave, metallic mirror, about 1£ inch in diameter and of 6 to 8 inches focal length. It has a central perforation, about a line in diameter, and is mounted in a light frame with a handle of convenient length. A movable arm, attached to the side of the frame, supports a clip, in which may be placed, behind the sight-hole, an ocular lens, either concave or convex, according to the needs of the observer. Accompanying the ophthal- moscope is a double-convex object lens, for use in the method of indirect examination. 1 Etymologically the words are synonymous, both signifying, literally, dimness of vision. THE OPHTHALMOSCOPE. 657 Fired Ophthalmoscopes and Binocular Ophthalmoscopes (in which the surgeon uses both eyes at once) have each some particular advan- tages in special cases. Prof. Beale has recently devised a self-illuminating Fig. 355. ophthalmoscope, which, by an ingenious arrangement of lamp and mirror (the latter of which is inclosed with the ob- ject lens in a darkened tube), can be used without the necessity of pre- viously darkening the room. The ordinary ophthalmoscope is used in a darkened room, the patient being firmly seated, and the surgeon standing or sitting in front of him; an Argand lamp or gas-burner is placed to one (usually the left) side of, and a little behind the patient's head, with the flame on a level with his eyes (Fig. 356). The patient's pupil may, if deemed Liebreich's portable ophthalmoscope. necessary, be dilated with atropia. For the indirect method of examination, which is that commonly employed, the surgeon holds the mirror close to his own eye, and about a foot and a half from that of the patient. Looking through the cen- Fig. 356. I'se of the ophthalmoscope. tral perforation, the surgeon is soon able, by a little manoeuvring, to catch the rays from the lamp and reflect them directly into the patient's eye, the pupillary space of which now appears of a reddish-yellow color. Then taking in the other hand the object lens, the surgeon holds it from 42 658 DISEASES OF THE EYE. an inch and a half to two inches in front of the eye which he is observing, fixing it in that position by resting his fingers on the patient's forehead. By now moving his own head a little backwards or forwards, the opera- tor obtains an inverted aerial image of the fundus of the observed eye. By directing the patient to turn his eye in various directions, the sur- geon can explore the whole fundus of the eye, it being remembered that, in the aerial image which is seen, the position of every part is inverted. In the direct method of examination, no object lens is used. The sur- geon at first holds the mirror about a foot from the eye of the patient, and then, by gradually approximating it more closely, can illuminate and ex- amine in succession the cornea, crystalline lens, and vitreous; the fundus oculi is not fairly brought into view until the mirror is within about two inches of the observed eye, when a virtual erect image becomes apparent, seeming to be placed some distance behind the patient's eye. If either the surgeon or patient be short-sighted, a concave lens must be placed behind the sight-hole of the mirror. The entrance of the optic nerve, which is usually the part first in- spected, may be brought into view by causing the patient to look at that ear of the operator which corresponds to the eye under examination; thus, the right ear for the right eye, and the left, for the left. The optic papilla gives a whiter reflection than the rest of the fundus, and, when brought into distinct view by the adjustment of the object lens (in indirect ex- amination), appears as a pinkish, white, or gray disk, marked by the convergence of the retinal vessels; of these, one artery and two veins commonly pass upwards, and as many downwards, each soon dividing and ramifying over the fundus. The veins may be made to pulsate by pressing on the eye, and sometimes do so spontaneously in a normal state. Spontaneous pulsation of the retinal arteries, on the other hand, is always an evidence of increased intra-ocular pressure, and is a symp- tom of glaucoma. The maculea lutea, or yellow spot, may be brought into view by directing the patient to look at the central perforation of the mirror, and may be recognized by the absence of retinal vessels. The macula lutea is frequently the seat of hemorrhagic extravasations or other lesions. It is not my purpose to offer any detailed account of the various ophthalmoscopic appearances observed in different morbid states of the eye: the limits of this volume would not justify my doing so, and, indeed, as justly remarked by Dixon, it is not possible to convey, by mere verbal description, any information upon these topics which would be of much real value. The use of the ophthalmoscope can only be satisfactorily acquired by long and continued actual practice, and the assistance which the student can derive from any verbal description of what he is expected to see, will not prove of material advantage. Those, however, who cannot pursue their labors in this branch under the direction of an experienced and skilful ophthalmoscopist (which is much the best manner of acquiring a practical knowledge of the instrument), may study with benefit the works of Zander and Hulke, and the colored illustra- tions of ophthalmoscopic appearances published by Jaeger, Liebreich, Stellwag, Power, Wells, and others. The morbid changes of the deep structures of the eye which induce amaurosis and amblyopia, may now be briefly referred to. Changes in the Vitreous Humor.—Opacities of the Vitreous.— These may consist of filaments of lymph, shreds of pigment, or the con- CHANGES IN THE CHOROID. 659 tracted remnants of blood clots. They result frequently from diseases of the iris, retina, or choroid, especially when of a syphilitic character— in which case they are to be treated by means of remedies addressed to that condition. Dense membranous opacities have been successfully treated by Von Graefe by means of a needle-operation, as in cases of capsular cataract. Muscas Volitantes are floating opacities of the vitreous, consisting of filaments, cells, or cell-debris derived from that structure, which are not unfrequently observed by those who are short-sighted, or who strain their eyes by fine work: they frequently persist for years, causing annoyance by their presence, but being productive of no further evil con- sequences. The only treatment to be recommended is the administra- tion of tonics to improve the general health, with rest for the eyes, and the use of dark glasses. Hemorrhage into the Vitreous, is a much more serious affair than hem- orrhage into the aqueous humor. In the former situation, absorption takes place very slowly, and shreds of clot are apt to be left which per- manently interfere with vision. The treatment consists in local depletion, the application of cold, etc. Synchisis is a term used to denote a softened and fluid condition of the vitreous. In some cases, the vitreous holds in suspension numerous scales of cholestearine, giving a sparkling appearance when examined with the ophthalmoscope; the condition is then called synchisis scintil- lans. Fluid vitreous may result from injuries, or from various non- traumatic inflammatory affections of the eye; it usually causes dimi- nished tension of the eyeball, though it may be met with in cases of glaucoma. The condition is, I believe, irremediable. Changes in the Choroid.— Choroiditis frequently occurs in con- nection with inflammation of the iris and retina. The changes revealed by the ophthalmoscope may consist merely of increased vascularity, of cloudiness due to serous effusion, or of yellowish-white patches of lymph, often surrounded by pigment, and perhaps traversed by the retinal vessels. Choroiditis is frequently an accident of constitutional syphilis, in which case it is said that the lymphy patches are more circumscribed than in the simple variety of the affection. The treatment consists in the cautious administration of mercury, or iodide of potassium, with tonics, especially iron and quinia. Atrophy of the Choroid, commonly of a local character, usually accom- panies posterior staphyloma, in severe cases of myopia. In an advanced stage of atrophy, the choroid is entirely deficient in parts, the exposed sclerotic appearing in its place in the form of white patches. The treat- ment consists in the enforcement of rest to the eyes, with local depletion and counter-irritation. If the disease be rapidly progressive, Lawson advises the administration of the bichloride of mercury. Anaemia of the Choroid is characterized by paleness of the fundus oculi, and is often accompanied by contraction of the retinal vessels. Bony Deposits are occasionally found in the choroid, apparently result- ing from ossific change in previously formed inflammatory lymph ; cal- careous deposits are in the same cases often found in the lens and cornea. Tubercles of the Choroid are met with in cases of acute tuberculosis ; the coexistence of the choroidal affection with tuberculosis of the lungs, is, according to Steffen, more constant than with the same condition of the pia mater. 660 DISEASES OF THE EYE. Tumors of the Choroid.—The morbid growths met with in this situa- tion, belong either to the group which Virchow designates as sarcomata (see page 416), or to the medullary form of cancer. In either case the tumor is apt to contain a certain amount of melanotic deposit. The only treatment to be recommended is excision of the globe, which should, if possible, be performed before the tumor has made its way through the external coats of the eye. Changes in the Retina.—Hypereemia of the Retina may be due to over-exertion of the eyes, in which case its treatment consists in rest of the organ, and in the use of local depletion, counter-irritation, and the cold douche, with the administration of tonics, etc. In other cases there is a passive venous congestion, due to cerebral disease or the pressure of a tumor. The iodide and bromide of potassium are recommended under such circumstances, but the results of treatment are far from satisfactory. Retinitis is very often associated with choroiditis, and not unfre- quently with iritis. It is marked in its early stages by increased vascu- larity, and subsequently by the occurrence of extravasation, serous effu- sion, or lymphy deposit. It is often clue to syphilitic or nephritic dis- ease, particularly the former (see p. 445). Mercury, which is serviceable in the syphilitic variety, is totally contra-indicated in that which depends on kidney disease, the most useful remedy in the latter form of the affec- tion being probably the muriated tincture of iron. Retinitis Pigmentosa (which, from night-blindness being one of its promi- nent symptoms, is also called Retinitis Hemeralopica) is characterized by the deposit of pigment matter on the retina ; the disease is incurable, going on to the production of total blindness, though, as the course of the affection is very slow, old age may be attained before this consum- mation is reached. Prof. Arlt, of Vienna, has given the name Retinitis Nyctalopica to certain cases of inflammation of the retina, in which the opposite condition is present, the patients seeing better in the dusk than in a bright light; the treatment which he recommends is functional rest, with the use of colored glasses and the administration of mercury. Apoplexy of the Retina may occur in any of the forms of retinitis (more particularly in the nephritic), or may result from other causes, such as heart disease, atheroma of the retinal vessels, embolism, or sup- pressed menstruation. The treatment consists in obviating a recurrence of the hemorrhage by endeavoring to remove the cause, if this can be ascertained. Advantage may perhaps be derived from the use of iodide of potassium in hastening the absorption of the effused clots. Anaemia of the Retina, may accompany anaemia of the choroid. Such a condition, when met with in cases of epileptiform convulsions, has been called by Hughlings Jackson, Epilepsy of the Retina. Detachment of the Retina may occur in cases of extreme posterior sta- phyloma, or may be due to loss of vitreous, to hemorrhagic or serous effusion, or to the growth of tumors of the choroid. When the detach- ment is caused by sub-retinal effusion, an attempt may be made to evacu- ate the fluid by puncturing the retina with one or two needles, passed through the sclerotic and vitreous, as advised by Von Graefe and Bow- man ; or with a delicate trocar, as recommended by Wecker; or by punc- turing the choroid from without, as suggested by Laurence. Fatty Degeneration of the Retina sometimes occurs in cases of albu- minuria. Embolism of the Central Artery of the Retina produces contraction of both sets of retinal vessels, but particularly of the arteries, and is AMAUROSIS AND AMBLYOPIA. 661 often accompanied with sub-retinal effusion in the neighborhood of the macula lutea. Embolism of the retinal artery often depends upon the existence of cardiac valvular disease of the left side. It produces sud- den and total blindness, and is rarely recovered from. Tumors of the Retina__Cystic degeneration of the retina is occasion- ally observed in an eye which has long been blind, and may require ex- cision of the globe, if the disease should produce pain and threaten the in- tegrity of the other eye. The most common retinal tumor, however, is the Glioma, which runs an almost malignant course, and was indeed formerly considered to be of an encephaloid character. The only treatment to be recommended is early excision, which may be required in the case of both eyes, if both be affected. The disease often recurs in the orbit. Changes in the Optic Papilla.—Optic Neuritis.—Two forms are recognized, one confined to the optic nerve, and the other likewise involving the retina (neuro-retinitis). The former is often an attendant upon cerebral disease (descending optic neuritis), while the latter is fre- quently of a syphilitic nature. In some cases the optic disk is first affected, the disease subsequently extending upwards (engorged papilla, or ascending neuritis). The optic papilla is at first swollen and con- gested, afterwards assuming a peculiar " woolly" appearance. The prog- nosis is unfavorable, and the treatment usually unsatisfactory ; mercury, cautiously administered, with the iodide and bromide of potassium, are the remedies commonly employed. Excavation, or Cupping of the Optic Papilla.—A slight depression in the centre of the optic disk may exist in the normal state, constituting what is known as the physiological cup. In glaucoma, and in some cases of advanced myopia, a much more marked and abrupt form of cup- ping is observed; the most distinctive characteristic of this condition is the bending of the retinal vessels at the margin of the optic disk, the whole of which is occupied by the glaucomatous cup; if the excavation be very deep, the retinal and papillary portions of the vessels may be seemingly quite disconnected. A third form of cupping often accom- panies atrophy of the optic nerve, a condition which may result from the pressure of intra-orbital tumors, from disease of the brain or spinal cord, or from the abuse of tobacco, etc. Amaurosis and Amblyopia from Extra-Ocular Causes.—Im- pairment or loss of vision, without any recognizable primary lesion of the eye, may result from disease of the cerebrum, cerebellum, or spinal cord; from sudden suppression of the menses, or other uterine disturb- ance (even from pregnancy); from profuse hemorrhage; from reflex irri- tation, as from a carious tooth; from compression of the optic nerve; from embolism; from the toxic influence of tobacco, alcohol, lead, or quinia; from uraemic poisoning, etc. In all cases the immediate cause of the loss of sight is interference with the circulation of the nervous structures concerned in vision, or, in permanent cases, atrophy of the optic nerve. A symptom, which by some authors is considered of value, in the diagnosis between amaurosis from cerebral and that from spinal disease, is that, in the former, both eyes are usually affected, and the pupils dilated, while in the latter, one eye only is commonly involved, and the pupil contracted. The field of vision is differently affected in different cases; thus the centre, or the periphery of the field may be chiefly involved, or the loss of sight may involve just half of the field (hemiopia), vision being 662 DISEASES OF THE EYE. perfect on one side of a vertical line, and absent on the other. I have seen a well-marked case of hemiopia following a fracture of the base of the skull. The treatment of these forms of amaurosis consists in endeavoring to remove the cause, when that can be ascertained; when resulting from disease of the central nervous system, the prognosis is extremely un- favorable. Hemeralopia, Day-Sight, or Night-Blindness, is a functional condition consisting in a diminished sensibility of the retina, due appa- rently to excessive exposure of the eyes to light, together with a debili- tated and especially a scorbutic condition of the system. It is most common among residents in tropical countries, soldiers and sailors, etc. This affection must not be confounded with Retinitis Pigmentosa, in which night-blindness is a frequent symptom; in the true hemeralopia, no morbid changes, whatever, are revealed by the ophthalmoscope. The treatment consists in the administration of tonics, especially cod-liver oil, with the use of dark-colored glasses to protect the eyes. If the dis- ease can be traced to scurvy, or to malarial fever, remedies suitable to those affections must be employed. Snow-Blindness is a condition analogous to hemeralopia, resulting from exposure to the dazzling reflection from snow; the eyes should be shielded by colored glasses, and tonics administered if the patient's general condition demand their use. . • Nyctalopia.—This rare affection is the reverse of hemeralopia, and consists in a hyperaesthetic state of the central portion of the retina, the peripheral part being anaesthetie. The treatment consists in protecting the eyes from light, and in improving the constitutional state of the patient, by the use of tonics, particularly the preparations of zinc and iron. Color-Blindness, or, as Dixon more accurately terms it, Acrito- chromacy, is a defect of vision in which the power of distinguishing one or more colors is lost. Usually red and green are the two colors which are confused together, but in some cases vision is achromatic, all colors alike appearing as white, black, or gray. Color-blindness is usually congenital, but may result from disease; achromatic vision ex- isted, as a temporary condition, in a case of optic neuritis observed by Chisolm, of Maryland. When congenital, the affection is probably in- curable. Accommodation and Refraction. Accommodation is the power of self-adjustment which an eye pos- sesses, by means of which, objects at various distances are equally well seen. This adjustment is accomplished by a muscular effort (on the part of the ciliary muscle), of which the individual is, however, usually unconscious. Refraction is the passive power by which, when the eye is at rest, rays of light are brought to a focus on the retina; it is a purely physical property, depending upon the shape of the eye and of its various refract- ing media, as the cornea, lens, etc. ACCOMMODATION AND REFRACTION. 663 The various anomalies of refraction, and defects of accommodation, to which the human eye is subject, have received of late years a great deal of attention from ophthalmologists, and the means by which these anomalies and defects may be recognized and corrected, have been tho- roughly studied and systematized; for information on these topics, I must, however, refer the student to special treatises on the subject, con- tenting myself with merely mentioning and explaining the principal terms employed. Emmetropia.—This is the normal condition; an eye is emmetropic, when parallel rays are converged to a focus on the retina, by the refrac- tive power of the eye itself, without any effort of accommodation. Myopia or Brachymetropia (Short Sight).—In this condition, dis- tant rays are brought to a focus in front of the retina, the image formed upon which is therefore indistinct. Myopia is usually due to an elon- gation of the antero-posterior diameter of the eye, and commonly results from a prolongation of the posterior half of the eye, often accompanied with thinning of the sclerotic and partial atrophy of the choroid, consti- tuting posterior staphyloma. This condition requires the use of concave glasses. Hypermetropia or Hyperopia is a condition exactly the reverse of the preceding ; here, distinct rays come to a focus behind the retina, the image on the latter being of course indistinct as in the previous case. A hypermetropic, is usually smaller than an emmetropic eye, particularly in its antero-posterior diameter, whence it has a flattened appearance. Hypermetropia requires the use of convex glasses. Ametropia1 is a general term embracing both the preceding con- ditions ; it is therefore the opposite of emmetropia. Astigmatism is a condition in which the refracting power varies in different meridians of the eye. Thus one meridian may be emmetropic, and others ametropic; or there may be myopia in one meridian, and hypermetropia in another. Many persons have slightly astigmatic vision without knowing it, and it is only when the want of symmetry is marked that the affection excites attention: the remedy is the use of cylindrical glasses. Aphakia is an anomalous state of refraction caused by the absence of the crystalline lens, as after cataract operations. Aphakia renders the normal eye markedly hypermetropic, while it diminishes myopia, and may even make a myopic eye emmetropic. The remedy for aphakia (which is accompanied with loss of accommodation) is the use of powerful convex lenses. Presbyopia is a diminution of the range of accommodation, inter- fering with vision of near objects, while distant vision remains unim- paired. Presbyopia is an almost constant attendant upon old age, and can scarcely be looked upon as abnormal: the treatment consists in the use of convex glasses. 1 For a convenient mode of determining the degree of ametropia, see an able paper by Dr. W. Thomson, in the American Journal of Medical Sciences for Octo- ber, 1870. 664 DISEASES OF THE EYE. Paralysis, and Spasm of the Ciliary Muscle may each be a cause of loss of accommodation. The Calabar bean may be used for the former, and atropia for the latter condition. Asthenopia, or Weak Sight, may depend upon exhaustion of the power of accommodation in cases of hypermetropia, or upon insufficiency of the internal recti muscles, by which the necessary convergence of the eyes for near vision cannot be long maintained. The former (which is called accommodative asthenopia) requires the use of convex glasses, while the latter (muscular asthenopia) may demand division of one or both external recti, or the use of appropriate prisms. Glaucoma. Glaucoma is the term which was formerly applied to all cases of im- paired vision accompanied by a greenish hue of the pupil, and not mani- festly due to lesions situated in front of the iris. The affection was variously supposed to consist in an abnormal condition of the vitreous, retina, optic nerve, or choroid, but its pathology was not well understood until quite recently, and in a great degree through the labors of Von Graefe, who has shown that all the symptoms of this formidable disease are clue to an increased intra-ocular tension, caused by the augmented volume of the vitreous and aqueous humors, and probably originating in an irido-choroiditis. The distinctive Symptoms of glaucoma are increased hardness or tension of the eyeball; diminished sensibility, and, at a later period, haziness of the cornea; distension of the ciliary vessels; diminution in the size of the anterior chamber; sluggishness and dilatation of the pupil (which has a green hue); partial atrophy of the iris; and lastly opacity of the crystalline lens. By the ophthalmoscope, the retinal arteries are seen to pulsate; the optic papilla presents the character- istic glaucomatous cup (page 661); the vitreous appears cloudy; and hemorrhages into the deep structures of the eye may be observed. Vision is hypermetropic and presbyopic; the field of vision becomes contracted; amblyopia, at first periodic, ends in complete amaurosis; halos or prismatic spectra are seen on looking at the flame of a candle; and pain, more or less intense, is felt in the eyeball, and along the course of the optic nerve. Glaucoma is usually met with in persons past the middle period of life, and may arise spontaneously, or as the result of some injury or antecedent inflammation. It is said to be occasionally traceable to the shock of mental or moral emotions. Various forms of the disease are recognized by systematic writers, as the glaucoma fulminans, in which the symptoms may be fully developed in a few days or even hours, the acute, the subacute, the chronic or simple, and the consecutive or secondary, the latter being often of traumatic origin. The Treatment of glaucoma consists essentially in the adoption of means to lessen the intra-ocular tension. In very mild cases, advantage may no doubt be derived from the assiduous use of atropia, and of con- stitutional remedies, but in the majority of instances, no time should be lost in resorting to iridectomy, which, under these circumstances, should be performed as directed at page 646. The benefits to be expected from this operation, for the introduction of which we are indebted to Von Graefe, are in inverse proportion to the duration of the disease; thus, if performed during the forming stage of the affection, a perfect yAFFECTIONS OF THE ENTIRE EYEBALL. 665 cure may be reasonably hoped for; an early operation, even in fully developed acute glaucoma, will probably at least arrest the course of the disease, and prevent further deterioration of sight; while in chronic glaucoma, the structural changes are usually so far advanced before the nature of the case is recognized, that comparatively little can be expected from any mode of treatment. Other operations for the relief of glaucoma have been practised, and with alleged good results. Thus repeated paracentesis of the cornea is highly recommended by Sperino, and cylicotomy, or division of the cili- ary muscle, by Hancock and others. The weight of testimony in favor of iridectomy is, however, so overwhelming, that it can scarcely be regarded as justifiable for the surgeon to delay the latter operation while experimenting with any other mode of treatment. Affections of the Entire Eyeball. Ophthalmitis, or Inflammation of the Eyeball, may result from trau- matic causes, may be idiopathic, or may be an incident of pyaemia, etc. The symptoms are those of deep-seated inflammation generally, with such special phenomena as are traceable to the implication of the various ocular tissues. The disease usually terminates in suppuration and rup- ture of the globe, or in sloughing of the cornea. The treatment during the early stages consists in the use of cold applications, with local de- pletion, scarification of the conjunctiva, and the instillation of atropia. If there be much tension, the cornea may be tapped with advantage. When suppuration has occurred, warm should be substituted for cold applications, and a free incision made as soon as fluctuation reveals the presence of pus. If the eyeball be totally disorganized, excision may be required. Sympathetic Ophthalmia, or the secondary implication of one eye as the result of disease or injury of the other, is especially apt to occur in consequence of wounds involving the ciliary region, particularly if complicated by the presence of a foreign body. Sympathetic ophthalmia is usually developed five or six weeks after the reception of an injuiy, though sometimes not until a much later period. In its common form it appears as a severe irido-cyclitis, though it also occurs as a serous iritis, or as a retino-choroiditis. In some cases the sympathetic irrita- tion, though so great as to render the eye practically useless, does not reach the point of structural change, constituting then what Donders describes as Sympathetic Neurosis. The treatment of sympathetic ophthalmia, as regards the eye origi- nally affected, depends upon the stage of the disease, and the amount of vision possessed by the injured organ. Foreign bodies should be ex- tracted before the development of any sympathetic symptoms, and if the lesion of the eye be so great as to render it useless, excision should be unhesitatingly performed. The same operation would, of course, be indicated, should the case be first seen when the second eye is becoming involved. If the injured eye still retains some sight, at the time of occurrence of sympathetic symptoms, the course to be pursued is more doubtful; for it has sometimes happened, under these circumstances, that the eye first affected has in the end proved more useful than the other. If the case be seen at a very early period, an iridectomy on the sympathetically affected eye may occasionally prove serviceable, but iu most instances it is better to wait until the subsidence of acute 666 DISEASES OF THE EYE. v- symptoms,.and then, if necessary, extract the lens and make an artificial pupil. The general treatment of sympathetic ophthalmia consists in the enforcement of functional rest, with the administration of tonics, espe- cially quinia, the cautious use of mercurial inunction, and the free instillation of atropia. Von Graefe has suggested, in some cases, the formation of a seton through the vitreous, as a substitute for enucle- ation of the injured globe; while, in the comparatively mild cases of sympathetic neurosis, division of the nerves of the ciliary region has been successfully practised by Meyer, Secondi, and Laurence. Excision or Enucleation of the Eyeball, is thus performed: The patient being fully etherized, the lids are held apart with a stop- speculum, while the surgeon divides the conjunctiva and subjacent fascia with scissors, in a circle as close as possible to the margin of the cornea. The tendons of the ocular muscles are then successively raised upon a strabismus hook and divided, when the eye, being drawn forwards and outwards, the optic nerve can be cut with long and narrow scissors, curved on the flat. The eye being removed, hemorrhage is to be checked by the application of cold, when, if thought proper, the conjunctival wound may be closed with a silk suture. This, however, should not be done when the operation is performed upon an inflamed eye, as a free vent should then be provided for the discharges. The after-dressing consists in the introduction of a piece of sponge or strip of lint within the lids, and the application of a firm bandage. When cicatrization is complete, and all inflammatory symptoms have subsided, an artificial eye may be adapted. In some cases of malignant disease, it may be necessary to extirpate the whole contents of the orbit. This may be done by dividing the ex- ternal commissure of the lids, incising the conjunctiva, severing the le- vator palpebrae, attachments of the oblique muscles, and all other orbital connections of the eye, and then, drawing the globe inwards, cutting the optic nerve with curved scissors, introduced on the outer side. The lachrymal gland should be also removed, if it be diseased. Strabismus. Strabismus, or Squint, is defined by Donders as "a deviation in the direction of the eyes, in consequence of which the two yellow spots receive images from different objects." When the squinting is constant in one eye, the strabismus is said to be monocular; when the patient can use either eye at will, but not both simultaneously, it is called con- comitant, alternating, or binocular. Strabismus is usually convergent (cross-eyes), or divergent—the former beiug commonly associated with hypermetropia, and the latter with myopia. Squinting may be periodic, or persistent; it may be brought on by various forms of reflex irritation, or may depend on some anomaly of refraction, on defective vision in one eye, or on paralysis of some of the nerves which supply the ocular muscles. Treatment.—If the affection be periodic, an attempt may be made to effect a cure by suitable constitutional treatment, by the use of glasses to remedy the defect in refraction, etc. If the strabismus be persistent, and not dependent on mechanical causes, such as the contraction of a cicatrix, or the pressure of a tumor, an operation may be resorted to, one or both internal or external recti muscles being divided, accord- STRABISMUS. 667 Galezowski's strabismometer. ing to the nature and extent of the squint. Before having recourse to an operation, the surgeon should (in a case of concomitant squint) de- termine which eye is primarily affected, and the degree of convergence or divergence, as the case may be; the former point Fig. 357. may conveniently be ascer- tained by repeatedly causing the patient to close both eyes and suddenly open them, that eye which constantly or ha- bitually deviates from the straight position being the one primarily affected. The degree of squinting can be best ascertained by using the strabismometer devised by Laurence, or that of Gale- zowski; but in the absence of these instruments, may be simply determined by marking on the lower lid points corresponding to the centre of the pupil, when the eye is fixed, and when it is squinting. If the degree of strabismus be moderate, less than three lines for instance, the primarily affected eye alone need be submitted to operation; but in cases of greater deviation, a better result will be obtained by dividing the operation between both eyes. The object to be accomplished in an operation for strabismus, is to alter the point of attachment of the divided tendon, and thus diminish the range of motion which it can impart to the eye; hence the importance of ascertaining the degree of deviation, that the separation of the tendon from its attachment may be more or less complete, according to the exigencies of the particular case. The operation for Division of the Internal Rectus Tendon is thus per- formed: The eyelids being separated with a stop-speculum, the surgeon catches with fine-toothed forceps a fold of the conjunctiva and subjacent fascia, on a level with the lower border of the tendon, and with delicate probe- Fig. 358. pointed scissors makes an opening just large enough to admit the stra- bismus hook; the latter is then in- sinuated behind the tendon, which it renders tense by drawing it forwards and outwards; the scissors are next introduced closed, and then opened, so as to place one blade behind, and the latter in front of the tendon, which is subsequently divided sub-conjunctivally, close to its sclerotic attachment, by a number of slight cuts. A counter-opening in the con- junctiva, to allow the escape of blood, may be made, as is done by Bowman, by cutting with the scissors on the point of the strabismus hook before this is withdrawn. The above is known as the sub-conjunc- tival operation, and was introduced by Critchett. Other surgeons prefer to divide the conjunctiva more freely, afterwards bringing the edges of the wound together with a suture. The surgeon can regulate the effect of the operation by separating more or less freely the sub-conjunctival fascia from the tendon to be divided, thus allowing the greater or less retrac- tion of the latter. The application of a suture also serves to lessen the effect of the operation. Strabismus hook. 668 DISEASES OF THE EYE. The External Rectus Tendon may be divided by an operation analogous to that above described. Considerable difference of opinion exists among surgeons as to whether both eyes should be operated on simultaneously (when both require operation), or whether the second operation should be postponed until after an interval of several days. Probably a safe rule is that given by Wells, to wait and observe the effect of the first operation, in cases of deviation of less than five lines; by this pre- caution the surgeon can form an estimate as to how much remains to be accomplished in the second operation. In cases in which by too free division of the internal recti muscles, a convergent has been converted into a divergent squint, it may be necessary to divide the new attach- ments of one or both tendons, and bring them forward to insert them nearer the cornea, holding them in place with fine sutures, and thus reversing the effect of the original operation. A similar procedure is sometimes employed in cases of paralytic strabismus. Anaesthesia is, as a rule, undesirable in squint operations, though it may be employed in cases of children, or in those of nervous adults. The after-treatment in cases of strabismus, consists (if both eyes have been operated on) in simply bathing the parts with cold water; if one eye only has been submitted to operation, the other should be closed with a bandage, so as to force the patient to use that of which the tendon has been divided. Advantage may often be subsequently derived from the use of suitably adjusted prismatic glasses, so as gradually to restore binocular vision. These glasses may, indeed, suffice to effect a cure without operation, in slight cases of periodic squint. Diseases of the Eyelids. Ophthalmia Tarsi (Tinea Tarsi) is the name given to a subacute or chronic form of inflammation, affecting the edges of the eyelids and the follicles of the lashes, which become loosened and fall out. The palpebral edges are red, thickened, and sometimes ulcerated, and become glued together by the drying of the accumulating secretion. In its severer forms, the affection gives rise to the condition known as Lippi- tudo or Blear-eye. The puncta lacrymalia are often everted or obliter- ated, giving rise to a constant stillicidium of tears, which excoriate the skin and add to the patient's discomfort. The treatment consists in removing the dried secretion by warm fomentations, and smearing the edges of the lids with dilute citrine ointment.1 In severer cases the local application of nitrate of silver will be of service, and if the puncta be everted or obliterated, the canaliculi should be freely slit up, the incision being directed inwards. As this affection commonly occurs in scrofulous children, cod-liver oil may be properly administered in most cases. Hordeolum or Stye is a small boil occurring at the edge of the lid, and often originating in the follicle of an eyelash ; it is met with usually in debilitated persons, and occasionally as the result of over-exertion of the eyes, or of exposure to too bright a light, as to the glare reflected from snow. When situated just within the edge of the lid, it produces pain by pressing on the globe; relief may be sometimes afforded under these circumstances by fixing the lid in a position of slight eversion, by means 1 Ung. hydrargyri nitrat. 3j ; Vug. aq. rosae Jvij. M. TRICHIASIS AND DISTICHIASIS. 669 of collodion. The treatment consists in the use of warm fomentations, with a puncture if required, the induration which remains being dispersed by the use of dilute citrine ointment. Tonics are usually indicated as constitutional remedies. Trichiasis and Distichiasis.—The former term signifies an irregu- lar displacement of the eyelashes, some of which, stunted and inverted, produce great irritation by friction on the conjunctiva and cornea, the latter becoming, in extreme cases, cloudy and vascular. In distichiasis a complete double row of lashes exists, the inner row being inverted, and producing great irritation as in the previous case. The treatment of either affection consists in carefully extracting with cilia forceps the offending lashes, or, in severe cases (if the upper lid be involved), excising the whole row of cilia, by means of two incisions parallel to the lashes and one on either side, the tarsal cartilage being thus split, and a wedge-shaped strip bearing the cilia removed. The operation may be facilitated by first fixing the lid with Snellen's forceps. In the case of Fig. 359. Snellen's forceps. the lower lid, it will usually be sufficient to remove an elliptical strip of skin with the subjacent fibres of the orbicularis muscle, thus producing eversion as in the operation for entropion. Entropion, or Inversion of the Lids, may result simply from spas- modic action of the orbicularis palpebrarum, as in the entropion after cataract operation in old persons, or from long-continued conjunctival inflammation, the injudicious use of caustics, etc. The irritation pro- duced by the friction of the inverted lashes is very great, and some- times induces opacity of the cornea. The treatment of the spasmodic cases consists in restoring the lid to its proper position by traction with 670 DISEASES OF THE EYE. the fingers, and then fixing it by the application of collodion, the contractile property of which serves to obviate the tendency to inver- sion. Chronic cases of entropion may be ■"g- 360, remedied by various operations, such as (1) pinching up with entropion forceps, and ex- cising a small strip of skin with the subjacent fibres of the orbicular muscle, parallel to the ciliary border of the lid—the wound being subsequently closed or not with sutures; (2) " grooving the tarsal cartilage," as recom- mended by Streatfeild, the operation consist- ing in the removal of a tranverse strip of the cartilage by means of two parallel incisions meeting at the apex of a V—the skin wound being subsequently closed with stitches; (3) the introduction of two or three threads in a longitudinal direction through the cutaneous surface of the lid, the ligatures embracing the ciliary margin and being allowed to cut their way out by ulceration, as advised by Pagen- stecher, or embracing the skin and muscle of the lid only, as recommended by Laurence; (4) the excision of a triangular portion of skin, with or without a part of the subjacent cartilage, as recommended by Von Graefe; (5) the removal of the whole row of cilia, as described in speaking of trichiasis; or (6) transplantation of the cilia to a better posi- tion on the lid, as advised by Arlt. As a preliminary to any of these operations, it will often be advisable to slit up the external canthus (canthoplasty), re-adhesion being pre- vented by uniting the skin and mucous mem- brane on either side with a stitch. Ectropion, or Eversion of the Lids,*m&y be of an acute character, resulting from spasm of the inner fibres of the orbicularis palpebra- rum in cases of purulent conjunctivitis, in which case its treatment is that of the disease which it accompanies, or may appear as a chronic affection, resulting from ophthalmia tarsi, chronic conjunctivitis, etc. Under these circumstances the treatment consists in the application of nitrate of silver to the mucous membrane just within the line of eversion, with slitting of the canaliculi if the puncta be everted or occluded. Ectropion from the contraction of cicatrices, abscesses, etc., usually requires an operation, which may consist (1) in excising a portion of the everted conjunctiva; (2) in removing a triangular-shaped piece of all the tissues of the lid near the external canthus, and bringing the edges of the wound together with harelip pins, thus shortening the lid (Figs. 361, 362); (3) in making a transverse incision through the lid down to the conjunctiva, drawing this through the wound to the requisite extent, and cutting it off with scissors ; or (4) in dissecting out the vicious cicatrix and filling Entropion forceps. SYMBLEPHARON. 671 Fig. 361. Fig. 362. Adams's operation for ectropion. the gap by transplanting a flap of skin, from the forehead in case of the upper, and from the nose or cheek in case of the lower lid. Excurvation of the Eyelids is the name used by Laurence for the peculiar deformity, observed, particularly in the upper lid, in cases of inveterate trachoma; the remedy, according to this writer, consists simply in dividing the outer canthus, and uniting the cut edges of con- junctiva and skin by stitches above and below. Ptosis, or Falling of the Upper Lid, may be congenital, or may result from the increased weight of the part due to inflammatory thickening, from wounds dividing the levator palpebrae or its nerve, or from pa- ralysis of the third nerve. The treatment (in cases of sufficient severity to justify operation) consists in removing an elliptical portion of the skin and subjacent muscle of the lid, the edges of the wound being then approximated transversely so as to place the part under control of the occipito-frontalis muscle, which sends fibres to the upper portion of the orbicularis—or in the introduction of ligatures as described in speaking of entropion. In paralytic cases, the endermic application of strychnia has been occasionally resorted to with advantage. Lagophthalmos, or Hare-eye, denotes an inability to close the eye- lids; it may result from the contraction of cicatrices, when its treatment is that directed for ectropion, but more often depends on paralysis of the orbicular muscle from some local affection of the portio dura, or from intra-cranial causes. If the affection appear to result from the pres- sure of a tumor on the portio dura, the offending growth should, of course, be removed; a blister to the temple may be of service in cases resulting from exposure to cold; while, if a syphilitic origin be sus- pected, the iodide of potassium may be administered. Symblepharon is a morbid adhesion of the eyelid to the eyeball, resulting usually from the cicatrization of burns, ulcers, etc. The treat- ment consists in (1) dividing the adhesions, and uniting the cut edges of conjunctiva with sutures (Wilde); (2) covering the raw surfaces, left after severing the adhesions, with flaps of healthy conjunctiva taken from unaffected parts of the eyeball (Teale); or (3) dissecting back the symblepharon as far as the retro-tarsal fold, doubling it upon itself 672 DISEASES OF THE EYE. so as to oppose a mucous surface to the globe, and fixing it in this position by means of a ligature which is armed with two needles and passed through the lid from within outwards (Arlt). Ankyloblepharon is an abnormal adhesion of the free edges of the upper and lower lids, either congenital or the result of injury, etc. The treatment con- sists in severing the adhesions with a small knife and grooved director, reunion being prevented by touching the cut edges with collodion. Epicanthus is a congenital affection, in which a crescentic fold of skin overlaps the inner canthus of the eye, producing considerable de- formity; the treatment consists in excising a vertical fold of skin and bringing the edges of the wound together with sutures, so that the subse- quent contraction may expose the previously hidden canthus. Tumors of the Eyelids.—Sebaceous, Vascular, and other Tumors occur on the eyelids, and are to be treated as similar growths in other situations. The Chalazion, or common tarsal tumor, appears to origi- nate in a distended state of a Meibomian follicle, and often suppurates; the treatment consists in making an incision on the conjunctival surface and squeezing out the contents of the mass. Diseases of the Lachrymal Apparatus. Diseases of the Lachrymal Gland.—This organ maybe inflamed (Dacryo-adenitis), or may be the seat of various morbid growths. These affections are, however, rare, and their treatment presents no features calling for special comment. Fistula of the Lachrymal Gland may result from abscess or wound of this part; it may be treated by paring the edges and introducing a suture, by the application of caustic or the galvanic cautery, or by establishing a free communication with the con- junctival surface by the use of a seton, as has been successfully done by Bowman. Excision of the Lachrymal Gland is recommended by Laurence in cases of obstruction of the canaliculi, in which it is found impossible to restore their permeability ; the operation consists in making an incision below the upper and outer third of the orbital ridge, cautiously opening the orbit, seizing the gland with a double hobk, and carefully dissecting it from its attachments; hemorrhage having ceased, the wound' is closed with sutures. To avoid the risk of ptosis, which occasionally follows the operation, Mr. Laurence suggests that an internal incision should be made through the upper sinus of the palpebral conjunctiva, with an external division of the outer canthus; the substance of the lid would not thus be involved in the operation. Xerophthalmia, or Dryness of the Conjunctiva, from deficiency of the tears and mucous secretion which naturally lubricate the part, may be greatly alleviated by the local use of glycerine. Fig. 363. Symblepharon. DISEASES OF THE LACHRYMAL APPARATUS. 673 Epiphora, strictly speaking, signifies an excessive secretion of tears, but the term is often used as equivalent to Stillicidium Lacrymarum, which is the overflow from obstruction of the canaliculi or nasal duct. Excessive lachrymation may be a symptom of various inflammatory con- ditions of the eye, or may result from the presence of foreign bodies, entropion, etc., under which circumstances its treatment requires, of course, the removal of the cause to which the epiphora is due. Obstruction of the Canaliculi may occasionally be remedied by dilatation of the passage with probes of gradually increasing size, but it will usually be necessary to slit up the canal with a delicate grooved director and cataract knife, with scissors, or with a delicate beaked knife, which is perhaps the most convenient instrument. The same Fig. 364. ^---------------■------— 11 irT== Bowman's canaliculus knife. operation is required in cases of eversion or obliteration of the puncta lacrxjmalia. The lower canaliculus is the one usually slit, the incision being made towards the conjunctival surface, so as to open a passage for the tears. Reunion is to be prevented by the daily introduction of a probe, by the application of nitrate of silver, or by excising a small portion of the mucous membrane. If the punctum be indistinguishable, the lachrymal sac may be opened beneath the tendo oculi, and the cana- liculus slit from below upwards, as recommended by Bowman, or a bent director may be introduced through the upper punctum and brought around into the lower canaliculus, or vice versa, as advised by Streatfeild. Obstruction of the Nasal Duct usually results from thickening of its mucous lining, as the consequence of chronic inflammation. The treatment consists in effecting gradual dilatation by means of probes, introduced through the punctum, the canaliculus being, if necessary,. previously slit. In passing probes through the canaliculi and nasal duct, the position of the instrument is at first longitudinal, then trans- verse, and then somewhat longitudinal again, with a slight inclination inwards and backwards in correspondence with the anatomical disposi- tion of the parts, which must be borne in mind. Metal probes are com- monly to be preferred for dilation of the lachrymal passages, though bougies of the laminaria digitata have been successfully employed by several surgeons. Other modes of treatment are the introduction of a style through the slit canaliculus into the nasal duct, the instrument being allowed to remain several days (Bowman), the internal division of the strictured part by nicking the seat of obstruction in several directions with a suitable knife (Stilling), and the forcible dilatation or rupture of the stricture, as in Holt's method of treating stricture of the urethra (Herzenstein). The old plan of introducing a style through an external incision, is now generally abandoned. Inflammation of the Lachrymal Sac may be acute (Dacryocys- titis), or chronic (Blennorrhcea, Mucocele). The former variety of the affection is to be treated with warm fomentations, and an early punc- ture from the conjunctival surface, if suppuration occur; and the latter 43 674 DISEASES OF THE EYE. by the use of astringent lotions, by slitting the canaliculus and dilating any stricture that may be found, and by washing out the sac with astringent injections introduced by means of a canula and syringe. In obstinate cases it maybe necessarvto excise the anterior wall of the sac (Lawson), or to obliterate the sac itself by the use of caustic or the gal- vanic cautery, applied through an incision, which is best made, as advised by Agnew, of New York, through the conjunctiva. Fistula Lacrymalis, or fistula of the lachrymal sac, may result from either acute or chronic inflammation of the part; the treatment con- sists in the removal of any obstruction to the natural course of the tears. and in the use of astringent injections; if necessary, the sinus may be laid open with a cataract knife, or its edges may be pared and a suture introduced. Diseases of the Orbit. Abscess of the Orbit may be acute or chronic; the symptoms of the former are those of abscess in general—deep-seated and constantly increasing pain, aggravated by motion or pressure, with a swollen, glazed, and oedematous state of the eyelids (particularly the upper), chemosis of the conjunctiva, and protrusion of the eye, the displacement being usu- ally somewhat downwards and inwards, as well as forwards. Impairment of sight results from pressure on and stretching of the optic nerve. Fluctuation is finally developed, and pointing usually occurs below the inner portion of the supra-orbital ridge. The symptoms of chronic abscess are much less distinctive, the diagnosis from encephaloid or other soft tumor being often impossible without the aid of the exploring needle. The treatment of either form of abscess consists in making an incision with a knife introduced flatwise at the point of greatest fluctua- tion, the subsequent management of the case being conducted on gene- ral principles. If a sinus persist after the evacuation of an orbital abscess, it may be stimulated to heal by the use of astringent injections. Periostitis, Caries, and Necrosis of the orbital walls are occa- sionally observed, usually as the result of constitutional syphilis. The treatment of these affections presents no features requiring special com- ment. Tumors of the Orbit.—Various forms of morbid growth are met with in this region, as the cystic, cartilaginous, osseous, fibrous, recur- rent, vascular, and cancerous. The treatment of these different affec- tions has been sufficiently considered in Chapter XXVI.; in dealing with the non-malignant growths, the eyeball should, if uninvolved, be, if pos- sible, allowed to remain ; but in the case of cancerous tumors of the orbit, it must commonly be removed, to allow space for complete excision of the morbid growth. Lawson recommends that after the removal of a malignant tumor from the orbit, lint spread with a paste of chloride of zinc should be carefully applied to the whole surface from which the growth sprang. Aneurisms of the Orbit.—The orbit may be the seat of ordinary aneurism, affecting the ophthalmic artery, of traumatic aneurism, or of aneurism by anastomosis. In each of these conditions there is exoph- thalmos, with more or less pulsation; while vascular protrusion without DISEASES OF THE AURICLE. 675 pulsation may result from venous obstruction, or from hypertrophy and hyperaemia of the adipose tissue of the orbit, as in the peculiar affection known as Exophthalmic Goitre, or Graves's, or Basedow's Disease.1 The surgical treatment of orbital aneurisms has already been considered. (See pages 520, 54T.) Distension of the Frontal Sinus by the accumulation of pent-up fluid, may, by forming a tumor at the upper and inner portion of the orbit, cause displacement of the eyeball, and entail great disfiguration on the patient. The treatment consists in evacuating the fluid by perfo- rating the thinned wall of the sinus and then establishing a free commu- nication with the nose, re-accumulation being prevented by the introduc- tion of a drainage tube. CHAPTER XXXYI. DISEASES OF THE EAR. As in dealing with Diseases of the Eye, it is not my intention in the following pages to discuss all those subjects which properly belong to the domain of aural surgery, but to refer only to those more common affections of the ear which the general practitioner may at any time be called upon to treat, and to describe those operations upon the organ of hearing which every surgeon should be competent to perform. Diseases op the Auricle. Malformations of the Auricle are occasionally met with, usually in conjunction with other congenital defects: if the malformation con- sist in contraction of the orifice of the meatus, from undue projection of the tragus or antitragus, advantage may be derived from the employ- ment of dilatation, or from excision of a portion of the cartilage. Con- genital closure of the meatus by an abnormal membrane, may be reme- died by an incision and the subsequent use of tents. Supernumerary auricles may be treated by excision, as in cases related by Birkett and Gross. Chronic Inflammation of the auricle, attended with great thick- ening, induration, itching, and tenderness, is chiefly observed in debili- tated women who have passed the middle period of life; it sometimes remains after the subsidence of an attack of erysipelas, and is commonly called chronic erysipelas of the ear. The treatment consists in the ap- plication of nitrate of silver or other astringent lotions, with the admin- istration of tonics, if required. The itching may be relieved by the local use of glycerine or collodion, and a silver tube may be fitted to the meatus, if this be permanently contracted. Chronic Eczema is another affection of the auricle which produces much annoyance; during the early stages, soothing applications are ' See an able paper by Dr. T. G. Morton, in Amer. Journ. of Med. Sciences for July, 1870. 676 DISEASES OF THE EAR. required, while at a later period advantage may be derived from the use of astringent lotions, or of slightly stimulating substances, such as the dilute citrine ointment. Tumors of the Auricle.—These may be cystic, fatty, fibrous, vas- cular, malignant, etc. Those particularly deserving mention are the blood-cyst, or Haematoma Auris, frequently observed in the insane, and the fibrous, cheloid-looking growth, which occasionally follows the use of ear-rings. The former affection requires the use of evaporating lotions during the acute stage, followed by the introduction of a seton; while the latter may be treated by excision, though the disease is apt to return. Diseases of the External Meatus. In some cases, it is possible to obtain a satisfactory view of the meatus by simply placing the patient in a good light and drawing the ear slightly backwards and upwards, while the tragus Fig. 365. is pressed in the opposite direction; it is usually necessary, however, to employ a speculum—the best instrument being, I think, that known as Toynbee's (Fig. 365), which may be used with either natural or artificial light: in the latter case, a reflector is required, and the same may be employed to utilize diffused day- light, which is usually preferable to the direct rays of the sun. The speculum may be made of polished silver or of vulcanite, the latter being probably the best material for the purpose. Accumulations of Cerumen or Ear Wax, mingled with short hairs and flakes of cuticle, are Toynbee's speculum, often met with, and are a frequent cause of deafness; the treatment consists in the removal of the hardened mass by syringing, as directed for foreign bodies in the ear (page 340), subsequent irritation being prevented by the application of a little olive oil or glycerine. Vegetable Parasites have been met with in the meatus, causing a constant accumulation of dense, white flakes of thickened cuticle; the treatment consists in frequent syringing with lead-water or a weak solu- tion of chlorinated lime. Follicular Abscesses occur in the meatus, constituting an ex- tremely painful and annoying affection; they are chiefly met with in those of debilitated constitution, and are said to be common among patients who suffer from styes of the eyelids. The treatment consists in the use of hot anodyne poultices or fomentations, irrigation with warm water, and evacuation of the pus as soon as its presence is detected, with the application of dilute citrine ointment to remove any induration which may be left. The preparations of iron may be administered internally, if a tendency to recurrence be observed. Catarrhal Inflammation of the external meatus, or Otorrhcea,is characterized by the presence of a muco-purulent discharge and is, according to Hinton, usually accompanied by a similar affection of the tympanic cavity. The treatment (as far as the meatus is concerned) AURAL POLYPI. 677 consists in syringing to insure cleanliness, followed by the use of astrin- gent lotions, or by the insufflation of powdered talc, which is particu- larly recommended by the above-named author. The administration of tonics is usually indicated by the constitutional condition of the patient. Counter-irritation over the region of the mastoid process may often be advantageously employed. Chronic Inflammation of the meatus often results in the produc- tion of a thickened state of the epidermis, with desquamation, and accu- mulation of flakes of cuticle. These must be removed by syringing, a solution of nitrate of silver, or the dilute citrine ointment, being subse- quently applied. Another occasional result of chronic inflammation is the development of a granular condition of the lower part of the meatus and membrana tympaui, somewhat analogous to granular lids. The treatment consists in the use of a solution of nitrate of silver, or in the insufflation of powdered alum or tannic acid. Polypi frequently arise from the deeper portions of the meatus, though, according to Hinton, their more common seat is the inner wall of the tympanum, whence they protrude, distending and finally ruptur- ing the tympanic membrane. Polypi of the ear occur under several forms, but in structure all appear to correspond with the fibro-cellular variety of tumor1 (p. 461). They produce, when large, a feeling of dis- Fig. 366. Wilde's snare. tension and irritation, and are sometimes attended with grave cerebral symptoms. The treatment, from whatever position they spring, consists Figs. 367, 368. Forceps for aural polypus. 1 Toynbee describes three varieties, the raspberry cellular, the flbro-cartilagi- nous, and the globular cellular polypus. 678 DISEASES OF THE EAR. in subduing any existing irritation by the use of lead lotions, counter- irritation, etc., removing the growth, and adopting means to prevent its recurrence. The removal of an aural polypus is usually best effected by means of the "snare" of Sir W. Wilde (Fig. 366), or by delicate forceps, of which two forms are exhibited in the annexed cuts (Figs. 367, 368). The more vascular polypi may be treated by caustic applications, such as the potassa cum calce, introduced through a glass speculum. If the snare be used, Hinton recommends that it should be armed with the gimp employed by anglers, instead of wire. After the removal of a polypus, its root must be treated with caustic applications, such as chromic acid, chloride of zinc, or potassa fusa — astringent lotions being at the same time used, and the Eustachian tube rendered per- vious, if occluded. If the membrana tympani be perforated, Hinton's plan of throwing a stream, by the syringe, from the meatus through to the fauces, should also be adopted. When a decided impression has been made upon the root of the polypus, astringents, such as weak solu- tions of nitrate of silver or lead-water, may be substituted for the caus- tics, or insufflations of powdered talc or alum may be employed. Tumors of the Meatus.-—Exostoses are occasionally met with in the walls of the meatus, and, if large, may encroach so much on the canal as to cause deafness. The treatment, in the early stage, consists in the application of the tincture of iodine to the surface of the growth and behind the ear, and by a perseverance in this plan the increase of the tumor may sometimes be arrested. At a later period, little can be done beyond preventing the accumulation of wax and cuticle by frequent syringing. Sebaceous or molluscous tumors result from the enlargement of sebaceous follicles, and when laid open are found to consist of a cyst-wall containing layers of epidermis. If neglected, they are apt to cause absorption of the bone, and grave or even fatal cerebral compli- cations. The treatment consists in laying open the cyst, evacuating its contents by syringing, and then drawing out the cyst-wall with forceps. Diseases op the Membrana Tympani. The Dermoid Lamina of the membrana tympani may be the sub- ject of simple acute, chronic, or catarrhal inflammation, these affections often accompanying similar conditions of the external meatus. Acute inflammation of the dermoid lamina can usually be made to terminate in resolution, by the use of local depletion, hot fomentations, and fre- quent syringing with warm water. Chronic inflammation often causes an accumulation of epidermis, requiring the employment of the syringe, and perhaps the use of an astringent lotion, with counter-irritation over the region of the mastoid process. The catarrhal form of inflammation is of a more serious character, being apt to terminate in the formation of granulations, or even of polypi—or in ulceration, which may extend to the fibrous laminae. The treatment is the same as for the ordinary chronic inflammation. Tonics, especially iron, quinia, and cod-liver oil, are usually indicated by the constitutional condition of the patient. The Fibrous Laminae are also subject to inflammation of an acute or chronic character, very often associated with a gouty or rheumatic state of the system. Chronic inflammation often leads to a dense and rigid condition of the membrane of the tympanum, which may be recognized through the speculum when air is forced into the tympanic cavity, and DISEASES OF THE MEMBRANA TYMPANI. 679 which is not usually accompanied with pain, but with an annoying tinnitus' or ringing in the ears, and with deafness—the latter symptom, howeven being in all probability due rather to the state of the tympanic cavity itself, than to that of its membrane. Toynbee recommends for this rigidity of the membrana tympani, the application of nitrate of silver 0ss-j to fjj), and Hinton speaks highly of a combination of ether or tincture of camphor, with opium and glycerine, as a means of relieving the tinnitus, when all inflammatory symptoms have subsided. In the opposite con- dition, viz. relaxation of the 'membrana tympani (which may result from inflammation, or from simple atrophy), temporary benefit may often be derived from inflating the cavity of the tympanum; and in some in- stances, advantage may be obtained from the use of astringent lotions with counter-irritation over the mastoid process, or from the application of an artificial membrane. In most cases, however, the treatment must be principally directed to the condition of the Eustachian tube and cavity of the tympanum—the former requiring dilatation by the use of the catheter, while the latter may require syringing, after previous in- cision of its membrane. Ulceration of the dermoid and fibrous laminae of the membrana tympani may persist for many years, being accom- panied with a muco-purulent discharge, and constituting one of the varieties of Otorrhcea. If the ulceration extend only to, but not through the mucous lamina, the latter appears at the base of a depression corre- sponding to the ulcer, and protrudes when the tympanum is inflated. If the mucous lamina be also involved, perforation is apt to occur. The treatment consists in the application of a weak solution of nitrate of silver, with the administration of suitable constitutional remedies, and the adaptation of an artificial membrana tympani in case of perforation. Calcareous Deposits in the fibrous laminae of the membrana tym- pani, may assume a concentric or a radiating arrangement, corresponding to the particular lamina involved. They cdnsist chiefly of phosphate of lime, and do not appear to interfere particularly with the power of hearing, except when complicated with anchylosis of the stapes to the fenestra ovalis, or other deep-seated disease. No treatment is likely to prove of much service, but a trial maybe given to the plan recommended by Toynbee, which consists in employing counter-irritation over the mastoid process, and in administering alteratives. Incision of the Membrana Tympani, or even Excision of a portion of this structure, is occasionally of service in the management of the various affections which have been described. The chief objection to the treatment by incision, is the temporary nature of the improvement, owing to the rapid healing of the wound; to obviate this, the surgeon may resort to the insertion into the cut, of a grooved vulcanite ring, provided with a silken thread to prevent its falling into the tympanum, as suggested by A. Politzer. Excision may be performed with an in- strument specially devised for the purpose by Fabrizzi, or more con- veniently with a simple double-edged knife, and delicate forceps. In some cases, incision appears to act by diminishing intra-tympanic tension, as shown by the gaping of the wound; but in other instances uo such effect is observed, though the resulting benefit may be equally great. Wreden, of St. Petersburg, recommends Excision of a Portion of the Malleus with the adjacent membrane, and has devised an instrument hy which the operation can be accomplished. 680 DISEASES OF THE EAR. Perforation of the Membrana Tympani may result from trau- matic causes, from ulceration of this structure itself, or as a consequence of intra-tympanic inflamma- Fig. 369. tion—the mucus which accumu- lates within the cavity gradually making its way through the mem- brane, and being discharged ex- ternally. The perforation may be commonly seen by means of the speculum, and the patient can, if the Eustachian tube be pervious, blow air through the meatus by making a forcible expiration, with the mouth and nostrils closed; or the surgeon may do the same by the use of the Eustachian catheter, or by Politzer's method, which con- sists in blowing air through the nostril into the pharynx while the patient swallows—the Eu- stachian tube opening during this act, and the air thus readily entering the tympanum. The surgeon may simply blow through a flexible tube; or, which is preferable, may use an India-rubber bag provided with a well-fitting nozzle. The treat- ment of perforation of the mem- bran'a tympani should be di- rected, in the first place, to an attempt to secure closure of the opening, which may sometimes be effected by the application of nitrate of silver or other as- tringent lotions, the insufflation of talc, etc. If, as often happens, the perforation is prevented from healing by the accumulation of inspissated mucus in the tympanum, the surgeon may resort to Hinton's plan of washing out this cavity, first with alkaline, and afterwards with as- tringent solutions, injected by the Fig. 370. syringe from the meatus through to the fauces. The nozzle of the instrument should be attached to a flexible tube which closely fits the meatus. By these means the parts may usually be restored to a healthy condition, when, even if the per- foration persist, the hearing may be but little affected; if such is not the case, there is reason to suspect some loosening of the connections of the ossicula, and under such cir- cumstances great benefit may be derived from the adaptation of an artificial membrana tympani, which may consist simply of a plug of cotton-wool dipped in glycerine, or in an India-rubber disk or globe, as Politzer's method of inflating the tympanum. Toynbee's artificial membrana tympani. DISEASES OF THE EUSTACHIAN TUBE. 681 recommended by Toynbee. If the latter contrivance is used, a thread or delicate silver wire should be attached, in order to facilitate removal. Diseases of the Eustachian Tube. It has been shown by Toynbee and Jago, that the Eustachian tube is, contrary to what was formerly supposed, closed when in its ordinary condition, and opened in the act of swallowing. In some cases, how- ever, the Eustachian tube is more or less permanently open, giving rise to an abnormal sensibility to sounds originating in the patient's own throat, with a sense of discomfort in the fauces. This condition may arise in the course of catarrhal affections, and usually subsides sponta- neously. Obstruction of the Eustachian Tube may be due to a thickening of the mucous membrane of the fauces or tympanum, to a relaxed state of the fauces, to contraction of the bony walls of the tube itself, to the presence of inflammatory adhesions, to accumulations of mucus, etc. The diagnosis may be made by inspecting the membrana tympani through the speculum (the membrane, in cases of Eustachian obstruction, appear- ing concave, dull, and somewhat opaque), and by means of the otoscope, Fig. 371. Application of the otoscope. an instrument consisting of a flexible tube, one end of which is adapted to the patient's and the other to the surgeon's ear. If, when the otoscope is adjusted, the patient makes a forcible expiration (the mouth and nos- trils being closed), the air, if the Eustachian tube be pervious, rushes into the tympanum, producing a sound which is distinctly audible to the surgeon. This sound, in a normal state, has been compared to that of a bullet striking a target at a great distance; it undergoes various modi- fications as the result of disease, being of a creaking or whistling char- acter if the lining membrane of the tube be thickened, and gurgling if the tube or tympanum contain fluid. In cases of complete obstruction the sound is of course absent. 682 DISEASES OF THE EAR. Obstruction from Thickening of the Mucous Membrane of the Fauces, is a frequent cause of deafness in scrofulous children, and is often accom- panied with enlargement of the tonsils. The treatment consists in restoring the throat to a healthy condition by suitable means, such as syringing solutions of carbonate of soda or of common salt through the nostrils, applying nitrate of silver to the thickened membrane, or blow- ing powdered alum through a curved tube into the angle behind the tonsil, with the employment of counter-irritation around the throat, the use of tonics, etc. The cavity of the tympanum should be also inflated "by Politzer's method (p. 680), this procedure being repeated as often as necessary. Obstruction from Relaxation of the Fauces occurs in adults, usually in those who are otherwise debilitated, and is said to be often due to ex- cess in smoking. The treatment consists in the adoption of means to improve the general health, with the local use of stimulating and astrin- gent applications. Obstruction from Stricture of the Bony Walls of the Eustachian Tube, or from Inflammatory Adhesions, would require for recognition the intro- duction of an elastic sound as a means of exploration, but little or no benefit could be expected from treatment. Eustachian Catheter.—In cases of obstinate Eustachian obstruc- tion, the operation of catheterization is often required. This is effected simply by passing the catheter, its point being turned downwards, along the floor of the nostril, until the posterior pharyngeal wall is reached, and then drawing the instrument about half an inch forwards while its point is turned gently outwards and upwards, when it will usually Fig. 372. Catheter for the Eustachian tube. readily enter the orifice of the Eustachian tube. The tympanum may now be inflated, when the surgeon can recognize the passage of air by means of the otoscope, or if inflation be impossible, dilatation of the tube may be attempted by means of bougies1 of whalebone or laminaria digi- tata, introduced through the catheter, aided perhaps by the use of alka- line or astringent solutions injected through a smaller flexible tube. When inflation can at last be effected, a few drops of a weak solution of nitrate of silver may be syringed into the tympanum. Diseases of the Cavity of the Tympanum. The diagnosis between deafness from tympanic lesions and nervous deafness, may commonly be made by the use of the tuning-fork, the fol- lowing rules for the employment of which are given by Hinton:— 1. In a normal state a tuning-fork is heard before the meatus after it has ceased to be heard on the vertex. 1 The dilatation of the Eustachian tube by the introduction of bougies is an ope- ration which is by no means free from risk; it should therefore be looked upon as a last resort, and should be practised with great caution. DISEASES OF THE CAVITY OF THE TYMPANUM. 683 2. When placed on the vertex, it is heard more plainly when the ex- ternal meatus is closed. 3. Consequently, when one meatus alone is closed, the tuning-fork is heard most plainly in the closed ear. Hence, 4. In cases of one-sided deafness, if the tuning-fork, when placed on the vertex, is heard most plainly in the deaf, or more deaf ear, the cause is seated in the conducting apparatus ; if it is heard loudest in the better ear, the cause is probably in some part of the nervous apparatus. 5. If, on closing the meatus, the tuning-fork is heard decidedly louder, there is no considerable impediment to the passage of sound through the tympanum. 6. If the tuning-fork is heard longer on the vertex than when placed close before the meatus, the cause of the deafness is in the conducting media. 7. However imperfectly the tuning-fork may be heard when placed on the vertex, it gives reason for suspecting only, and is not proof of, a nerve affection. Inflammation of the Mucous Membrane of the Tympanum is not unfrequently present, in its milder forms, in cases of common "cold" and sorethroat, giving rise to a deeply-seated pain in the ear, with buzzing noises, and slight impairment of hearing; inflation of the tympanum is painful, and an inspection with the speculum shows the membrana tympani to be more vascular than in the normal state. This affection, which Constitutes the ordinary ear-ache of children, is very apt to recur at intervals, giving rise ultimately to a thickened and rigid con- dition of the mucous lining of the tympanum, and thus leading to per- manent deafness. The treatment consists in the use of soothing appli- cations (such as warm olive oil and laudanum) to the meatus, with coun- ter-irritation over the region of the mastoid process, during the attacks: —followed by cold sponging, friction, and attention to the state of the throat during the intervals, so as to obviate recurrence. Hinton recom- mends that the tympanum should be inflated with warm vapor every evening for a few days after each attack. In its severer forms, inflammation of the mucous lining of the tympa- num is an extremely painful affection, attended with much constitutional disturbance, and sometimes with delirium. The symptoms of the milder form of the disease are all aggravated, and there is, besides, often great tenderness over the mastoid process, and in front of the ear. The affec- tion may terminate in resolution, or in discharge through the Eustachian tube, or through the membrane of the tympanum; caries and consequent intra-cranial disease, and paralysis of the facial nerve, are occasionally met with as sequelae of this affection. The treatment consists in the use of local depletion, with the application of hot anodyne poultices or fomentations, laxatives and diaphoretics being at the same time admin- istered internally. Toynbee recommends gargling the throat with hot water, and the use of mercury with opium. Druitt advises an incision over the mastoid process, and the subsequent conversion of a part of the cut into an issue. If the case terminate in resolution, or in dis- charge through the Eustachian tube, the hearing will probably be gra- dually restored, and recovery may be promoted by the employment of counter-irritation, inflation of the tympanum with dilute vapor of iodine, etc., and syringing alkaline lotions through the nose. If the mem- brana tympani have given way, hearing may still be restored, and advantage may be derived in these cases from washing out the ear, 684 DISEASES OF THE EAR. by syringing alkaline and astringent lotions from the meatus through to the fauces, in the way already described (p. 680). If the inflammation spread from the ear to the adjacent cranial bones, coma or death may follow. Accumulation of Mucus -within the Tympanum is, according to Hinton, a frequent cause of deafness, and when occurring in children may give rise to convulsions, or, as in the otorrhoea of scarlet fever, etc., may even prove the immediate cause of death. The patient has very frequently the sensation of something being present in the ear and moving with the movements of the head ; this feeling sometimes induces a habit of giving the head a peculiar shake, as if to shake the offending body out of the way; the hearing is often improved by holding the head down on the affected side. The membrane of the tympanum, as seen through the speculum, appears abnormally white, either generally or in parts. The treatment consists in incising the membrana tympani, usually at its upper and posterior part, thus converting the case into one of perforation of the membrane, and then daily washing out the cavity as directed in speaking of that affection (p. 680). The incision usually heals in four or five days, and the operation may be repeated, if necessary, in the course of a fortnight. As there is no doubt that convulsions in children are sometimes connected with, and probably dependent upon, the presence of mucus in the tympanum, Hinton judiciously advises that in cases of cerebral irritation in the young, the ears should be examined as regularly as the gums; a habit of rubbing the ears is almost as constant a symp- tom of this condition, as that of rubbing the gums is of the irritation of teething, and should receive at least as much attention. In these cases, besides incising the membrana tympani, counter-irritation by iodine may be properly applied around the ear, while the iodide of iron may be ad- ministered internally. The state of the throat should also be looked to. Membranous Bands are not unfrequently found in the tympanum, binding together the ossicula, or connecting them with the walls of the cavity itself. In many instances these bands consist merely of dried mucus, but in other cases they result from the organization of inflam- matory lymph. They do not materially interfere with the function of the part unless so situated as to restrain the motions of the ossicula. The presence of these bands may be suspected if the membrana tympani appear irregularly concave, the Eus- tachian tube being pervious; but the most satisfactory means of diagnosis is the use of Siegle'spneumatic speculum, an instrument consisting of a box pro- vided at one end with a magnifying lens, and at the other with an ear speculum which is made to fit the meatus closely by means of an India-rubber tube; another tube passes off from the box and is furnished with a mouth-piece, so that the surgeon can by suction make the membrana tympani move backwards and forwards, while at the same time he can, by looking through the lens, observe the effect produced. The treat- s'iegie's pneumatic speculum. ment consists in inflating the tympanum, Fig. 373. INFLAMMATION OF THE MASTOID CELLS. 685 by which means the bands may sometimes be ruptured, in injecting solvent fluids, such as a solution of carbonate of soda (gr. x-f|j) through the Eustachian catheter, in the use of an ear-trumpet, etc. Rigidity of the Mucous Lining of the Tympanum may result from the effect of chronic inflammation, or may be due to the gradual drying of accumulated mucus. The meatus in these cases usually con- tains little or no wax, and the membrane of the tympanum is normal, or slightly opaque, and is occasionally the seat of calcareous deposits. There is tinnitus, but no pain, and the air enters the Eustachian tube naturally, or with a flapping sound. There is not much absolute deaf- ness, the patient hearing single sounds well enough, but failing to hear when a variety of sounds succeed each other in rapid succession—it being thus the adapting power, or, to borrow a word from ophthalmic surgery, the accommodation of the ear which is chiefly interfered with. The patient may hear better when exposed to a noise, as the rattling of a railway train, than when in a still room. The treatment recommended by Toynbee, consists in the application of a strong solution of nitrate of silver (3ss-5j to f^j) to the meatus, and of a weaker solution (gr. vj-f^j) to the membrana tympani, with leeches below and counter-irritation behind the ear, and the internal ex- hibition of mercury. Hinton relies chiefly on the injection of medicated liquids into the tympanum, the substances which he prefers being car- bonate of soda (gr. x-xx to fgj), muriate of ammonia (gr. x-f3j) with % grain of corrosive sublimate, and sulphate of zinc (gr. ij-vj to 1*3j)- A few drops of the solution may be introduced by the Eustachian catheter, aud blown into the tympanum by means of an' elastic bag; or the patient may make the application himself by Gruber's plan, which con- sists in syringing about two fluidrachms of the solution through the nos- tril into the pharynx, and inclining the head to the affected side so as to bring the remedy into contact with the Eustachian orifice; by then inflating the tympanum without swallowing, a small quantity is forced into the cavity. Before resorting to either of these methods, the throat should be cleared of mucus by syringing an alkaline lotion through the nostrils. Applications may be made directly to the tympanum (as ad- vised by Weber) by means of a flexible tube passed through the Eusta- chian catheter. Anchylosis of the Stapes to the Fenestra Ovalis presents symptoms very analogous to those of the affection just described. The treatment usually recommended consists in the administration of altera- tives, with the use of counter-irritation, but the results are not very satis- factory. Exostoses are sometimes developed on the ossicula, which may also be the seat of fracture, dislocation, caries, etc. The artificial mem- brana tympani is of use in some of these cases. Inflammation of the Mastoid Cells may accompany a similar condition of the tympanum, or may exist independently. If neglected, caries or necrosis may occur, followed, perhaps, by grave or even fatal cerebral complications. The most important point in the treatment, is to make a free and early incision down to the bone in a longitudinal direction, half an inch behind the ear and extending the whole length of the mas- toid process. If the symptoms persist, the mastoid process itself should be perforated with a small trephine, or other suitable instrument, so as to lay open its cells and allow the free escape of matter. A seton to the nucha may also be of service in some cases. 686 DISEASES OF THE EAR. Nervous Deafness.—The researches of modern aural surgeons have shown that most of the cases formerly classed under this head, are really instances of some of the affections of the conducting media, which have already been described. Still, there are cases in which the auditory apparatus itself is at fault, and deafness may result from "con- cussion" or apoplexy of the auditory nerve, from cerebral disease, from syphilis, etc., while it may also occur as a reflex phenomenon, depend- ent on disease of the fifth nerve, or upon the irritation produced by intestinal parasites—or even as a "functional" affection, the result of anaemia and general nervous exhaustion. Treatment cannot be ex- pected to accomplish much in cases of organic lesion of the brain or auditory nerve, but when the deafness is dependent on syphilis, or is a reflex or functional condition, the iodide of potassium, anthelmintics, or such other remedies should be given as may seem to be indicated by the particular circumstances of the case. Ear-trumpets will often prove of service. Paralysis of the Tympanic Muscles is an annoying affection, interfering rather with the accommodation of the ear than with the ab- solute power of hearing, Galvanism might be properly tried in these cases. Neuralgia of the ear is rare, except in cases of caries or other dis- ease of the teeth. The treatment presents no peculiar features. Tinnitus Aurium sometimes exists as an isolated symptom, and cannot be referred to any discoverable disease. In such cases, Hinton recommends muriate of ammonia, in 20-grain doses three times a day, with perhaps the injection of a few drops of a solution of atropia (gr. jM"3J) int° tne cavity of the tympanum. Fatal Consequences of Inflammatory Affections of the Ear. —Inflammation attacking any of the deeper-seated structures of the ear, may occasionally lead to a fatal result by implication of the brain or lateral sinus—the immediate cause of death being, in the former case, meningitis or cerebral abscess, and, in the latter, thrombosis and in- flammation of the lateral sinus, giving rise to secondary pneumonia or even sloughing of the lung. Nothing probably can be done to avert the fatal issue when these lesions are actually present, but much can be accomplished in the way of preventive treatment at the first onset of threatening symptoms. Rest in bed, local depletion followed by counter- irritation, the use of warm fomentations and syringing, with the internal administration of cathartics and the cautious employment of calomel and opium, may all be of service; but the most important point is to secure a free exit for discharge, by removing obstructions, incising the membrana tympani, trephining the mastoid cells, etc. Medullary Cancer is occasionally observed in the ear (usually ori- ginating in the mucous membrane of the tympanum), and has been mis- taken for polypus. Palliative treatment only is admissible in these cases, complete extirpation being out of the question, and a partial operation worse than useless. DISEASES OF THE NOSE. 687 CHAPTEE XXXYII. Fig. 374. DISEASES OF THE FACE AND NECK. Diseases of the Xose. Lipoma is a hypertrophied condition of the cutaneous and subjacent cellular tissues of the nose, forming a red or purple, soft, lobulated mass, and causing great deformity. Anatomically, the disease should be classed as a fibro-cellular outgrowth. The sebaceous follicles of the nose often appear to be the parts principally involved. The treatment consists in ex- cision, the only point in the operation requiring any particular attention being not to lay open the nostril; the occurrence of this accident may be avoid- ed by causing an assistant to distend the part with a forefinger, that he may warn the surgeon if the knife penetrate too deeply. There is usually a good deal of hemorrhage, which may be checked by the application of cold. Heal- ing takes place by granu- lation and cicatrization. Lipoma. Imperforate Nostril.—This is occasionally, though rarely, met with as a congenital deformity ; if the obstruction be not too deeply seated, it may be removed by incision and subsequent dilatation with bougies. Epistaxis, or Hemorrhage from the Nostrils, is in many cases, par- ticularly when occurring in young persons, an effort of nature to relieve internal congestion, and may be looked upon under such circumstances as rather salutary than otherwise. It is, however, even when not in- jurious, often annoying and inconvenient, and an attempt should be therefore made to prevent its occurrence, in persons liable to it, by ad- ministering laxatives to relieve visceral congestion, by attention to the menstrual function, etc. In most cases, no further local treatment will he required than the application of cold to the nucha and forehead, but in some instances, if the flow of blood be profuse and exhausting, more active measures must be adopted. The patient should, under these 688 DISEASES OF THE FACE AND NECK. circumstances, be kept quiet in bed, with the head and shoulders slightly elevated, the cold applications should be continued, and opium and gallic acid, or the acetate of lead, may be administered internally. An efficient local remedy is the muriated tincture of iron, which may be applied to the mucous surface of the nostril by means of a camel's-hair brush. As a last resort, it may be necessary to plug the nostrils; the anterior nares may be readily plugged with a piece of compressed sponge, or with a pledget of lint, introduced with slender forceps, and having a ligature attached to facilitate withdrawal; if the blood continues to Fig. 375. Plugging the nostrils with Bellocq's sound. flow backwards into the pharynx, the posterior nares must also be plugged—this being most conveniently accomplished by the use of Bel- locq's sound, though, in the absence of this instrument, a double canula, or even a flexible catheter, may be used instead. The sound, previously armed with a strong ligature, is passed along the floor of the nostril, till it reaches the pharynx, when, the spring being protruded, the liga- ture may easily be brought out of the mouth, and furnished with a plug of the required size. By withdrawing the instrument, the plug is now brought into position, the end of the ligature being allowed to hangout of the mouth to facilitate removal. Instead of merely plugging the posterior nares, it is often better to apply pressure to the whole floor of the nostril from behind forwards; this may readily be done by attach- ing to the ligature a series of moderate-sized plugs, which, as the instru- ment is withdrawn, are successively brought into position, or by using an instrument, described by Closset under the name of rhineurynter, which consists' of a bag or sac, to be inflated after introduction, like the colpeurynter of the accoucheur. Chronic Inflammation with Thickening of the Schneide- rian Membrane is not infrequent, especially among strumous children, though by no means confined to them. I have observed it in an adult, as the result of the mechanical congestion produced by constant vomit- ing during pregnancy. The portion of mucous membrane which lines RHINORRHCEA OR OZ.ENA. 689 the turbinated bones, is that which is chiefly affected, appearing as a projecting ridge, or mass, of a red color and velvety appearance, some- times covered with muco-purulent secretion. Respiration is obstructed, particularly in wet weather, the tone of the voice being altered, and a constant disposition to snuffling induced. The treatment consists in the application of astringents, frequent syringing with cold water, and (in a strumous patient) the administration of cod-liver oil, iodide of iron, etc. No operative treatment, except perhaps scarification, is admissible. Change of air is often beneficial. Rhinorrhcea or Ozaena (the latter term referring to the fetid nature of the discharge) signifies a flow of muco-purulent matter from the nos- trils, one or both of which may be affected. This condition is a symp- tom rather than a disease, and may be due to a simple catarrhal affection, to the presence of a foreign body, to scrofulous inflammation of the various nasal tissues, or to constitutional syphilis. In children it some- times appears to be a reflex condition, dependent upon the irritation of teething. Scrofulous and syphilitic ozaena are often accompanied by ulceration, which may lead to caries or necrosis of the nasal bones, pro- ducing eventually great deformity. In the treatment of ozaena, such constitutional means must be adopted as are indicated by the general condition of the patient; before resort- ing to local treatment, it may be necessary to explore the nasal cavity, the anterior portion of which may be readily inspected by means of a small bivalve speculum, but the deeper portions of which can only be ex- amined by the cautious introduction of a female catheter, or Bellocq's sound, and by a resort to Rhinoscopy. This mode of inspection requires the use of a small mirror which can be introduced into the pharynx, and of a reflector, if artificial light is to be employed. The ordinary mirror employed in laryngoscopy will commonly answer every purpose, or the ingenious instrument devised by Dr. Simrock, of New York, may be used instead: this apparatus is provided with a movable spatula by which the soft palate may be raised, so as not to obstruct the surgeon's view. The most important point in the local treatment of ozaena is to secure cleanliness, by the use of a solution of the permanganate of potassa, or other disinfectant lotion, which may be applied with a large syringe, or, better, by means of Thudichum's douche. This consists of a reservoir containing the disinfectant, which is placed a little above the level of the patient's head, and is provided with a flexible tube which is intro- duced into the nostril. If the patient be now directed to breathe through the mouth, the soft palate closes the communication between the nose and pharynx, and a continuous stream is made to flow by atmospheric pressure into one nostril and out by the other. The force of the stream can be regulated by varying the elevation of the reservoir. If one nos- tril only be affected, the stream should pass from the healthy to the diseased side; while if both be affected, the direction of the stream may be alternated from one to the other. Any ulcers that are detected should be touched with nitrate of silver, and, to prevent the formation of scabs, dilute citrine ointment may be applied at night by means of a camel's-hair brush. If necrosis occur, the sequestra should be removed as soon as they have become loose. Adenoid Vegetations.—This name is given by Meyer, of Copenha- gen, to certain growths met with in the naso-pharyngeal cavity, which appear to be identical in structure with the closed follicles of the mucous 44 690 DISEASES OF THE FACE AND NECK. membrane from which they arise. The most prominent symptom is an interference with speech, the patient being unable to pronounce the nasal consonants m and n, and the voice being deficient in resonance; breathing through the nose is prevented, and the mouth is consequently kept open; there is, moreover, a feeling of obstruction at the back of the throat, with a copious flow of mucus, and sometimes slight hemorrhage; the patient frequently is deaf, and often suffers from otorrhoea or an- noying tinnitus. The growths themselves have a velvety appearance, and a deep red or sometimes yellowish hue. The diagnosis may be made by the aid of rhinoscopy, or by digital examination. The treatment con- sists in cauterization with nitrate of silver, or in excision; this may be done with a knife, composed of a ring-shaped blade with a slender shaft, and the operation should be followed by injections of saline or alkaline solutions. Polypi.—The term polypus has been applied to a variety of nasal tumors, which have in common merely their locality and their peduncu- lated character. 1. The ordinary Soft, Mucous, or Gelatinous Nasal Polypus belongs to the fibro-cellular variety of tumor (myxoma), and may spring from any part of the nasal cavity except the septum, though its more usual point of origin is one of the turbinated bones; occasionally polypi pro- ject into the nose from the frontal sinuses or antrum. These growths are usually multiple, of a soft semi-gelatinous consistence, and of a grayish-yellow color while in the nasal cavity, becoming shrivelled and brown when they protrude externally. They produce a feeling of dis- tension, and by obstructing the nostril impede respiration, alter the tone of the voice,, and give rise to a disagreeable habit of snuffling; all the symptoms are aggravated in damp weather. As the polypi grow, they press upon and displace the neighboring bones, producing great deform- ity, obstructing the nasal duct and thus causing a stillicidium of tears, anel eventually leading to caries of the turbinated bones. They some- times protrude into the pharynx, where they may be seen, or at least felt by the finger introduced behind the soft palate. Treatment.—Nasal polypi have occasionally been successfully treated by the use of astringent injections, but in the large majority of cases it is better to resort at once to an operation, which may consist in avulsion, in strangulation with the ligature, or in the use of the galvanic cautery; before attempting removal by any of these methods, the position of the pedicle of the tumor must be ascertained by exploration with a probe. (1.) Avulsion is effected with delicate but strong forceps madeforthe purpose, with serrated blades and a longitudinal groove so as to afford a firm grasp. The patient being seated, with the head thrown backwards, one blade of the forceps is introduced on either side of the neck of the tumor, and the latter is then torn away by a combined process of twisting and pulling. The hemorrhage, though free, is seldom trouble- some. Several polypi usually require removal, and the process has generally to be repeated at intervals. Insufflation of powdered alum has been recommended, with a view of preventing a recurrence of the disease. (2.) Ligation is particularly adapted to large polypi with a broad base, or to such as project into the pharynx ; the ligature, or, which Fergus- son prefers, a loop of silver wire, is passed along the floor of the nostril by means of a double canula (Fig. 376), and slipped around the tumor by the aid of the finger introduced behind the soft palate. The loop being then tightened, the mass may be left to slough, or may be cut through, as NASAL POLYPI. 691 by an ecraseur. Sometimes the polypus may be thus withdrawn through the nostril, but it will commonly fall backwards into the throat—when it should be instantly removed with forceps, lest by falling on the glottis it should cause suffocation. Fig. 376. Gooch's double canula. (3.) Certainly the neatest, as well as the most expeditious, way of re- moving nasal polypi, however, is by means of the platinum wire loop ecraseur and galvanic cautery. The loop being adjusted"around the base of the growth, is heated by connecting the instrument with the poles of the battery, when the mass is severed with a slight hissing noise: the ope- ration is both painless and bloodless. In some rare cases, in which the growth is very large, it is necessary, in order to expose the polypus suffi- ciently for the application of any means of removal, to lay open the cavity of the nose, by an incision along the junction of the ala with the cheek. 2. The Hard or Firm Polypi of the nose belong to the class of fibrous tumors; they usually spring from the superior turbinated bone, or poste- rior part of the septum, project into the pharynx, and occasionally find their way into the antrum, through the pterygo-maxillary fissure, or even into the orbit. On the other hand, fibrous or fibro-nucleated tumors, originating in the antrum, or from the periosteum at the base of the skull (Naso-pharyngeal Polypi), may project into the nostril, and be mistaken for intra-nasal tumors. Hence it may be, in some cases, an extremely difficult matter to decide, whether a particular growth should be called a tumor of the antrum, a nasal, or a naso-pharyngeal polypus. The fibrous polypus is usually single, very vascular, and is apt by dis- placing the walls of the nose to produce the deformity known as frog- face. The symptoms are pretty much those of the soft polypus, but the fibrous growth may be distinguished by its consistence, by its color (a deep modena red), by its tendency to bleed, and by its not possessing hygrometric properties. The treatment consists in avulsion or ligation, if the tumor be so small as to render these operations applicable, or in excision. In order to ex- pose the growth sufficiently to render its complete removal possible, the surgeon may lay open the cavity of the nose, removing with cutting pliers the nasal bone and the ascending process of the superior max- illary ; may turn down the nose over the mouth by means of a fl-shaped incision, as recommended by Oilier, the bridge of the nose being sawn through in the line of the external cut; may cut through the hard and soft palate, as advised by Nelaton ; or finally may resort to preliminary excision of the upper jaw. Either of the last-named operations may be employed in cases of true naso-pharyngeal polypus, tije latter, which appears to have been first practised by Flaubert in 1840,, feeing proba- bly the best procedure. The operation is certainly justifiable, in view of the hopeless nature of the affection which it, is designed to remedy (these cases, according to Nelaton, always proving fatal, either by hem- orrhage, or by the obstruction to breathing and swallowing), but should not be too lightly undertaken, as it may prove immediately fatal by 692 DISEASES OF THE FACE AND NECK. shock and profuse bleeding, or may cause death at a later period by pyaemia or consecutive inflammation of the brain. Osteo-plastic Resection of the Upper Jaw.—This is the name given by Langenbeck to an operation by which he has proposed to remove tumors lying behind the upper maxilla, without the extirpation of that bone. The necessary incisions being made, the saw is applied in such a way as to sever the connections of the jaw except at its nasal side, where it is left attached; it is then forcibly turned inwards, to be replaced after removal of the growth from behind it. Cheever, of Boston, has modified this operation by leaving the jaw attached by its palatal, instead of its nasal connections, and has thus operated twice successfully on the same individual. In another case, the same surgeon displaced simultaneously both upper maxillary bones downwards, to facilitate the removal of a naso-pharyngeal polypus occupying a median position, but the patient never fairly reacted from the operation, and died on the fifth day. Malignant Tumors of the nostrils usually belong to the Encepha- loid or Epitheliomatous varieties. They may be recognized by their rapid growth ; by their involving the neighboring bones, forming an elastic swelling; by their tendency to ulcerate and bleed; by the pain which attends their progress, and by the early implication of the neigh- boring lymphatic glands. In most cases, palliative treatment only is justifiable—complete extirpation being rarely practicable, while a partial removal could but aggravate the disease. If, however, the nature of the tumor be recognized at a very early period, and it appear that the growth actually originates in the nose, and does not (as sometimes happens) spring from the sphenoid or ethmoid cells, or even from within the skull, excision may perhaps be attempted by the following method. An incision carried from the inner angle of the eye downwards, alongside of the nose, lays open the nostril, while another incision across the cheek forms a flap which is to be dissected up. The superior maxilla is divided above its alveolar border, with saw and cutting pliers, a second section passing from the outer extremity of the first into the orbit; the nasal process and nasal bone are then similarly severed, when a considerable part of the upper maxillary may be removed; the tumor is then to be extirpated, bleeding being checked by the use of the actual cautery, and by stuffing the cavity with lint soaked in Monsel's solution, or in the muriated tinc- ture of iron. In cases not admitting of any attempt at excision, tracheotomy may sometimes be required to avert death from suffocation. Rhinolites, or Nasal Calculi, are sometimes met with in the cavity of the nostril, when they may be extracted with forceps, etc., as other foreign bodies; or they may be found beneath the mucous membrane, when they must be removed by careful dissection. They consist of phosphate and carbonate of lime, with magnesia and inspissated mucus, and are usually formed around a nucleus of some extraneous substance. Diseases of the Septum.—The septum nasi may be the seat of haematoma or thrombus (the result of injury), of abscess, or of cystic, or cartilaginous growths. The treatment of thrombus in this situation, consists in the adoption of measures to promote absorption, while, on the other hand, an early incision is indicated in case of abscess. Cystic tumors may be treated by cutting away a portion of the wall and apply- ing nitrate of silver, while the cartilaginous growths require excision by RHINOPLASTY. 693 the use of the knife and gouge. If perforation of the septum occur, in any of these affections, a plastic operation may be required to relieve the consequent deformity. Rhinoplasty. The whole, or a portion merely, of the nose may be destroyed by injury, by ulceration with or without caries or necrosis, or by the ravages of lupus, or of constitutional syphilis. Under these circumstances, various rhinoplastic operations may be employed to relieve the deformity, it being, however, an invariable rule, that no operation is to be performed until the destructive process has been completely and permanently arrested. Operation for Partial Restoration of Nose.—If the columna and part of the septum only be destroyed, a new columna should be fashioned from the upper lip, by making incisions on either side of the median line, so as to detach a strip of tissue about four lines wide and embracing the entire thickness of the lip; this strip, with its end suita- bly pared, is then turned upwards, and attached by means of the twisted suture to the lower surface of the nasal tip, which is previously fresh- ened for the purpose. The wound of the lip is united with harelip pins, a few narrow strips of adhesive plaster serving to support the new columna in its place until firm union has occurred. The size of the newly-formed nostrils must be maintained by the occasional introduc- tion of gutta-percha or silver tubes. If one ala of the nose only be deficient, the surgeon may, if the loss of tissue be but slight, take a flap from the upper part of the nose itself, and, freshening the edges of the border of the gap, attach the trans- planted portion by a few points of suture. Under other circumstances the flap may be taken from the cheek, or, if the loss of substance be very considerable, from the forehead; in the latter case, the pedicle of the flap must be twisted upon itself, and, to prevent its sloughing, a groove may be cut for its reception on the dorsum of the nose. When union of the transplanted flap is complete, the pedicle may be raised and cut away, the groove being then closed with sutures. Fistulous Openings through the nasal bones occasionally result from necrosis following scarlet fever, etc. Under such circumstances, a flap may be raised from the cheek or forehead, and attached by sutures to the freshened edges of the gap. Operations for Restoration of the Entire Nose.—The whole nose may be restored by several methods, those best known being desig- nated respectively as the Taliacotian and the Indian operation. 1. The Taliacotian Operation (so called from Taliacotius, a dis- tinguished Italian surgeon of the sixteenth century) consists in fashion- ing a nose from the fleshy tissues of the arm.1 A flap of sufficient size of skin and areolar tissue is first marked out, and partially detached, being left in this condition for a fortnight to become vascular and thickened by the process of granulation; the remains of the original nose are then pared, and the flap reduced to a proper shape and 1 It is scarcely necessary to say that the well-known Hudibrastic legend, which represents Taliacotius as making noses for his patients from the gluteal regions of other persons, is ufacetia merely, without any foundation in fact. 694 DISEASES OF THE FACE AND NECK. attached in its new position by numerous points of suture, the arm being approximated to the head, and fixed by a complicated system of bandages. After about ten days, when union may be supposed to be complete, the attachment of the flap to the arm is severed, and any trimming of the new organ which may be necessary effected. A columna is subsequently made from the upper lip. This process is so tedious and unsatisfactory, that it is seldom resorted to at the present day. It has been modified by Warren and others, by taking the flap from the forearm, and by shortening the time during which the head and arm are fastened together. Fig. 3^ 2. The Indian Method, which was introduced into England by Carpue, in 1814, is that which is now generally preferred. In this pro- cedure, a flap is taken from the forehead to form the greater part of the nose, the columna being subsequently made from the upper lip, though in some cases it is possible to derive the columna from the forehead also. The operation, as usually performed, may be divided into three stages. (1.) The first stage consists in the formation and attachment of the frontal flap. A piece of thin gutta-percha should be first modelled to the size and shape of the organ which it is desired to reconstruct, and then should be flattened out and laid upon the forehead so as to form a guide for the incisions, as shown in Fig. 377. As the flap—which may be taken from the middle or from either side of the forehead—is sure to shrink after its formation, a mar- gin of a quarter of an inch should be allowed on all sides of the pat- tern, and it is convenient to mark out the lines in which it is designed to cut, with the tincture of iodine. If the patient have a very high fore- head, the central portion of the flap may be prolonged so as to form a columna, but, under ordinary circum- stances, it is better to leave this part of the operation until a subsequent occasion. In raising the frontal flap, the surgeon should cut fairly down to the periosteum, beginning at the root, which should be made long, so that its circulation may not be interfered with when it is twisted. The flap should embrace all the soft tissues of the forehead down to the peri- osteum; and, indeed, it has been suggested that even this tissue should be included, in hope that osseous matter would be developed in the structure of the new nose. It does not appear, however, that such a result would be attended by any particular benefit, while the removal of the periosteum from the frontal bone exposes that part to the risk of necrosis. The flap, having been raised, is laid back upon a piece of wet lint, while the stump of the nose is pared and made ready for its recep- tion. The integument should be dissected up in such a way as to form a groove for the reception of the frontal flap, the edges of which should themselves be shaved so as to furnish two raw surfaces. All hemorrhage Rhinoplasty by Indian method. RHINOPLASTY. 695 Fig. 378. Tongue and groove suture. having been checked (if possible, without the use of ligatures), the flap is to be twisted upon its root and adjusted, being held in place by means of the interrupted suture, or, which is better, the "tongue and groove suture" employed by Prof. Pancoast, of this city, the mechanism of which can be readily un- derstood from the annexed diagram. The flap should be supported by gently intro- ducing beneath it a plug of oiled lint, or, if the columna have been made at the same time, two small plugs, one corresponding to each nostril. The extent of raw surface left upon the forehead may be diminished by the use of harelip pins. The patient is then put to bed in a warm room, with a fold of oiled lint over the part to preserve its temperature. The dressings should not be disturbed for several days, when it will usually be necessary to renew the plug, the sutures being allowed to remain until union has occurred. (2.) The second stage of the operation consists in the formation of a columna, if this has not already been done in the previous part of the proceeding. The columna may be formed from the upper lip in the way directed at page 693. (3.) The third and last stage consists in the separation of the root of the frontal flap, which may be done after an interval of about a month. A narrow bistoury being introduced beneath the twisted pedicle, is made to cut upwards, a wedge-shaped portion being removed, so as to make a smooth bridge to the nose; or, as recommended by Fergusson, the root of the newly-formed nose may itself be cut into a wedge and laid into an incision made for it in the forehead. The size of the nostrils must be maintained by the patient's wearing, for some months after the operation, tubes of gutta-percha or silver. Rhinoplasty is usually a very successful procedure, though failure may ensue from sloughing of the flaps, or from a recurrence of the disease which caused the original deformity. Hemorrhage on the ninth day occurred in one of Liston's cases, and death even has followed the pro- cedure, in the hands of so distinguished an operator as Dieffenbach. 3. Syme's Method.—The late Prof. Syme, of Edinburgh, devised an ingenious operation for the restoration of the nose, taking flaps of skin from the cheeks, as shown in the diagram, uniting them in the Fig. 379. middle by sutures, and fixing their outer edges to raw surfaces pre- viously prepared at a suitable dis- tance from the nostrils. 4. Wood's Method.—Mr. John Wood has restored the nose by taking lateral flaps from the cheeks, and uniting them over an inverted flap, derived from the upper lip and elongated by splitting its mu- cous from its cutaneous surface, from the root of the flap to, but not through, its free border. Diagram of Syme's rhinoplastic operation. 696 DISEASES OF THE FACE AND NECK. Operation for Depressed Nose.—The nose may be flat and sunken from disease of its bones and cartilages, without external ulceration. Fergusson, modifying a proceeding of Dieffenbach's, remedied a de- formity of this kind by separating the soft parts from the subjacent bones with a narrow knife, introduced within the nostril, and then bringing the whole organ forward by passing long steel-pointed silver needles across from cheek to cheek, and twisting them over a piece of perforated sole-leather. A columna was subsequently formed in the way already described. Diseases of the Frontal Sinuses. Distension of the Frontal Sinuses from an accumulation of the natural secretion of the part has already been referred to (see p. 675). These cavities may also be the seat of Abscess, or may give origin to Polypi, which subsequently descend into the nostrils. In either case the appli- cation of a trephine to the anterior wall of the sinus may be required. Diseases op the Cheeks. The cheeks may be the seat of Encysted Tumors, of Epitheliomatous or Cancerous Growths, of Rodent Ulcer, Lupus, Warts, Moles, etc. Encysted tumors may be removed by careful dissection, the operation being done from within the mouth if the cyst be nearer the mucous membrane than the skin. Cancer or epithelioma, occurring in this situation, if recog- nized at a very early period, might possibly admit of removal by ex- cision ; operative interference is, however, rarely justifiable in these cases, and would be positively contra-indicated by the existence of glandular implication. The treatment of rodent ulcer and lupus has already been considered (pp. 498, 499). If it be thought desirable to remove a wart or mole of doubtful nature from the face, this may be conveniently done by excision, the ensuing gap being closed, Fig. 380. as advised by Stokes, of Dub- lin, by what is known as Burow's operation. A triangle of skin embracing the growth having been dissected off, the base of the triangle is ex- tended to three times its length, and a similar triangle denuded in a reversed posi- tion, as shown in the diagram. Two flaps (a be and def) are thus marked out, which are to be dissected up and slid in op- posite directions, the edges Diagram of Burow's plastic operation; the triangles » ^ woun(J COmin°- readily ctdb and e/c aredissected off, theflaps abc and de/ loos- .. ° . j. ■_. ened, and the lines a d-ab and ef-cf brought together. together, and a linear Cicatrix resulting. Salivary Fistula usually results from accidental injury, but may occur as a consequence of operations on the cheeks, of the opening of abscesses, etc. For the treatment of this affection, see page 341. if diseases of the lips. 697 Diseases of the Lips. Contraction, or even Closure, of the Buccal Orifice is occa- sionally met with as a congenital affection, or may result from the cica- trization of a burn, etc. The deformity may be remedied by a plastic operation, the details of such a procedure varying, of course, with each particular case. As a rule, the skin and mucous membrane should be separately divided, in the direction in which it is meant to enlarge the mouth, the cut surfaces being then pared and the mucous membrane everted, so as to form a new prolabium. Hypertrophy of the Lips may depend upon the existence of the scrofulous diathesis, or may be caused by the irritation produced by fissures or ulcers. In some rare cases, hypertrophy exists without any apparent cause, and under such circumstances the surgeon may be called upon to retrench the pouting lips, which, however charming in poetry, may, in real life, by the resulting deformity, occasion their owners no little annoyance. The operation consists in making two transverse in- cisions, so as to remove a sufficient slip from the thickness of the part, and then approximating the edges with delicate sutures. A similar operation may be employed to relieve the deformity known as double lip. Tumors of the Lips.— Cystic tumors should be removed by careful dissection, mere excision of a part of the cyst wall not being sufficient in this locality. Erectile or vascular tumors of the lip may be treated by the applica- tion of caustic, by ligation, or by excision, according to the size of the growth and other circumstances of the case (see pages 520-522). Epithelioma.—The lower lip is the favorite seat of epithelioma, though the disease occasionally attacks the upper lip. Epithelioma (which in this situation constitutes the affection commonly known as cancer of the lip) may begin either as a wart, or as an indurated fissure. It is much commoner in men than in women, rarely occurs before fifty years of age, and appears in many instances to be predisposed to by the use of a short pipe. This affection is to be diagnosticated from rodent ulcer, lupus, and labial chancre. Rodent ulcer is as rare in the lower as epithelioma is in the upper lip, while chancre may be distinguished by the early implication of the neighboring lymphatic glands, and by the effect of antisyphilitic treatment, which should always be tried in a doubtful case. The diagnosis of epithelioma from Iujjus may occasionally be very difficult, and indeed a lupous ulcer may sometimes become the seat of a true epitheliomatous formation. Lupus is, however, essen- tially a local disease, and does not involve the neighboring glands. The prognosis of epithelioma in this situation, if left to itself, is extremely unfavorable, death eventually ensuing from pain and exhaustion, or, if the disease extend to the neck, perhaps from hemorrhage. On the other hand, if submitted to early and thorough extirpation, the chances of permanent recovery are more favorable than in almost any other case of malignant disease. The treatment consists in free excision with the knife, which is in almost all cases preferable to the application of caustics. As in some instances an ordinary ulcer may be so irritated by the presence of a broken tooth, or by the accumulation of tartar, as to assume an epithe- 698 DISEASES OF THE FACE AND NECK. liomatous appearance, any such sources of irritation should be first removed, when, if non-malignant, the ulcer will quickly heal under simple applications. Glandular implication does not necessarily forbid the excision of an epithelioma, provided that the affected glands are so sit- uated as to render their own removal possible. The operation must be modified according to the exigencies of each individual case: in most instances a simple V-shaped incision will be sufficient, an assistant compressing the lip and thus restraining the bleeding, while the surgeon Fig. 381. transfixes the part from within, and cuts from below upwards, taking care to remove with the diseased part a wide margin of healthy tissue; the cut surfaces are then brought together with harelip pins, one of which serves to acupress the labial artery, while the accurate adjustment of the prolabium is secured by the introduction of a delicate metal- lic suture. If a considerable ex- tent of the margin of the lip be involved, it maybe better simply to shave off the diseased portion, the mucous membrane being then brought forward, as ad- vised by Serres, and stitched to the skin, so as to form a new prolabium. The result of such an operation is shown in the annexed wood-cut, from the photograph of a patient lately under my care in the Episcopal Hospital. When a large portion of the lip has been removed, it may be necessary to close the gap by means of a cheilo-plastic operation. In all cases, advantage may be obtained by freely dissecting the lip from its attach- ments to the jaw. Cheiloplasty.—Various operations for restoration of the lower lip have been practised, the most generally applicable being, probably, those Formation of prolabium by Serres's method a patient in the Episcopal Hospital.) (From Fig. 382. Fi«:. 383. Serres's cheiloplastic operation, modified by Erichsen. recommended by Malgaigne, Serres, Mutter, Buchanan, and Syme. The operation practised by Chopart, consisted in the dissection of a quadri- lateral flap from beneath the chin, as far as the position of the hyoid bone, this flap being then brought forward and attached in the normal CHEILOPLASTY. 699 position of the lip, while the head was flexed on the chest to prevent tension. In Malgaigne's, and in Serres's operation (Figs. 382,383), as in the old Celsian method, the tissues of the cheek are utilized in forming the new lip, while in Mutter's and Buchanan's methods, the flaps are derived from the chin. The diseased mass is first excised by an elliptical cut, from the centre of which1 two incisions are carried downwards and outwards, the Fig. 384. Fiar. 385. Cheiloplasty by Buchanan's method. outline of the flaps being completed by two more incisions, parallel and corresponding to the branches of the first. These flaps are then raised and brought together in the median line by means of the twisted suture. Syme's method differs from the above in that the diseased structure is removed by means of a V-shaped incision, passing from the angles of the mouth to the apex of the chin, the flaps to supply the gap being taken from below the ramus of the jaw and curved at their lower Fig. 386. angle, so that by a little stretch- ing the whole wound may be accurately closed with sutures, and union by adhesion thus obtained. In both methods, the new prolabium is formed by Serres's plan of uniting the mucous and cutaneous edges of the original wound of excision. The result of Syme's method is shown in the annexed illus- tration from a patient of mine in the Episcopal Hospital. Restoration of a portion of the upper lip and of the angle of the mouth may be occasion- ally required to remedy the destructive effect of lupus. In a case of this kind at the Episcopal Hospital, I made a lozenge-shaped incision, as seen in Fig. 387, A B C D, when, by slitting the cheek transversely in the line B E, enough tissue was brought forward, as in Serres's operation, to close the gap in the lip, a ' The late Mr. Collis, of Dublin, modified this procedure by leaving a space between the oblique incisions, as in Teale's operation (Fig. 156), having found that the central pillar, on which the new lip was elevated, gave better support if made square and not angular. Result of cheiloplastic operation by Syme's method. (From a patient in the Episcopal Hospital.) 700 DISEASES OF THE FACE AND NECK. new prolabium above and below being formed by stitching together the skin and mucous membrane. The result is shown in Fig. 388. Fig. 387. Fig. 388. Diagram of operation for restoration of the Result of operation for restoration of the upper upper lip and angle of the mouth. lip and angle of the mouth. (From a patient in the Episcopal Hospital.) Harelip.—This term is used to signify a congenital deformity, con- sisting of one or more fissures in the upper lip, resulting from an arrest of development. The fissure in harelip does not occupy the median line, as in the lip of the animal which has given the disease its name, but corresponds to the line of junction between the intermaxillary and superior maxillary bones, this line of junction being itself often deficient. When one side only is involved, the harelip is said to be single; in double harelip the intermaxillary portion is often displaced forwards, and may even be attached to the base of the nose, giving a peculiar snout-like appearance. In these cases one or both fissures may extend into the nostril, and the affection is not unfrequently complicated with cleft palate. Age for Operation___As the deformity of harelip can only be remedied by operative interference, the age at which this should be attempted be- comes an important matter for consideration. Some surgeons have depre- cated early operations, and have even advised that all treatment should be postponed until adult life; while others, going to the opposite extreme, have operated within a few hours of birth. Although it is impossible to give any positive rule upon this subject, it may be said, in general terms, that from six weeks to three months after birth is, in most instances, the period during which this operation should be by preference per- formed. If, however, the deformity interfere with the nutrition of the child, by preventing suckling, or by allowing regurgitation of food, the surgeon should not hesitate to operate at a much earlier period. The popular opinion that operations in infants are apt to be followed by convulsions, though sanctioned by the authority of Sir Astley Cooper, is, according to Butcher and Fergusson, incorrect; shock was, however, the cause of death in two cases of harelip operated on by the last-named surgeon. HARELIP. 701 Operation.—The operation for harelip consists essentially in paring the edges of the fissure, approximating the cut surfaces, and adopting means to prevent tension during the process of healing. Ether or chlorc> form may be properly used if the patient be beyond the period of early infancy, but in children less than three or four months old, it is, I think, better, on the whole, to dispense with any anaesthetic. The child should be firmly wrapped in a sheet and held by an assistant, the surgeon sitting behind the patient, and fixing its head between his knees. The lip should be first freely separated from the upper jaw by dividing the fi-aenum and any membranous adhesions; an assistant then grasps the lip so as to control the labial artery, while the surgeon, seizing with toothed forceps the extremity of one side of the fissure, transfixes the part, near the summit of the gap, with a small straight bistoury, and cuts downwards in a slightly curvilinear direction, concave inwards, so as to insure sufficient length to the cicatrix when the parts are brought together. The opposite side of the fissure is Fig. 389. then pared in a similar manner, the incisions being evenly united above the summit of the Fig. 390. Operation for harelip. Right side of lip drawn down by spring-hook forceps; long, nar- row knife entered at angle; (lotted line shows direction of incision. Cheek compressor. gap, and extending far enough outwards to cut away the rounded edges of the prolabium at the base of the fissure. The cut surfaces are then accurately adjusted and held together with two or more harelip pins, the lowest of which is made to acupress the cut labial artery on either side. These pins should enter and leave the tissues at least a quarter of an inch from the lines of incision, and should embrace the whole thickness of the lip except its mucous lining. The more accurate adjustment of the prolabium may be effected by inserting a single inter- rupted suture through the mucous membrane, just behind the edge of the lip. In applying the twisted suture oyer the harelip pins, a sepa- rate thread or wire should be employed for each ; the points of the pins being cut off, a strip of adhesive plaster is placed beneath them to pro- tect the skin, and the dressing completed by supporting the tissues on 702 DISEASES OF THE FACE AND NECK. Malgaigne's operation. The dot ted lines mark the fissure. either side by the use of gauze and collodion. Tension may be still further lessened by the use of Dewar's or Hainsby's cheek compressor (Fig. 390), or, in the absence of such an apparatus, by simply applying a long strip of adhesive plaster across the wound and around the head, as recom- mended by Coote. The pins and interrupted suture may commonly be removed on the third or fourth day, but the parts should be supported with adhesive plaster for at least a week or ten days longer. The above description will suffice for what may be considered the simplest form of operation in a typical case of single harelip. Various modifications are required under different cir- Fig. 391. cumstances; thus, if, as often happens, the sides of the fissure be of different lengths, the red edge pared from the shorter side may be left attached at its base to the lower border of the lip, and fastened to the previously sloped border on the other side, as advised by Holmes; or a flap may be taken from the longer, and attached to the base of the shorter side, as recommended by Giraldes. To ob- viate the notch, which is apt to be left at the lower border of the cicatrix, Malgaigne's plan may be followed, the incisions being made as shown in the annexed cut, or Nelaton's method may be adopted; this consists in surrounding the fissure with an inverted /\-shaped cut, and bringing down the flap, which is left attached at both sides, so as to convert the wound into one of a diamond y form. Many other very ingenious operations have been devised by Collis, Stokes, and other surgeons, but, while more compli- cated than those in common use, have not, so far as I am aware, been proved to possess any practical superiority. Butcher and others operate with scissors, instead of the knife, while the use of harelip pins has been abandoned by Mr. Erichsen, in favor of the simple interrupted suture, as was likewise done by the late Mr. Collis; the latter surgeon used horsehair as a material for his sutures, while the former gives the pre- ference to fine silver wire. Double Harelip.—The treatment of double harelip is conducted on the same principles as that of the simpler form of the affection, both fissures being pared, and pins inserted so as Fig. 392. to transfix the middle flap, and close both gaps at once; Coote, however, advises that the fissures should be operated upon on dif- ferent occasions. In some instances, it is better to cut away the median portion, or to carry it upwards and backwards, so as to increase the length of the columna of the nose. The chief difficulty in cases of double harelip is in the management of the inter- maxillary bone, if, as often happens, this in- terferes with the operation by its anterior projection. If very small, the intermaxil- lary bone may be cut away, but it is usually Double harelip; projecting inter- better to fracture its base, and bend it back- maxiiiary portion. wards into its proper position, with broad forceps covered with vulcanized India-rub- ber; this proceeding may be sometimes facilitated by dividing the attach- ment of the projecting bone to the septum with cutting forceps, as DISEASES OF THE NECK. 703 advised by Blandin and others, or by grooving its base with ingenious forceps devised for the purpose by Butcher, of Dublin ; in case the inter- maxillary portion should be found too large for the gap which it is meant to fill, its sides may be cut away with forceps, when the edges of the superior maxillary bones should be similarly freshened at the same time. In making these bone-sections, particularly in dividing the attach- ment of the projecting intermaxillary bone to the nasal septum, there is often free hemorrhage, which may require the use of the actual cautery; hence, in a case of this kind, chloroform should be used as an anaesthetic in preference to ether. Primary union is usually obtained without difficulty in cases of hare- lip operation, but if it should fail (which may happen from too early withdrawal of the pins, or from a depressed state of health in the pa- tient), the surgeon should not despair, but should re-approximate the parts, in hope that union of the granulating surfaces will occur; in this way I have obtained a much more satisfactory result than might at first have been anticipated. If it be necessary to repeat the entire operation, an interval of at least a month should be allowed to elapse, in order that the parts may have time to return to a healthy condition. After the operation for harelip, the child, if an infant, may be allowed immediately to take the breast, the action of sucking tending rather to keep the parts together than to separate them; if already weaned, abundant nutri- ment in a fluid form should be supplied, and may be most conveniently administered with a spoon. For further information with regard to the treatment of harelip, the reader is re- spectfully invited to refer to the chapter on this subject in Mr. Holmes's well-known work on the Surgical Treatment of Chil- dren's Diseases, where will be found an ex- cellent account of the more complicated forms of the affection, and of the special operations required for each. Macrostoma, or congenital fissure at the angle of the mouth. (From a pa- tient under Dr. Harlan's care, at the Children's Hospital.) Congenital Fissure of the lower lip is occasionally met with, as is the same de- formity at the angle of the mouth, where it constitutes the affection known as Macrostoma; these rare conditions require to be treated on precisely the same principles as those which have been laid down for the management of ordinary harelip. Diseases of the Neck. Bronchocele or Goitre is a hypertrophied state of the thyroid gland, and may exist as an independent condition, or in connection with anaemia and protrusion of the eyeballs, as in the affection known as Graves's or Basedow's disease (Exophthalmic Goitre). Other varieties are recognized by systematic writers, such as the Cystic Bronchocele, in which cysts are developed in the structure of the thyroid, with or with- out hypertrophy of the gland tissue itself, and the Pulsating Bronchocele (an affection which may be mistaken for carotid aneurism), in which the tumor has a distinct expanding pulsation, synchronous with the cardiac 704 DISEASES OF THE FACE AND NECK. Fig. 394. systole, and evidently depending upon the intrinsic vascularity of the growth itself. Bronchocele appears as a soft, fluctuating, indo- lent tumor, occupying the situation of the thyroid gland, of which either lobe, or the isthmus, may be alone or chiefly involved, though in other cases the whole gland is equally implicated. The causes of bronchocele are somewhat obscure; it prevails in certain localities, as in the Tyrol and some parts of England, as an endemic affection, but is occasion- ally met with sporadically in all parts of the world, and as an acute affection has even been observed as an epidemic. In many instances, the prevalence of the disease appears to be traceable to the use of melted snow or of water impregnated with cer- tain saline constituents, for drinking purposes; but in other cases no such cause can be assigned. The use of a tightly-fitting military stock, or other source of constriction about the neck, appears sometimes to have been an exciting cause of the affection. When of moderate size, bronchocele gives rise to no particular incon- venience, except by the deformity produced, and by a certain amount of dyspnoea when stooping, with occasional pain in the head. In its' more aggravated conditions, however, it may cause serious if not fatal inter- ference with the functions of respiration and deglutition, cerebral con- gestion, organic disease of the air-passages, etc. Treatment.—The treatment of goitre is not very satisfactory; the remedy which has acquired most reputation in this affection is iodine, which may be given in the form of the Liq. iodin. compositus, of the U. S. Pharmacopoeia, and should be continuously administered for a consider- able time. Iodine may also be used externally, in the form of the Ung. plumbi iodid., or the iodide of cadmium incorporated with simple cerate 0j-.?j), or, which is particularly recommended by Mouat, the biniodide of mercury ointment (gr. xvj-^j). Pressure sometimes forms a valuable adjunct to iodine inunction, but care must be taken not to irritate the skin, lest the disease should be thereby aggravated. Change of residence would naturally be recommended in any case in which the affection appeared to be due to climatic or other hygienic influences. Yarious Operative Measures have been employed in the treatment of bronchocele, each having been occasionally successful, but more often resulting in failure, if not even more disastrously. Iodine injection and the formation of a seton are probably the safest of these measures, but could only be expected to succeed in cases in which the cystic element predominated. Injection of the perchloride of iron might be tried, if the growth were of the character described as pulsating bronchocele. Ligation of the thyroid arteries, so as to cut off the vascular supply of the diseased gland, is a dangerous mode of treatment, and one which, on account of the freedom of the collateral circulation, is very apt to result in failure. Extirpation of the gland is an expedient fraught with the highest risk to life, and can only be justifiable in very exceptionable cases; if performed at all, care should be taken to plan the incisions so that the large vessels may be encountered in an early stage of the pro- ceeding, in order that, being secured once for all, the risk of subsequent bleeding may be less. Exophthalmic Goitre (Graves's or Basedoiv's disease) comes more often under the care of the physician than of the surgeon; its treatment TUMORS OF THE PAROTID. 705 demands the adoption of means to improve the general health, rather than of measures specifically directed to the cure of the thyroid enlarge- ment. Inflammation of the Parotid Gland may occur as an epidemic and probably contagious affection, when it constitutes the disease known as Parotitis or Mumps; or as the more serious condition denominated Parotid Bubo, which occurs as a sequel of several of the exanthemata. The former affection very rarely, but the latter frequently, runs on to suppuration, demanding an early incision for the evacuation of matter, and the free administration of tonics and stimulants to support the strength of the patient. These cases are never unattended by danger, and in one case which I saw in consultation some years ago, death ensued from secondary hemorrhage into the cavity of the abscess. Tumors of the Parotid.—Most of the tumors met with in the parotid region do not, probably, involve the gland, though they overlay and compress its structure; in some cases, however, the parotid itself is implicated in the morbid growth, which may be of a fibrous, cystic, fatty, cartilaginous, or can- cerous nature. The only treatment applicable to these cases, is extirpation of the growth, and if the tumor be of a non-malignant charac- ter, such an operation may be commonly undertaken with the probability of a favorable result. If, how- ever, the growth be cancer- ous, its attachments will probably be so deep as to forbid any hope of success- ful operative interference: The mobility of such growths is, according to Fergusson, the best criterion by which to decide whether or not to operate; and in any case in which it can be determined that the tumor, though perhaps bound down by superincumbent tissues, is not firmly fixed to the parts beneath, the inference is reasonable that an operation may be attempted with hope of benefit. Another point of importance is the rate of increase of the tumor, one of a non-malignant being of much slower growth than one of a malignant character. In attempting the removal of tumors from the parotid region, the external incisions should be free, and may be made in any direction that way be indicated by the shape of the growth; after dividing the super- incumbent tissues, and thus loosening the tumor, the surgeon should accomplish the rest of the operation as far as possible by pulling and tearing with his fingers, aided with the handle of the knife, being chary of employing the cutting edge in the deeper portions of the wound. 45 Tumor of parotid region. 706 DISEASES OF THE FACE AND NECK. The accidents to be particularly guarded against are wounds of the temporo-maxillary artery and facial nerve, division of the latter of which would of course entail paralysis of the corresponding side of the face. Excision of the Parotid Gland itself is probably less often done than is supposed; yet so many cases of this operation havebeen recorded by perfectly competent and trustworthy observers, that it is impossible to deny the practicability of the procedure. In this operation, which is one of the gravest in the whole range of surgery, the external carotid artery and portio dura nerve are necessarily cut across, and in some instances it is said that the internal jugular vein, and even the spinal accessory and pneumogastric nerves have been likewise divided. Ex- tirpation of the parotid, which is said to have been performed by Heister, is chiefly known in this country through the operations of the late Dr. George McClellan, of this city, who reported eleven cases with only one death. Tumors of the Neck.—Various morbid growths are met with in the side of the neck, where they may occupy the submaxillary space, or one of the triangles of this region. The most common varieties of cervical tumor are the cystic, fatty, fibrous, and glandular, though can- cerous and epitheliomatous growths are also met with in this part. The remarks which were made with regard to the excision of parotid tumors, are equally applicable here; if the tumor be movable and of slow growth, its extirpation may, if the other circumstances of the case are favorable, be properly undertaken. If, however, the deep attachments of the mass be firm, and if its rate of increase has been such as to render its malig- nancy probable, the surgeon will, as a rule, do wisely to avoid operative interference. Hydrocele of the Neck is a name applied by Maunoir, Phillips, Syme, and other surgeons, to a cystic tumor, usually met with in the posterior inferior cervical triangle, and containing a fluid which may be of a limpid yellow color, or of a deep, grumous, chocolate hue. The treat- ment consists in the evacuation of the contents of the cyst, with a trocar and canula, followed by the subsequent injection of iodine, the establishment of a seton, or the conversion of the cyst into an abscess, by cutting away a portion of its anterior wall. A similar course may be adopted in the treatment of Cysts of the Parotid Region (unconnected with the gland itself), of Hygromata of the Hyoid Bursa, and of similar enlargements of the subcutaneous bursa sometimes found in front of the larynx, which constitute the "Superlaryngeal Encysted Tumors" of Pro- fessor Hamilton. Enlargement of the Cervical Lymphatic Glands is often observed as a manifestation of scrofula. Its treatment has been already described in the chapter on that subject (see page 417). DISEASES OF THE TONGUE. 707 CHAPTEE XXXYIII. DISEASES OF THE MOUTH, JAWS, AND THROAT. Diseases of the Tongue. Glossitis, or Acute Inflammation of the Tongue, may occur from trau- matic causes, from the abuse of mercury, or as an idiopathic affection. The tongue rapidly swells, becomes oedematous, and protrudes from the mouth, preventing the patient from speaking or swallowing, and per- haps threatening actual suffocation. There is profuse salivation, and the teeth often become covered with sordes. The treatment consists in the local use of ice, with detergent and astringent gargles, the adminis- tration of tonics (if the patient can swallow), and, if necessary, the use of nutritive enemata. Free incisions on the dorsum of the tongue may be required if the symptoms are urgent, and commonly afford great relief, by allowing the escape of the blood and serum by which the organ is distended. Tracheotomy may possibly be required to avert suffocation. Sub-Glossitis.—Under this name, C. Holthouse has described a case in which inflammatory swelling, occurring without obvious cause, was limited to the sublingual and submental regions; the tongue was re- tracted instead of being protruded, and there was no dyspnoea, though speech and deglutition were both rendered difficult; there was profuse salivation. Incisions on the dorsum of the tongue were productive of no benefit, but rapid recovery followed the use of borax gargles, with cataplasms externally, and the administration of quinia. Abscess of the tongue is occasionally met with, and requires a free incision for the evacuation of pus. An abscess beneath the tongue may? hy pressing on the glottis, threaten suffocation, in which case the incision must be made below the chin, through the mylo-hyoid muscle.' Hypertrophy or Prolapsus of the Tongue may be met with either as a congenital or as an acquired affection. The protruded organ is very much swollen, with enlarged papillae, of a purple or brownish hue, and dry from exposure to the air. The saliva constantly dribbles from the mouth, and, in chronic cases, the alveolus and teeth of the lower jaw are displaced forwards by the pressure of the hypertrophied mass. The treatment consists in the use of astringents, with the application of ( compression by means of a pad and bandage, supplemented, if neces- sary, by excision of a V-shaped piece from the tip of the organ, with the knife or ecraseur. Ligation is objectionable on account of the prox- imity of the organ of smelling to the point at which the slough would he produced, and the risk of septic poisoning which would be necessarily entailed. Dr. Gurdon Buck, of New York, has recently suggested, that as the thickness of the protruding portion is commonly more obnoxious 708 DISEASES OF THE MOUTH, JAWS, AND THROAT. than its breadth, the flaps for excision should be made in a transverse rather than in a longitudinal direction. Atrophy, affecting only one side of the tongue, has been observed by Fairlie Clarke, and by Paget. In the case recorded by the last-named surgeon, the disease was connected with necrosis of the occipital bone, and yielded upon the extraction of sequestra from that part. Ulceration of the Tongue may be due to the irritation caused by broken or carious teeth, to disorders of the digestive system, to the ex- istence of various diseases of the skin (such as psoriasis), to syphilis, to the presence of a malignant growth, to a deposit of tubercle, etc. The differential diagnosis between these various forms of ulceration, is highly important in a therapeutic point of view, as the treatment re- quired varies widely, according to the cause of the ulceration in each case. In most instances, the diagnosis can be readily made by careful observation of concomitant symptoms; the most difficult cases being, perhaps, those in which a chancre or tertiary syphilitic deposit is to be distinguished from an epithelioma (see pages 447,452), or the latter from an ulcerated mass of tubercle. The Tuberculous Ulcer has been particularly studied by Tre'lat,1 who remarks that any chronic, intractable, superficial ulcer, with red, irregu- lar borders, which occurs, without appreciable cause, and without enlarge- ment of the neighboring lymphatic glands, on the tongue or in the mouth, is probably a tuberculous ulcer; and that the probability is increased, if the patient be phthisical or tuberculous, or even predisposed to tuber- culosis. The diagnosis, he adds, may be considered certain, if the sur- geon can detect the presence of peculiar spots or patches, which are very slightly elevated, round, from half a line to two lines wide, of a yellowish, pus-like color, at first covered with epithelium, and exhibiting one or more follicular orifices—the epithelium disappearing in the course of a few days, and leaving an ulcerated surface. The only topical remedy which proved of benefit in M. Trelat's case was the application of the actual cautery. Tongue-tie consists in a congenital shortening of the fraenum linguae, which prevents the tongue from being protruded beyond the line of the teeth. If present in an aggravated degree, this deformity may interfere with suckling, and, under any circumstances, the operation for its relief is so trifling, that it may properly be done, if, as usually happens, the parents desire its performance. The operation consists simply in dividing the fraenum for about an eighth of an inch with blunt-pointed scissors, the cut being made towards the floor of the mouth, so as to avoid the ranine vessels. There is a popular notion that tongue-tie may cause dumbness, and myotomy of the lingual muscles, through an incision beneath the chin, has even been performed, with a view of restoring the power of speech—a totally useless operation, since, as justly remarked by Holmes, the whole tongue itself may be extirpated, and yet the power of speech remain. Tumors of the Tongue.— Cystic Tumors may occur in various parts of the tongue, but are most common beneath this organ, or in the floor of the mouth below the buccal mucous membrane, constituting in 1 Archives Gen. de Medecine, Janv. 1870. TUMORS OF THE TONGUE. 709 these situations the affection known as Ranula. The common form of ranula has thin walls, and contains a fluid somewhat resembling saliva, whence it was formerly supposed to be a dilatation of the duct of the submaxillary gland. Such is, indeed, probably the case in some in- stances, as when occlusion of the duct is caused by the presence of a salivary calculus; but the majority of ranulae appear to Fig. 3^6. be distinct cystic formations, analogous to those which are met with in other organs. The ordinary form of ranula may be treated by the for- mation of a seton, or by excision of a portion of its anterior wall, the cavity being subsequently allowed to heal by granulation. That vari- ety of the disease which is met with between the floor of the mouth and the mylo- hyoid muscles, often forms a more decided prominence in the neck than in the buccal cavity, and hence would ap- pear to be most accessible through an external incision. The risk of hemorrhage, how- ever, in any attempt at com- plete extirpation, is so great, that it is, as a rule, better to lay open the tumor from within, and turn out its contents, thus con- verting the cyst into an abscess, the healing of which may be promoted by stuffing the cavity with lint. Erectile and Vascular Tumors are occasionally seen in the tongue, and may be treated by the ligature, by excision, or by strangulation with the ecraseur, according to the size and situation of the growth. Fatty and Glandular Tumors of the tongue may be treated by ex- cision, the organ being drawn well forwards with a tenaculum or cord passed through its tip. Hemorrhage in these cases is sometimes rather troublesome, but may usually be arrested by passing a metallic suture deeply around and across the bleeding point, by means of an ordinary naevus needle or one with a spiral extremity. Excision would appear to be a safer operation than ligation, in cases of tumor involving the root of the tongue. Apart from the risk of inflammatory swelling and oedema of the glottis, which attends the use of the ligature in this situa- tion, severe or even fatal cerebral complications may be developed as reflex phenomena (as in a case recorded by Hunt), from injury to fibres of the glossopharyngeal nerve. Malignant Tumors of the Tongue are almost invariably of an epithe- liomatous character, though true lingual cancers, both of the scirrhous and encephaloid kinds, are described by systematic writers. The only treatment which offers any prospect of benefit, consists in removing the diseased mass, which, when a portion only of the organ is affected, may be accomplished by the application of ligatures, as in cases of naevus, or by excision, which is the preferable operation when the tip only is Ranula, between floor of mouth and mylo-hyoid muscles. 710 DISEASES OF THE MOUTH, JAWS, AND THROAT. involved. The tongue may usually be sufficiently exposed in these cases by drawing it well forwards, the jaws being held apart and the cheek retracted, as shown in the annexed wood-cut (Fig. 397). If, how- Fig. 397. Tongue exposed for operation. ever, a large portion of the organ is to be removed, ligatures may be introduced through an incision between the genio-hyoid muscles, as practised by Cloquet and Arnott, or Regnoli's plan may be adopted, in which the buccal cavity is opened from below, and the tongue drawn out between the lower jaw and hyoid bone. Southam has devised forceps to grasp and draw forwards the base of the tongue, so as to allow the ecra- seur to be used without making an external wound. Fig. 398. Fig. 399. Tongue exposed by Regnoli's method. Removal of tongue by division of lower jaw and icraseur. Complete Extirpation of the Tongue was first performed by Syme, of Edinburgh, and has since been repeated by Fiddes, Nunneley, Heath, Annandale, and others—Syme, Fiddes, and Annandale having employed the knife, and Nunneley and Heath the ecraseur. Whichever instrument be chosen, access to the organ may be facilitated by Syme s plan of dividing the lower lip and the symphysis of the jaw, the parts being wired together again after the completion of the operation. Nun- neley's experience in extirpation of the tongue appears to have been un- usually large; he has, he declares, done the operation 19 times "without any untoward symptom following in a single instance." These operations are all dangerous in themselves, and are seldom pro- DISEASES OF THE JAWS. 711 ductive of more than temporary benefit; they are of course only applica- ble to cases in which the disease is limited to the tongue itself, implication of the floor of the mouth or of the neighboring lymphatic glands being a positive contra-indication. Hilton and Moore have recommended as a palliative measure, in cases not admitting of excision, the division of the gustatory nerve—an operation which may also be resorted to as a prelimi- nary to the application of ligatures. The nerve may be reached just behind the last molar tooth, by an incision crossing its course, made from within the mouth, and carried freely down to the bone. Ligation of the lingual artery has been also practised as a means of arresting the pro- gress of malignant disease of the tongue, and, according to Coote, with somewhat encouraging results. Contrary to what might perhaps be expected, the power of swallowing is not affected by extirpation of the tongue, while speech, though at first rendered imperfect by the operation, is eventually completely restored. Diseases op the Jaws. Abscess of the Gum (Gum-boil, Alveolar Abscess) is a common affection, resulting from the irritation of necrosed or carious teeth. The abscess forms in the socket of the tooth, and may extend inwards—burst- ing through the gum—or may spread outwards through the cheek. In the early stage of a gum-boil, the application of a few leeches to the inflamed gum will often afford great relief from pain, and may even pre- vent the occurrence of suppuration; if, however, pus have actually formed, it should be evacuated by an early and free incision, made from within the mouth as soon as fluctuation can be detected in that position. As it is very desirable to avoid the deformity caused by an external opening, an effort should be made to obtain resolution on the side of the cheek, pointing being at the same time encouraged within the mouth. For this purpose it will usually be advisable to avoid the use of poultices, substituting an embrocation of the extract of belladonna, diluted with glycerine. The patient may be at the same time directed to wash out the mouth frequently with warm water, or the domestic remedy of a hot fig may be applied to the inner side of the inflamed gum. As soon as the acute symptoms have subsided, whether by the occurrence of reso- lution or of suppuration, the services of a dentist should be invoked, to remedy the diseased state of the offending tooth, and thus avert a recur- rence of the affection. Lancing the Gums is a little operation often required in cases of difficult dentition. It is most conveniently performed with the instru- ment known as the " gum lancet," though, in an emergency, the small blade of an ordinary penknife will serve the purpose perfectly well. The child's hands should be restrained by the mother or nurse, while the sur- geon, separating the jaws with the left forefinger, introduces the blade of the lancet guarded with the right forefinger ; this serves to guide to the point at which the incision is to be made, and at the same time keeps the child's tongue out of the way of injury from the knife. Ulceration of the Gums may depend upon the presence of a scorbutic or syphilitic taint, or may result simply from a disordered state of the digestive system, the accumulation of tartar around the teeth, etc. The treatment consists in the adoption of means to improve the patient's general condition, with the enforcement of cleanliness of the part, and the local use of astringent and detergent washes. 712 DISEASES OF THE MOUTH, JAWS, AND THROAT. Epulis.—This is a general term signifying an outgrowth of the gum, the growth in these cases being rather of the nature, of a continuous hypertrophy than of a distinct tumor. The ordinary epulis is of a fibrous structure, but myeloid, cancerous, and epitheliomatous growths are also met with in this locality. The disease chiefly affects the lower, but is also met with in the upper jaw, rarely occurs before adult life, and is equally common in either sex. It is usually Fig. 400. traceable to the irritation produced by a decayed tooth. The Fibrous Epulis appears as a red, smooth, lobulated mass, caused by the natural structures of the gum, the mucous glands of which are some- (f j times abnormally developed. The growth is at first firm and resisting, but may become softened by central disintegration, or may ulcerate super- ficially. The Malignant Epulis, as it is commonly though improperly called, is usually of a myeloid character; in some instances, however, as already observed, these growths are really malignant, being of an epitheliomatous or cancerous nature. Epulis of lower jaw. The malignant, differs in appearance from the simple or fibrous epulis, in being softer, of a darker color, more vascular, and of more rapid growth, and in its tendency to recur after removal. The only available mode of treatment, in any case of epulis, is ex- cision, and as the growth commonly involves the periosteum, this, with a thin layer of the subjacent bone, should be removed with the gouge- forceps, so as to prevent a recurrence of the disease. In ordinary cases, the whole operation may be done from within the mouth, but if the tumor be large, and particularly if of a myeloid character, it may be necessary to make an incision through the median line of the lip, and then dissect off the cheek so as to freely expose the whole growth. A tooth should be extracted on either side of the diseased mass, and the alveolus divided with a strong but small saw as far as the base of the tumor. Cutting pliers, with the blades at a right angle to the handles, are then to be applied, one blade on either side of the jaw, when the whole growth, with the bone from which it springs, can be readily cut away. The base of the lower jaw should always be allowed to remain, in order to preserve the symmetry of the part; the removal of the whole thickness of the bone appears to be quite unnecessary, epulis, according to Heath, never involving the lower border of the jaw. If the bone be very thick, it may be-desirable, before applying the cutting forceps, to make a horizontal groove with a Hey's saw; but in most instances this will probably be found unnecessary. Hemorrhage is to be checked by compression, or, if this fail, by the use of the actual cautery, or of Monsel's solution of iron, the external wound, if one have been made, being then accurately adjusted with harelip pins and the twisted suture. The bleeding is often profuse, in operations for the removal of malignant epulis, requiring the free use of the hot iron ; in these cases, also, it may be necessary to remove the entire thickness of the bone, by means of an external incision beneath the horizontal ramus of the jaw. Necrosis of the Jaws may result from traumatic causes, from syphilis, from the abuse of mercury, or from the contact of the fumes of phosphorus (as in the makers of lucifer matches); it is, moreover, sometimes met with as a sequel of the eruptive fevers, and may even CYSTS OF THE ANTRUM. 713 occur without being traceable to any definite cause. In the upper jaw, the disease is almost invariably limited to the alveolar border, but in the lower jaw, may involve the whole thickness of the bone. The treatment consists in the administration of nutritious food and tonics, with the use of detergent lotions, and an early removal of sequestra; as long as a portion of dead bone remains in the mouth, the patient is constantly exposed to the risks of septic poisoning. Removal should, if possible, be effected without resorting to external incisions; in the upper jaw this can be readily accomplished, but, if the whole thickness of the lower jaw be involved, an incision below the ramus may be absolutely necessary; Perry and Boker have, however, each succeeded in removing the whole lower jaw, in a state of necrosis, through the mouth. Abscess of the Antrum.—Suppuration may occur in the antrum as the result of traumatic causes, or of the irritation produced by a diseased tooth. The symptoms are those of deep-seated suppuration in general, with enlargement of the part, causing swelling of the cheek, protrusion of the eyeball, occlusion of the lachrymal duct and nostril, and bulging of the hard palate. If the accumulation of purulent matter be very great, the walls of the antrum may become so attenuated as to crackle under pressure. Pointing may take place on the cheek, or within the mouth, or the abscess may possibly discharge itself through the nostril. The treatment consists in making a free opening into the antrum, and, subsequently, in daily washing out the cavity by syringing with warm water. If one of the molar teeth be carious, this may be extracted, and an opening made by thrusting a trocar, small perforator, or, which Fergusson recommends, an ordinary gimlet, through the socket, but, under other circumstances, it is better to make the opening through the front wall of the antrum beneath the cheek; the bone is here thin, and can be readily perforated with a strong knife or scissors. External pressure maybe afterwards employed to restore the part-to its original shape. Cysts of the Antrum (Dropsy of the Antrum).—The antrum is not unfrequently the seat of a collection of thin glairy mucus, or of a brownish serous fluid containing crystals of cholestearine. The older surgeons looked upon these cases as the result of an obstruction of the orifice of the antrum, causing accumulation of the natural secretion of the part, and hence applied to them the term hydrops antri, or dropsy of the antrum. Modern pathologists, however, believe that, at least in the large majority of instances, these are examples of true cystic disease, analogous to those which are met with in other parts. The symptoms of a cyst of the antrum are very much the same as those which charac- terize abscess of that cavity, except that no evidence of an inflammatory condition is present. The diagnosis is important, as these cases are curable by a very slight operation, whereas solid tumors of the antrum demand a much graver procedure for their removal; hence, in any case of doubt, the surgeon should make an exploratory puncture before resorting to more serious measures. The treatment of cystic disease of the antrum consists in perforating the anterior wall of the cavity from within the mouth, the cheek being previously dissected up if necessary. A small portion of the anterior wall may be excised, so as to allow thorough exploration of the part, and prevent re-accumulation. If, as sometimes happens, a tooth be discovered within the antrum (in which case the cyst is said to be dentigerous), the tooth should be removed with suitable instruments, introduced through the opening already made. 714 DISEASES OF THE MOUTH, JAWS, AND THROAT. Solid Tumors of the Upper Jaw.—These are of various kinds. Apart from those which have already been described under the name of epulis, there maybe exostoses springing from the surface of the jaw, and projecting in different directions, requiring removal with gouge, saw, or cutting pliers. Tu- Fig. 401. mors, again, may originate from either wall of the an- trum, from the malar bone, from the pterygo-maxillary fossa, or from behind the jaw; fibrous, myeloid, and encephaloid growths are probably those most fre- quently met with in these situations, though fatty, car- tilaginous, bony, and epi- theliomatous tumors have also been observed in the same localities. These va- rious growths, as they in- crease in size,produce swell- ing of the cheek; encroach upon the orbit, causing protrusion or compression of the eye, and sometimes interfering with vision; oc- clude the nostril, simulating Encephaloid of the antrum, encroaching upon the face. nasal polypus ; project into the pharynx, causing dysp- noea or dysphagia; and depress the alveolus and hard palate, causing bulging of the roof of the mouth. Beside the deformity produced, they eventually endanger life, by interfering with respiration and deglutition, by giving rise to profuse and repeated hemorrhages, or by involving the base of the skull, and inducing cerebral complications. Diagnosis.—Solid tumors, involving the antrum, may be distinguished from cysts or abscesses of the same part, by noting the history of the case, by observing the uniform, elastic, and semi-fluctuating character of the enlargement, in the case of a fluid collection, and, finally, by means of an exploratory puncture. It may, however, happen, as in a patient under my care at the Episcopal Hospital, that the entrance to the antrum is blocked by a solid growth, the natural secretion of the part accumulating as a consequence, and constituting a true dropsy of this cavity. Under such circumstances the diagnosis would necessarily be obscure, until the gradual increase of the solid tumor should render its nature apparent. It is sometimes a matter of great difficulty to determine the point of origin of a tumor involving the upper jaw; those growths which spring from the malar bone, dip downwards between the gum and cheek, causing the latter to project at an early period, and only secondarily involve the antrum; tumors, again, which originate in the antrum, distend its walls in various directions, and render the line of the teeth irregular; while, finally, growths which originate behind the jaw (as naso-pharyngeal polypi), thrust the latter downwards and forwards as a whole, without altering the line of the teeth, or changing the relative position of the several parts of the bone. These distinctive points are, however, in EXCISION OF THE UPPER JAW. 715 practice, often obscured by the fact that a tumor arising in one position may send prolongations in several different directions, so that, in any particular case, it may be almost impossible to decide from what part the growth originally sprang. The diagnosis between malignant and non-malignant tumors of the antrum, is often extremely difficult, so long as the morbid growth is con- fined within the walls of that cavity. A malignant affection may, how- ever be suspected, if the increase of the tumor be rapid, if the patient be past the period of middle age, and particularly if the submaxillary glands be enlarged and indurated. When the growth has spread beyond the cavity of the antrum, the diagnosis is comparatively easy, the ordi- nary characters of a malignant tumor being, under these circumstances, speedily developed. Treatment.—The only treatment which can be of any service in cases of tumor of the upper jaw, is extirpation of the growth, which may require the removal, partial or complete, of the superior maxillary and perhaps of the malar bone. In the case of a non-malignant growth, springing from the antrum, there can be no question as to the propriety of the operation; and even if the tumor originate behind the jaw, excision, though attendee! with danger from hemorrhage, a%d from the implication of the base of the skull, may be properly attempted, if the general con- dition of the patient be favorable to such a procedure. In the case of a malignant growth, provided that the glandular implication be not exten- sive, excision may be properly resorted to, if the case be seen before the tumor has spread beyond the cavity of the antrum; if, however, the soft structures of the cheek be involved, or if the submaxillary glands be much enlarged and indurated, even though the growth be still limited by the walls of the antrum, operative interference is, as a rule, to be avoided; complete extirpation would scarcely be practicable under such circumstances, while a partial removal of the disease could but render the patient's condition worse than before. Excision of the Upper Jaw.—To Lizars is justly ascribed the credit of having first proposed excision of the whole upper jaw for tumor of the antrum, and to Gensoul (in 1827), that of having first actually performed the Fig. 402. operation, though partial excisions had been previously done by Dupuytren, Jameson, of Bal- timore, and others. Various incisions are recommended by different surgeons, the best probably being that advised by Fergusson, which consists in dividing the upper lip in the mesial line, laying open the nostril corre- sponding to the side of the tumor, carrying the knife (if more space be necessary) from the root of the ala, between the side of the nose and the cheek, as far as the nasal bone, and then cutting transversely opposite the lower horder of the orbit to the zygomatic process of the malar bone. The flap thus marked out Exci8ion of the upper jaw Being dissected up, sufficient room is afforded (After Fergusson.) for the removal of the largest tumor. Lizars employed an incision from the angle of the mouth across the cheek to the malar bone, supplementing this cut, if necessary, by one through the lip into the nostril, and by a short longitudinal incision at the malar 716 DISEASES OF THE MOUTH, JAWS, AND THROAT. extremity of that first made. Liston's method, which, with various slight modifications, is that usually adopted, consists in making one incision from the external angular process of the frontal bone through the cheek to the corner of the mouth; a second along the zygoma, join- ing the first'; and a third from the nasal process of the maxilla, detaching the ala of the nose, and cutting through the lip in the mesial line. By any of these methods, the whole upper jaw may be readily removed, the flaps being dissected away from the surface of the tumor, and the bony connections of the part severed with a Hey's, or other small saw, and strong cutting pliers. One, or, if necessary, two incisor teeth being extracted, the saw may be applied to the alveolus, to the floor of the nostril, or to both, so as to cut a deep groove in which the blades of the cutting forceps may be applied ; the hard palate is then cut through with the latter instrument, the soft palate being detached by a transverse incision, or, if practicable, the mucous covering of the roof of the mouth being turned backwards in the form of a flap. The malar bone is next cut across into the spheno-maxillary fissure, or, if this bone is itself to be removed, its orbital and frontal processes, and the zygoma, are similarly divided. Finally, one blade of the forceps is introduced into the nostril, and the other into the f>rbit (the important structures in the latter cavity being pushed and held out of the way with the handle of a knife or spa- tula), and the inner angle of the orbit cut across. The tumor may then be grasped with the lion-jawed forceps devised by Fergusson (Fig. 297), and forcibly depressed, the infra-orbital nerve being carefully divided far back, and any remaining attachments severed with a few strokes of'the knife. Hemorrhage being arrested by ligation of any vessel that can be reached, or by the application of the hot iron, if necessary, the large cavity that is left is to be stuffed with pledgets of lint furnished with a string, to facilitate withdrawal through the mouth, and the external incisions accurately adjusted with the interrupted or twisted suture. Partial Excision of the Jaw may often, in cases of non-malignant tumor, be advantageously substituted for complete extirpation; thus, if the orbital plate be not involved, this may be left, a groove being cut with the saw across the bone below the orbit, and the cutting pliers sub- sequently applied in the same line; or if, on the other hand, the alveolus and hard palate be healthy, the saw may be applied above and parallel to the alveolar border of the jaw, and again in a line .perpendicular to this, so as to connect the former section with the orbit; the inner angle of the orbit being then cut across, the upper part of the jaw may be separated with the lion-jawed forceps, as already described. Finally, it may be advisable, in some instances, to adopt Fergusson's suggestion of cutting into the centre of the diseased mass, and working with curved forceps and gouge towards the circumference, instead of undertaking a formal excision. The feeling of surgeons, generally, is unquestionably opposed to these partial operations, the professional mind being proba- bly still influenced by Liston's unqualified condemnation of such "nib- bling and grubbing" procedures; as justly remarked, however, by 3Ir. Heath, it remains to be seen which practice gives the best results. In the case of small tumors, excision may be sometimes accomplished from within the mouth, without any external incision. The results of excision of the upper jaw are quite as favorable as could be expected, in view of the severity of the operation; 17 cases, quoted by Heath, from the Medical Times and Gazette, gave 14 recoveries and but 3 deaths. The chief dangers of the operation appear to be from EXCISION OF THE UPPER JAW. 717 shock, from hemorrhage, and (if chloroform be used) from entrance of blood into the air-passages. (1.) Shock is not so much a source of risk in cases of excision of the jaw merely, as in those cases in which the jaw is removed as a prelimi- nary step in the extirpation of retro-maxillary tumors. It is diminished by the use of chloroform, which, as the hot iron may be required in the latter stages of the operation, should in these cases be substituted for ether, on account of the inflammable nature of the latter agent. (2.) Hemorrhage is always pretty free in these operations, during the early stage, particularly if the incision through the cheek is adopted, when the facial artery is cut at a point at which its calibre is considerable; the surgeon may, if he think proper, apply a ligature to this vessel before proceeding to the other steps of the operation, but, as a rule, the pressure of an assistant's fingers, or the application of a serre-fine, will suffice to control the bleeding until the whole excision has been completed. At a later stage of the operation, there is again pretty free bleeding from branches of the internal maxillary, which are necessarily cut or torn across where the jaw is removed; these branches may be secured by ligation, or may be occluded by a few touches of the hot iron, which will often be found a more convenient application in this situation. In order to prevent hemorrhage during the operation, Lizars proposed and practised ligation of the carotid artery, as a preliminary proceeding; this plan is, however, abandoned at the present day, both as unneces- sary, and as, in itself, seriously complicating the patient's condition. The tendency of modern surgical writers, indeed, is to speak very lightly of the risk of hemorrhage in excision of the upper jaw, and Prof. Gross, in alluding to this subject, goes so far as to say that "no skilful surgeon now even employs compression of the carotid artery in these operations," and that "there are no structures in the body of the same extent, in their natural and diseased condition, the removal of which is attended with so little hemorrhage." With due diffidence, I must express my dis- sent from this opinion. I believe that profuse bleeding is a more fre- quent cause, if not of death, at least of danger, in excision of the upper jaw, than is commonly acknowledged, and should consider compression of one or even both carotids, during the operation, a highly proper and judicious precaution. Another plan, which is suggested by Fergusson, might also be adopted with advantage; this is to notch, if not fairly divide, the ascending process of the superior maxilla, with the alveolus and hard palate, before dissecting up the cheek or even cutting into the cheek at all—the most tedious part of the operation being thus accom- plished, before any incision is made into the most vascular parts. Liga- tion of the carotid may occasionally be rendered necessary by the occur- rence of secondary hemorrhage. (3.) The risk of suffocation from blood flowing into the air-passages, during the operation, is of course greater when the patient is in a state of anaesthesia, than it would be if chloroform were not employed; and in Mr. Hewett's well-known case,1 the fatal result was attributed to this cause. To prevent such an occurrence, anaesthesia should not be pushed further than absolutely necessary, and assistants should constantly mop out the mouth with sponges attached to sticks of a suitable length. Niissbaum, a German surgeon, believing that this is the principal source of risk in jaw operations, advises the preliminary performance of a temporary tracheotomy, the glottis to be closed with a piece of oiled lint, and 1 Med.-Chir. Trans., vol. xxxiv., p. 43. 718 DISEASES OF THE MOUTH, JAWS, AND THROAT. chloroform to be administered through a tracheal tube; such a plan would, however, I should fear, rather increase than lessen the risks of the operation. Excision of the greater part of both Upper Jaws was performed by Rogers, of New York, in 1824, and complete extirpation has since been practised by Heyfelder, Maisonneuve, and others; the whole number of operations on record, is about a dozen. The incisions for this opera- tion, which is one of the gravest character, consist of a median division of the upper lip, with separation of both nostrils—a duplication, in fact, of the operation recommended for excision of either jaw separately. In all operations upon the upper jaw, the skin covering the tumor should be scrupulously preserved, no matter how thin and distended it may appear. To complete the subject of excision of the upper jaw, the following statistics of the operation are quoted from Heyfelder. Nature of operation. Whole No. of cases. Cured. Relapsed or died. Result unknown. Partial " " Complete excision of both jaws--- Partial 141 153 11 8 51 48 5 7 33 35 6 1 57 70 Tumors of the Lower Jaw.—Cystic, Fibrous, Fibro-cellular, Car- tilaginous, Bony, Myeloid, and Encephaloid growths are met with in this situation, commonly originating in the cancellous structure in the centre of the bone, and projecting both into the mouth, and downwards into the side of the neck, in the form of rounded or irregularly lobed masses. The remarks which were made as to the importance of a correct diag- nosis, in cases of tumor of the upper jaw, are equally applicable with regard to those of the inferior maxilla—simple cystic growths being usually readily curable by laying open the cyst and stuffing its cavity with lint—non-malignant, solid tumors requiring excision with saw and cutting pliers—and cancers of this part, on the other hand, often not admitting of any operative interference whatever. Excision of the Lower Jaw.—It is occasionally possible, as re- cently advised by Heath, and as long ago done by the late J. Rhea Barton, of this city, to remove non-malignant solid tumors of the lower jaw, without sacrificing the whole thickness of the bone; and it is certainly desirable, under such circumstances, to preserve the base of the jaw, for the reasons already given in speaking of necrosis of this part. If, however, the whole thickness of the bone on one side be in- volved, excision may be performed by making a single incision along the base of the jaw, prolonging the cut, if necessary, in a line corresponding to the position of the ascending ramus, and curving the anterior ex- tremity of the wound upwards, toward but not through the prolabium. If the portion of bone to be removed extend beyond the median line, a ligature should be passed through the tip of the tongue, to prevent its retraction when the muscles of the floor of the mouth are divided. In this first incision the facial artery will be cut, and should be immediately secured with ligatures. The flap, formed as above directed, should be carefully dissected up, and the inner side of the jaw cautiously cleared, by separating the soft tissues of the mouth—a tooth having been pre- viously extracted on either side of the tumor; the saw is to be applied so EXCISION OF THE LOWER JAW. 719 as to cut a deep notch through the alveolus, the bone section being sub- sequently completed either with the saw or cutting pliers. The part to be removed is then seized with the lion-jawed forceps, and wrenched out, any remaining attachments being severed with a few strokes of the knife. If the morbid growth involve the angle of the jaw and part of the ascending ramus, it will be necessary to disarticulate the bone upon that side; in this case, the incision should be prolonged to the back of the ar- Fig- 403. ticulation, when the bone, having been divided in front of the tumor, is to be cleared by careful dissec- tion, the surgeon then depressing the body of the jaw, so as to render tense and facilitate -the division of the attachment of the temporal muscle to the coronoid process; the jaAv being twisted somewhat out- wards, the joint may now be opened from the front, and disarticulation completed. The edge of the knife , should, throughout, be kept close to the bone, lest the internal maxillary or even the external carotid artery should be accidentally wounded. Hemorrhage being checked by liga- tures, or, if from the dental artery in the cut surface of bone, by the application of Monsel's salt or the actual cautery, the external incision may be closed by means of the in- terrupted or twisted suture. Until union is completed, the patient's diet should be limited to liquid food, which may be given through a tube. Metallic caps, to fit the teeth of the remaining portions of the jaw, and connected with a spring to a similar contrivance applied to the teeth of the upper jaw, are sometimes employed to prevent distortion from the action of the muscles. Such an apparatus is, however, according to Heath, quite unnecessary, as the bone quickly resumes, unaided, its normal position. If the tumor be very large, involving both sides of the jaw, a U-shaped incision dividing both facial arteries may be employed, as recommended by Fergusson; or, as advised by Heath, the lower lip may be divided in the median line, and the flaps dissected back on either side. Excision of a part of the lower jaw for tumor, which was first per- formed by Deaderick, of Tennessee, in 1810 (though his case was not published until thirteen years later), has been practised a great many times; and, except in cases of malignant disease, with very good results. The proportion of failures under the latter circumstances (twenty-one out of thirty-nine cases, according to Heyfelder), authorizes the question whether, in a case of cancer of this part admitting of any operation, complete extirpation would not be better than any less sweeping measure. The following statistics of excision of the lower jaw, for all causes, are taken from Heyfelder. Disarticulation of lower jaw. 720 DISEASES OF THE MOUTH, JAWS, AND THROAT. Nature of operation. Whole No. of cases. Cured. Relapsed or died. Result unknown. 15 133 138 14 90 84 1 43 33 Disarticulation of half the jaw--- 21 Anchylosis or Closure of the Jaws may follow sloughing re- sulting from the abuse of mercury or from cancrum oris, or occurring in the course of low fevers ; it may also be caused by rheumatoid arthritis, by the contraction of the cicatrix of a burn, or by a wound of the tem- poro-maxillary articulation. If the anchylosis be confined to one side, it may be remedied by a resort to Rizzoli's or Esmarch's operation (see p. 301), the latter procedure being probably the better of the two. The section of the bone should always be made in front of the cicatrix. If both sides of the jaw are anchylosed, provided that the whole thickness of the cheek is not involved, an attempt may be made to restore the mobility of the part by dividing the cicatricial bands from within, and gradually separating the jaws by means of a screw dilator, or, which Heath prefers, by the use of metal shields adapted to the teeth, and forced apart with wedges. This mode of treatment, though both tedious and painful, can,. according to Heath, be made, with care and attention, to yield very good results. Diseases of the Palate. Cleft Palate.—This is a congenital deformity consisting of a .di- vision in the median line of the part, which may be confined to the uvula, or to that and the soft palate, or may involve the whole floor of the mouth, being, perhaps, additionally complicated by the coexistence of harelip. More rarely, the hard palate is cleft (in connection with harelip), the soft palate and uvula escaping. In some cases, there is a double fissure anteriorly, the intermaxillary bone projecting between the two clefts. If the deficiency be extensive, a cleft palate may interfere seriously with deglutition by allowing regurgitation through the hose, and in all cases it causes indistinct articulation, with a disagreeable modification in the tone of the voice. Treatment.—If very slight, and limited to the soft parts merely, a cure may sometimes be obtained by Cloquet's plan of repeatedly cauterizing the angle of the cleft, and then waiting for cicatrization to produce con- traction. As a rule, however, cleft palate can only be remedied by an operation, which, when applied to the soft palate, is called Staphylo- raphy, and when to the hard palate, Uranoplasty. Staphyloraphy. — If the case be complicated with harelip, this should be operated on in infancy, the patient wearing subsequently a suitable cheek-compressor, so as to encourage contraction of the fissure. As the operation of staphyloraphy is both painful and tedious, it was formerly considered necessary to wait until the patient should be old enough to be himself anxious for a cure, and willing to co-operate with patience and fortitude in the surgeon's efforts for his relief. At the pre- sent day, however, with the aid of anaesthetics, and particularly with the facility afforded by the use of T. Smith's gag and tongue-depressor, or such an one as is shown in Fig. 404, it is no longer thought imperative to wait in all cases until adult life, and several highly successful opera- STAPHYLORAPHY. 721 Fig. 404. Whitehead's gag and tongue-depressor. tions upon young children have been performed by T. Smith, Collis, Durham, Buszard, Billroth, Tait, Marsh, and other surgeons. The great object of operating at an early period, in these cases, is that the fissure may be closed be- fore the child has acquired the peculiar nasal tone of voice which habitually accompanies the deformity; and the age at which the operation should ordinarily be attempted, in suitable cases, may be given, upon the authority of Holmes, as about three years. The operation in infancy should, however, probably be reserved for those cases in which the cleft is confined chiefly, if not entirely, to the soft palate; and it is but right to add that the two surgical writers whose experience in staphyloraphy has been, perhaps, greater than that of any others—Sir W. Fergusson, and Dr. J. Mason "Warren, of Boston—both discourage early operations, and both deprecate the use of anaesthetics in these cases. The first successful staphyloraphy was done by Roux, in 1819, and the operation has since been illustrated by the Warrens, father and son, Mutter, Dieffenbach, Liston, Fergusson, Sedillot, Mettauer, Pancoast,. Avery, Collis, Pollock, and others. In its simplest form, the operation consists in freshening the edges of the cleft, and then bringing them together with a sufficient number of interrupted sutures. In order to diminish the tension upon the stitches, Roux employed transverse inci- sions, for which Dieffenbach judiciously substituted incisions parallel to the fissure. Warren, in 1843, introduced a further improvement, which consisted in dividing the muscles contained in the posterior pillar of the fauces; but to Fergusson, in 1844, is due the credit of first distinctly pointing out the importance of a preliminary myotomy, so as temporarily to paralyze the velum, and thus prevent disturbance of the line of union by the muscular action of the parts. Fergusson's operation consists in dividing the levator palati on either side, by introducing a curved knife through the fissure and cutting from above—then dividing the palato-pharyngeus by snipping the posterior pillar of the fauces (as was done by Warren), and, if necessary, similarly di- viding the anterior pillar, containing the palato- glossus. Pollock and SCdillot divide the levator palati by what might be called a submucous sec- tion, thrusting a knife through the palate near the hamular process on either side, and severing the muscular fibres by raising the handle and depress- mg the blade of the instrument. This division of the muscles is often attended with more bleed- mg than any other part of the operation, and 46 'Fior. 405. Se'dillot's operatim for , staphyloraphy. 722 DISEASES OF THE MOUTH, JAWS, AND THROAT. hence, if chloroform is to be used, may be advantageously postponed, as recommended by T. Smith, until after the introduction of the sutures, or, on the other hand, may be done, as advised by Callender, without chloroform, a few days before the rest of the operation is performed.1 Paring the edges of the fissure may be either the first or the second step of the operation, according as myotomy has or has not been previously per- formed. The surgeon may seize the tip of the uvula on either side and pare the edges from before backwards, by transfixing the part with a sharp-pointed bistoury near the angle of the cleft, the angle itself being subsequently freshened; or, as advised by Smith, may cut from behind forwards—the advantage of this plan being that the blood flows back- wards, and thus does not obscure the line of incision. The introduction of the sutures is probably the most difficult part of the operation for cleft palate. If the ordinary silk suture is to be used, the plan suggested by Avery will be found very convenient. This con- sists in introducing, with a small naevus needle, on one side a single thread, and on the other side a loop of silk: one end of the single thread being then passed through the loop, the latter is withdrawn, carrying the single thread with it, and thus readily bringing the suture into place. By this mode of proceeding the needle is introduced on either side from below, thus enabling the surgeon to regulate the distance between his stitches with greater accuracy than would otherwise be possible. Instead of the silk suture, T. Smith employs fine catgut or horsehair, while many American surgeons consider silver wire preferable to any other material. If wire be used, a short curved needle should be employed, its introduc- tion being facilitated by the use of suitable forceps. The mode of fastening the suture is a matter of some importance: Fergusson passes one end through a slip noose formed upon the other, and drawing this noose tight, runs it up so as to approximate the edges of the fissure, securing the whole with an ordinary surgeon's knot. If horsehair be used, a triple instead of the common double knot, is, accord- ing to T. Smith, necessary to prevent slipping. The wire suture may be secured by clamping upon it a perforated shot, both ends being passed through the same shot, or one shot applied to either side of the cleft, according to the surgeon's fancy. From three to five sutures are usually required, and they should enter and leave the palate about a quarter of an inch from the freshened edge on either side of the cleft: they must not be drawn too tight, it being always remembered that they are meant not to pull, but merely to hold the edges together. The anterior suture is usually introduced first, and when all are secured, if, in spite of the relaxation afforded by myotomy, the parts appear tense, free lateral in- cisions should be made on either side. The sutures, as a rule, should not be removed until the eighth or tenth day, and then one or two at a time—the patient during the interval being fed on liquid but nutritious food, and kept as quiet as possible, though not necessarily confined to bed. After the operation, the voice is occasionally observed to have under- gone immediate and decided improvement, but in most cases, at least in adults, a considerable length of time and a long course of vocal gym- nastics will be found necessary to restore distinct articulation. Uranoplasty.—The merit of first devising an operation for the cure of fissure of the hard palate, is due to the late Dr. J. Mason Warren, ol 1 According to Lawson Tait, myotomy by any method is occasionally followed by atrophy of the palate. ELONGATION OF THE UVULA. 723 Boston, who published an account of his procedure in 1843. His plan was to dissect up, with a long double-edged knife curved on the flat, the mucous covering of the hard palate, beginning on either side of the fissure, and carrying the dissection back to the alveolar processes; the pendu- lous flaps thus formed were then united in the median line. Another plan, which Fergusson prefers, is to make an incision parallel to the alveolus on either side, and carry the dissection towards the free margin of the fissure. Langenbeck uses a blunt instrument, with which to separate the periosteum from the bone, in order to take advantage of the osteo-genetic power of that membrane; and his operation, which has been frequently performed in Germany, has been successfully repeated in this country by Dr. Wm. R. Whitehead, of New York, who published an excellent paper on the subject, with an analysis of 55 cases, in the American Journal of Medical Sciences for October, 1868. It is a disputed point amongst surgeons, whether, in dealing with a fissure of both hard and soft palate, an attempt should be made to close the whole gap at once, or whether the operation should be divided be- tween several sittings: no positive rule can be given upon this point, but Holmes's advice appears judicious, viz., to be content with closing a portion of the hard palate at the first operation, provided the parts come easily together, but, if it should be found necessary to detach the soft parts through the whole extent of the cleft, then to attempt complete closure at one operation. According to T. Smith, if staphyloraphy be performed at an early age, the fissure of the hard palate will subsequently undergo contraction to such an extent as to render it possible, in most cases, to dispense with any further operation. In cases of cleft palate not admitting of surgical treatment, and in most cases of Acquired Perforation of the Hard Palate, particularly as the result of syphilis, obturators of metal, ivory, or vulcanized India- rubber, may be worn; one of the best instruments of the kind is that devised by Kingsley, of New York; it is provided with a soft curtain of India-rubber, to take the place of the natural velum. A judicious caution as to the use of obturators in cases of necrosis, is given by Heath. This is, that no plug should be introduced into the aperture itself, which would inevitably become still further enlarged by the pressure on its edges, but that the occluding apparatus should consist of a properly fitting plate, arching below the palate, and attached to the teeth. Elongation of the Uvula.—This affection is usually remediable by the use of astringent gargles or caustic solutions, but, if persistent, Fig. 406. Forceps-scissors for cutting nvnla. roay require a surgical operation for its relief. This operation consists simply in cutting off the pendulous part with scissors, at about a third of 724 DISEASES OF THE MOUTH, JAWS, AND THROAT. an inch from the root of the organ. The tip of the uvula may be seized with forceps held in the left hand, while the scissors are applied with the right, or an instrument may be used, which has been constructed for the purpose, and by which the part to be removed is caught and cut off at the same moment (Fig. 406). Diseases of the Tonsils. Tonsillitis, Inflammation of the Tonsils, or Quinsy, may terminate in resolution, or may run on to suppuration—in which case the patient may suffer a good deal from dyspnoea, before relief is afforded by the spontaneous opening of the abscess. Local depletion, by scarification of the part with a probe-pointed knife, may sometimes be of service in these cases, and, if the presence of pus can be determined, an incision should be made for its evacuation ; the ordinary gum lancet is a safe and con- venient instrument for this purpose. Fie. 407. Fahnestock's tonsillotome. Chronic Enlargement or Hypertrophy of the Tonsils may occur in healthy children as the result of frequent attacks of tonsillitis, croup, diph- theria, etc., or may be a manifestation of the scro- fulous diathesis, occurring without any obvious exciting cause. If excessive, this hypertrophy may lead to unpleasant results, such as snoring during sleep, obstruction to nasal respiration (giving rise to a habit of keeping the mouth open), and even permanent dyspnoea—producing perhaps con- traction of the chest, and eventually interfering with the general nutrition of the patient. Deaf- ness, also, is often attributed to tonsillar enlarge- ment. The treatment consists in the use of astrin- gent gargles, the application of nitrate of silver, in substance or solution, the muriated tinc- ture of iron, or the tincture of iodine, and in the adoption of means to improve the general health. Inhalations of diluted creasote vapor, or the use of the atomizer, may also prove of service. As a last resort, excision of a portion of the enlarged tonsil may be performed, either by seizing the pro- jecting part with forceps, and cutting off a slice with a probe-pointed bistoury, wrapped so as to protect the lips, or by means of an instrument de- vised for the purpose by Fahnestock, and since modified by others, which is known as a ton- sillotome or tonsil guillotine. If the simple knife be used, care should be taken to keep its edge directed somewhat towards the median line, so as to avoid the possibility of wounding the internal carotid artery. J. Wood advises that the section should be made from below upwards. The surgeon may stand behind the patient in operating on the right tonsil, and to the patient's right side in ope- rating on the left. Hemorrhage is rarely trouble- some after these operations, usually yielding readily to the application of ice or simple astringents; it bleeding should, however, persist, a turpentine gar- DISEASES OF THE PHARYNX AND (ESOPHAGUS. 725 gle, as advised by Erichsen, might be tried, or the part might be lightly touched with a brush or sponge dipped in Monsel's solution. Malignant Affections of the Tonsils.—The tonsil is occasionally, though rarely, the seat of cancer, which may be either scirrhus or en- cephaloid; epithelioma, also, is said to have been observed as a primary growth in this locality. The diagnosis from simple hypertrophy, may be made by observing the greater hardness of the tumor, its tendency to ulceration, and the implication of neighboring lymphatic glands. From syphilitic disease of the tonsil, the diagnosis is sometimes very difficult, but may be aided by observing the efficacy, or want of efficacy, of antisyphilitic treatment. In most cases of malignant disease, in this situation, palliative measures are alone applicable, but if the nature of the affection is recognized at an early period, while the disease is as yet confined to the tonsil itself, excision may be properly attempted. Ex- tirpation from within the mouth has been practised by Yelpeau, Warren, and Demarquay—the latter surgeon having employed the ecraseur—but, upon the whole, the operation by external excision, as successfully re- sorted to by Cheever, of Boston, would appear preferable. In the case recorded by this surgeon, two incisions were made, one from within the angle of the jaw downwards, in a line parallel to the sterno-mastoid muscle, and the other along the lower border of the jaw; by dissecting away the parts on either side, an enlarged lymphatic gland was first ex- posed and removed, and then, the digastric, stylo-hyoid, and stylo-glossus muscles being cut, the fibres of the superior pharyngeal constrictor were separated so as to allow the finger to enter the pharynx, when the tonsil was readily enucleated. The largest vessel divided was the facial artery, twelve ligatures in all being required. The horizontal wound was closed with a single suture, and recovery was complete in about a month. Diseases of the Pharynx and (Esophagus. Erysipelas of the Pharynx is occasionally met with, either as a primary affection, or as a complication in cases of ordinary facial ery- sipelas; the treatment consists in the administration of tonics and stimu- lants, with the local use of a solution of nitrate of silver, and of gargles of chlorate of potassa. Should sloughing occur, the mineral acids may be employed, both internally and topically. Laryngotomy may become necessary in the event of the sudden supervention of oedema of the glot- tis, while free incisions into the affected parts would be indicated by the occurrence of suppuration. Retro-Pharyngeal Abscess.—Abscesses are occasionally met with behind the pharynx, originating either in the areolar tissue in front of Fig. 408. Pharyngotome. the vertebral column, or in the lymphatic glands which exist in that situ- ation. The formation of pus in some cases evidently depends upon 726 DISEASES OF THE MOUTH, JAWS, AND THROAT. disease of the cervical vertebrae. Retro-pharyngeal abscess is a very grave affection, forty-one out of ninety-seven cases collected by Gautier having proved fatal. No age is exempt from the disease, though it is most common among young children. The early symptoms are in no wise distinctive, but when pus has formed, a distinct tumor may be ob- served, by the touch, if not by sight, usually involving one side of the pharynx only, and soon leading to unilateral swelling of the neck, and often to stiffness of the lower jaw. The treatment, which should be promptly applied to prevent suffocation, consists simply in making a free opening for the evacuation of the pus, either with a wrapped bis- toury, a trocar and canula, or an instrument devised for the purpose and known as a pharyngotome (Fig. 408). Pharyngeal Tumors may arise in the post-pharyngeal areolar tissue, may descend from the nasal cavities, or may spring from the epiglottis. They may be of the nature of polypi (fibro-cellular tumors, myxomata, etc.), or may be malignant growths, either of a cancerous or epitheliomatous nature. As they increase in size, they impede both deglutition and respiration, and may thus lead directly to a fatal termi- nation. Operative interference, further than tracheotomy to avert suf- focation, can rarely be justified in a case of malignant growth in this situation, but the treatment of innocent pharyngeal tumors may be more hopefully undertaken. In some cases, it may be possible to remove the mass through the mouth by avulsion, or by the use of the ligature, ecraseur, etc., but in dealing with growths springing from the epiglottis or adjoining parts, or with any pharyngeal tumors having a broad base, such a course would rarely be practicable, and under these circumstances the operation known as Sub-hyoidean Pharyngotomy may be properly performed. This procedure appears to have been first described by Malgaigne, under the name of Sub-hyoidean Laryngotomy, and has been recently revived by Langenbeck. In a case narrated by this surgeon, a pre- liminary tracheotomy having been performed and a tube introduced, the operator made a small transverse incision, close beneath the lower edge of* the hyoid bone, and divided the sterno-hyoid and omo-hyoid muscles. The thyro-hyoid membrane being opened, the finger of an assistant was placed in the pharynx, pushing forward the tumor for the removal of which the operation was undertaken, when the mucous membrane of the gullet was divided, and the epiglottis, which was found to be healthy, drawn forward with a strabismus hook. The tumor—a fibro-myxoma, the size of a pigeon's egg—was now seen arising from the left aryteno- epiglottic fold, and extending by a broad base to the left side of the pharynx. Excision was accomplished by drawing out the growth with forceps, and carefully separating it from its attachments, blood being kept from entering the larynx by pressing a sponge over the glottis. For several weeks it was necessary to feed the patient through a tube, but the ultimate result of the case was quite satisfactory. Spasm of the (Esophagus, or, as it is often called, Spasmodic Stricture of this tube, may be met with in connection with other hys- terical phenomena, or may be a reflex condition depending upon slight inflammation or ulceration of the part, upon hepatic disease, upon the irritation caused by hemorrhoids, etc. The diagnosis from actual ob- struction, may be made by observing the intermitting character of the affection, and by the use of the oesophageal bougie, which, in a case ot STRICTURE OF THE (ESOPHAGUS. 727 this description, will meet with little if any resistance. The treatment consists in removing any source of reflex irritation which can be de- tected, and in the administration of tonics, antispasmodics, and laxa- tives, with the use of cold bathing, and attention to the quality of the food, which should be unirritating and thoroughly masticated. Paralysis of the (Esophagus may occur as a symptom of disease of the central nervous system, and may be distinguished from oesopha- geal spasm, by the absence of pain or any sense of choking. Food may be cautiously administered in these cases through a stomach-tube, or the strength of the patient may be sustained by the use of nutritive enemata. The application of electricity is said to have occasionally proved beneficial. A Dilated and Sacculated Condition of the (Esophagus is sometimes met with—usually, however, as a consequence of organic stricture. A comparatively slight degree of obstruction, and one which does not prevent the passage of a bougie, may yet allow the temporary retention in the gullet of a portion, at least, of the food swallowed, and thus gradually lead to dilatation of the part, and the formation of pouches extending among the muscles of the neck in various directions. Such a condition existed in the case of the late Dr. Marshall Hall. The treatment of oesophageal dilatation, without stricture, can be palliative merely, consisting in the administration of liquid food through a tube, or in the use of nutrient enemata. Stricture of the (Esophagus.—Dysphagia, which is the prominent symptom of oesophageal obstruction, may depend upon a number of con- ditions totally independent of any organic disease of this part. Thus, as has been already mentioned, difficult deglutition may be due to the existence of enlarged tonsils, of pharyngeal tumors, or of retro-pharyn- geal abscess; it may also be caused by various affections of the larynx, by the pressure of cervical or intra-thoracic tumors, by aneurism of the carotid, innominate, or aorta, by displacement of the sternal extremity of the clavicle, or by the presence of a foreign body. Hence, the diag- nosis of stricture of the oesophagus should only be made after a careful investigation of the history of the case, and of all its circumstances; and the surgeon should beware of hastily thrusting in a bougie, which, if it might, by perforating the wall of an abscess, effect a cure, would, if it should perforate the sac of an aneurism, as certainly cause death. Varieties of Stricture.—Apart from the condition known as spasmodic stricture, which has already been referred to, we may recognize two varieties of the disease, the fibrous and the malignant. The fibrous stricture is usually due to traumatic causes, especially the contact of hot water, or of caustic alkalies or acids, but is also said to have been occasionally observed as a lesion of constitutional syphilis. It may occur in any part of the tube, and varies in extent from a few lines to several inches, involving sometimes a part only, and sometimes the whole calibre of the gullet. The oesophagus above the seat of stricture is usually dilated, and often ulcerated, that portion which is below being normal, or slightly contracted. The malignant stricture is due to the presence of a cancerous (usually scirrhous) or epitheliomatous deposit, which forms a more or less distinct tumor, and is often recog- nizable by external examination. The rational symptoms of these two forms of stricture are much the same; in both there is gradually increas- 728 DISEASES OF THE MOUTH, JAWS, AND THROAT. Stricture of the oesophagus. ing difficulty in deglutition, which culminates at last in total inability to swallow—food of all kinds being arrested at the point of obstruction, and ultimately rejected by vomiting after a longer or shorter interval. The diagnosis between fibrous and malignant stricture may, however, usually be made by investigating the etiology and previous history of the case, and by exploration with a gum-elastic bougie, or ivory-headed probang; the sensation given to the surgeon by the passage of the instru- ment through the stricture differs according to its nature. Thus, a fibrous stricture is felt to be smooth and evenly resisting, and the withdrawal of the bougie is unattended with bleeding; whereas a malignant growth gives the sensation of a rough and ulcerated sur- face, and a discharge of pus and blood is apt to follow the exploration. Treatment___The treatment of stricture of the oesophagus is very unsatisfactory. The strength of the patient must be maintained by the administration of liquid or finely chop- ped food, and, if necessary, by the employ- ment of the stomach-tube, or the use of nutri- tive enemata. If the stricture be of a fibrous character, temporary advantage, at least, may be often gained by the cautious use of bou- gies of gradually increasing size ; by the employment of fluid pressure, applied by means of a flexible catheter surrounded with a tube of vul- canized India-rubber, which can be distended with air or water after introduction; or by the use of an ingenious instrument recently described by Dr. Morrell Mackenzie, under the name of oesophageal dilator, which acts much on the principle of Holt's instrument for stricture of the urethra. Instruments for the dilation of oesophageal strictures have also been devised by Fletcher and Wakley, but seem to be inferior to that of Dr. Mackenzie. The application of caustic, as recommended by Home and others, is seldom resorted to at the present day. Internal section of the strictured part of the oesophagus, by means of an instrument consisting of a shaft with two concealed blades, which can be protruded after intro- duction, has been practised by Trelat. If the case be of a malignant character, the use of bougies, or other means of dilatation, will in most instances be rather prejudicial than advantageous; the bougie may, indeed, be cautiously employed, as a palliative measure, in the early stages of the disease, but after the estab- lishment of ulceration, can scarcely be expected to be of much benefit. Under these circumstances, the best that can be done is probably to sustain the strength of the patient with nutritive enemata, and to relieve his sufferings by the free use of anodynes. Tracheotomy may some- times be required to prevent suffocation in the latter stages of the disease. It occasionally happens that, even in a case of non-malignant stricture, the passage is so tightly occluded that the smallest instrument cannot be introduced, and the patient is in consequence reduced to a state in which death from starvation is imminent. Under such circumstances, t has naturally been suggested, that an opening should be made into the ah- CESOPHAGOTOMY AND GASTROSTOMY. 729 mentary canal below the seat of stricture, and a fistulous orifice thus established, through which the patient might be fed; and it has been reasonably argued that though such an operation might not be justifiable in a case of malignant disease, from which the patient must inevitably perish at no remote period, yet that in a case of impermeable fibrous stricture, the circumstances would be altogether different. The opera- tions which have been performed in these cases are cesophagotomy below the seat of stricture, and gastrotomy, or, as Sedillot, its introducer, has more accurately termed it, gastrostomy. (Esophagotomy below the Seat of Stricture.—This operation could manifestly be applied only to cases in which the obstruction was in the uppermost part of the tube, and, unfortunately, the stricture usually extends to such a point as to prevent the surgeon from reaching the oesophagus below it. In a suitable case, however, the operation might be properly tried, the necessary incisions being those described in speaking of cesophagotomy for the removal of foreign bodies (p. 354), though the procedure in the case of stricture would, of course, be more difficult, on account of the impossibility of introducing an instrument into the gullet as a guide upon which to cut. (Esophagotomy for stricture, is said to have been suggested by a surgeon named Stoffel, but, according to Velpeau, was first practised by Taranget, who was so far successful that his patient survived sixteen months. An unsuccessful case is attributed by Druitt to Watson, of New York, and another has been recently recorded by Billroth ; while Willett's (which is the only other case with which I am acquainted) likewise terminated fatally, on the eighteenth day, though there is reason to believe that, had the patient been more tractable, her life might have been saved. The record above presented is certainly not very encouraging, but, as will be presently seen, is far more so than that of gastrostomy—and as the operation is, though difficult, not in itself necessarily dangerous, it may, I think, be looked upon as a legitimate surgical resource. Gastrostomy is, as its name implies, an operation designed to establish an artificial mouth, communicating directly with the stomach. Its performance is naturally suggested by observation of the success with which gastric fistulae can be established in the lower animals, of the recoveries with persistent fistulae which are occasionally met with after penetrating wounds of the stomach, and of the remarkable success which has attended gastrotomy, or gastric section for the removal of foreign bodies (see p. 372). Sedillot, who first performed the operation, recommends a crucial incision on the left side of the abdomen, over the gastric region; the peritoneal cavity being opened, the surgeon feels for the left border of the liver, which is the guide to the stomach, and having reached the latter organ, draws it forwards with forceps, and fixes it in the wound by perforating the gastric wall with a steel-pointed ivory cylinder, secured externally on a disk of cork; after some days, when adhesions have formed, an opening is made into the middle of the stomach, at a point equidistant from either curvature, and from either extremity. Forster, Durham, and the other British surgeons who have performed the operation, prefer a single incision in the line of the left Hnea semilunaris, open the stomach immediately, and stitch the margins °f the aperture closely to the abdominal parietes. All agree that no attempt should be made to introduce food into the stomach until several days after the operation, lest primary union should be interfered with. 730 DISEASES OF THE MOUTH, JAWS, AND THROAT. Durham has collected nine cases of gastrostomy—Sedillot, Forster, and Sydney Jones having each operated twice, and Fenger, Curling, and himself each once; to these cases may be added a tenth, operated on by Dr. Maury, of this city, and an eleventh, attributed to Dr. John Lowe, of Lynn. The result in the last case, has not, I believe, been published, but in the other ten was uniformly fatal, death having been usually due to exhaustion, to peritonitis, or to these causes combined. The patient who survived the operation longest was one of Jones's, who died on the thirteenth day. In view of these statistics, is the repetition of the ope- ration justifiable? I think not: these cases are never quite hopeless, as is shown by one recorded by Hutchinson, in which spontaneous improve- ment was found to have occurred on the very day appointed for opera- tion—the patient convalescing from that moment, and, as ascertained by Durham, continuing in good health two years subsequently. It is true that this is but a single case, and that, as a rule, patients with imperme- able stricture of the oesophagus are doomed to a speedy death ; but, as justly remarked by Hutchinson, the advocates of gastrostomy are not as yet able to point to even one successful termination by their mode of treatment, while the operation (unlike tracheotomy and others which are performed in extremis) certainly cannot be considered as in itself innocuous. The fact that the operation succeeds in the lower animals, should not be of itself so cogent an argument as to induce the surgeon to resort to the operation in man, and the circumstances are very different from those under which the stomach is opened to remove a foreign body; in the one case, a man, presumably in previously good health, is certain to die unless relieved by an operation, which, though dangerous, is shown by experi- ence to be not necessarily fatal; while, in the other, the patient is a victim of chronic disease, worn down by suffering and reduced to the verge of starvation, and yet may possibly recover without operation— the best that can be said for the operation itself being, that in one or two cases it has probably not hastened the fatal issue. It is evident, moreover, that a simple incised wound of the stomach, such as would result from gastrotomy, would necessarily be attended with less danger than an operation designed to establish a permanent opening into the stomach, as in gastrostomy. The advocates of the latter operation give as a reason for its uni- formly fatal result, that it has always been performed too late; but, as justly remarked by Hutchinson, "the operation is confessedly so danger- ous, that it is not justifiable till the case is otherwise hopeless, whilst facts prove that it is not possible to make such a prognosis without risk of error" (London Hospital Reports, vol. iv., p. 60). Introduction of the Stomach Tube.—This may be required in cases of narcotic poisoning, in which vomiting cannot be excited, or as a means of administering fluid nutriment, in cases in which the patient cannot or will not swallow. The tube is introduced in the same manner as an oesophageal bougie, and the following description will apply to the use of either instrument. The patient is placed in a sitting posture with the head thrown backwards, so as to bring the mouth and gullet as nearly as possible into the same line; the mouth being held widely open (by means of a gag if necessary), the surgeon passes the tube, previously warmed and oiled, directly backwards to the pharynx without touching the tongue, and guiding the instrument over the epiglottis with the forefinger of the left hand, cautiously presses it onwards into DISEASES OF THE AIR-PASSAGES. 731 the stomach. If any obstruction be met with, the instrument should be slightly withdrawn and then again pushed forwards, very gently, however, lest the oesophageal wall should be perforated. When food is to be introduced into the stomach, the surgeon may employ a small gum-elastic bag, provided with a nozzle which closely fits the projecting portion of the tube; when it is designed to wash out the stomach, a pump is required, by which one or two pints of tepid water may be in- jected and a less quantity immediately pumped out again, the process being repeated until the returning fluid is colorless: the object of not completely emptying the stomach at once, is to'prevent the mucous coating of the organ from being sucked into the orifice of the tube and thus lacerated. The risk of passing a stomach-tube into'the trachea instead of the oesophagus is not entirely imaginary, as is shown by cases in which after death, food and medicines have actually been discovered in the lungs. Diseases of the Air-Passages. Laryngitis, Tracheitis, Croup, Diphtheria, and other affections involving the larynx and trachea, are commonly treated by the physician, and are described in works on the Practice of Medicine. These diseases are chiefly interesting to the surgeon, on account of the necessity which occasionally arises for a resort* to the operation of laryngotomy, or to that of tracheotomy, the comparative merits and modes of performing which have been already sufficiently discussed in a previous portion of the volume (pp. 350-353). Tumors, Warts, or Polypi of the larynx are sometimes met with, belonging usually to the fibro-cellular, papillary, or epitheliomatous varieties of tumor. They produce hoarseness, aphonia, croupy cough, and dyspnoea, the difficulty of breathing recurring paroxysmally, and eventually causing death by Fig. 410. suffocation. A flapping sound may often be heard as the tumor moves up and down in the act of breathing, and, by the use of the laryn- goscope, the size and position of the morbid growth maybe sometimes accurately determined. Treatment—In any case in which respiration is or has been at any previous time seriously embarrassed, there should be no delay in open- ing the trachea and inserting a tube; for expe- rience shows that fatal dyspnoea may in such a case supervene at any moment, and, besides, a preliminary tracheotomy will greatly facilitate Epithelioma of larynx. any operation for the removal of the tumor. Ya- rious plans may be adopted in dealing with the new growth itself: thus an attempt may be made to extract it by means of a wire snare or ecraseur (Fig. 411), as has been successfully done by Walker, Gibb, Johnson, and others; or delicate laryngeal forceps, as advised by Mackenzie, may be used to twist off or crush the tumor; or, if too firmly attached, this may be cautiously excised with the knife, scissors, or " laryngeal guillotine," or may be severed by the application of the galvanic cautery; simple puncture may suffice in the case of a cystic growth, while in other in- stances a cure may perhaps be effected by the repeated application of 732 DISEASES OF THE MOUTH, JAWS, AND THROAT. nitrate of silver in substance or solution. The latter mode of treat- ment may also be employed to prevent repullulation of the tumor after extirpation. In all of these methods, the application of the instrument should be guided by the use of the laryngoscope. Another plan is to open the crico-thyroid membrane and divide the thyroid cartilage, so as to expose the interior of the larynx and allow free excision of the morbid Fig. 411. Gibb's laryngeal icraseur. growth with knife or scissors : this operation appears to have been first successfully performed by Ehrman, of Strasburg, and has since been repeated by Holthouse, Holmes and Durham, of London, Buck and Sands, of New York, Cohen, of this city, and others. Krishaber, of Paris, has recently recommended, under the name of Restricted Thy- roideal Laryngotomy, an operation in winch the thyroid cartilage alone is divided in the median line, this incision being in his opinion ample for the removal of polypi situated in the ventricle of Morgagni; the vocal cords are not interfered with, and the voice is consequently unin- jured by the operation, which is in this respect decidedly preferable to that of Ehrman. Finally, in some cases, Malgaigne's operation, de- scribed at page 726, under the name of Sub-hyoidean Pharyngotomy, may perhaps be preferred to any other. Dr. Sands has tabulated 50 cases of laryngeal tumor treated by ope- ration; in 11 the growth was removed by external incision, and in 9 of these the patients recovered; in 39 cases the tumor was removed by the mouth, and recovery followed in 38. The operation was performed with the aid of the laryngoscope in 34 cases.1 Still more extended statistics have been published by Mackenzie and Durham, those of the former author showing conclusively that, when applicable, laryngoscopic treat- ment is much preferable to the operation by external incision. The fol- lowing table is condensed from Durham's, in Holmes's System of Sur- gery:— Operation. Whole No. of cages. Application of caustics, etc... Forceps....................., Wire snare................... Galvanic cautery.............. Excision..................... Puncture................... Operation by external section, Total................ 16 37 32 5 20 4 24 138 Completely successful. 12 33 28 3 14 4 15 Partially successful. 109 22 Died. 1 New York Med. Journal, May, 1865, p. 110. DISEASES OF THE BREAST. 733 CHAPTER XXXIX. DISEASES OF THE BREAST. Fisr. 412. Hypertrophy of the Breast may occur during the early months of pregnancy (when it may disappear spontaneously after confinement), or may be met with in young girls, originating usually at the period of puberty, and increasing until the bulk and weight of the enlarged gland prove a source of great inconveni- ence, and even of suffering. Both mammae are commonly affected, though not to the same extent. The treat- ment of this affection is usually un- satisfactory. Local applications of belladonna and iodine, with compres- sion, may be tried, while attention is given to the state of the patient's general health, and to the removal of any uterine disorder that may be pre- sent. As a last resource, excision of the hypertrophied mass may be em- ployed, but the operation should be reserved for extreme cases. Occa- sionally, the removal of one hypertro- phied breast has been followed by rapid diminution in the size of the other, and recovery of the patient. Hence, though both mammae be en- larged, only one should be removed at first, in hope that the other may return to its normal condition. Galactocele or Milk - Tumor . , , „ Simple hypertrophy of breast, in a girl consists in an accumulation of milk, fifteen yoa„ old- either in a fluid or concrete condition, due to obstruction of one or more of the lactiferous ducts, from inflam- mation, or from the presence of a calcareous nodule—the latter consti- tuting what is called a lacteal or mammary calculus. The quantity of milk which is found in these lacteal tumors is sometimes enormous. Birkett quotes from Scarpa the case of a woman aged twenty, in whom, two months after delivery, the breast was thirty-four inches in circum- ference, and rested on the thigh. The introduction of a trocar and canula allowed the evacuation of ten pints of fluid, which, by chemical examination, was shown to be normal human milk. The treatment in these cases consists in making an opening into the tumor, this being probably best done, as advised by Cooper, by intro- 734 DISEASES OF THE BREAST. ducing a trocar and canula, obliquely from the nipple towards the seat of accumulation, so as to leave a fistulous passage for the discharge of the milk. The child should, at the same time, be weaned (if the woman is suckling), and an attempt should be made to arrest the secretion by the local use of belladonna, the internal administration of iodide of potassium, etc. In those cases in which the accumulated milk is coagu- lated, an effort should be made to promote absorption by gentle friction and kneading with warm olive oil, or some other unirritating substance. Should these means fail, the tumor must be incised, when suppuration and subsequent healing will follow. The operation should not, however, be performed during pregnancy, lest abortion follow, an event which did occur, and with a fatal result, in one of the cases collected by Birkett. The treatment of lacteal calculus, which appears to be the result of calcareous degeneration in the seat of old inflammation, consists in excision. Fissures and Excoriations of the Nipple and Areola con- stitute the affection commonly known as Sore or Cracked Nipple, and are particularly apt to be met with in the early periods of lactation, and after first labors. Beside interfering with the process of suckling, on account of the intense pain produced by putting the child to the breast, these cracks or fissures are apt, if neglected, to lead to acute inflamma- tion of the nipple, if not of the mammary gland itself. This affection is sometimes traceable to contact of the delicate skin of the part with . aphthous ulcerations in the child's mouth. The fissures, if deep, some- times bleed, and, the blood being swallowed by the child while nursing, may be subsequently vomited. I have known a child only a few weeks old to be dosed with styptics, by direction of the practitioner in attend- ance, in order to check supposed haematemesis, until an inspection of the wet-nurse's breast, by another physician called in consultation, revealed the source of the vomited blood in a fissured state of the nipple. The treatment of cracked nipple consists in the employment of fre- quent ablutions, and in the use of astringent washes, such as those con- taining borax, alum, tannin, or catechu, with emollient ointments, such as that of oxide of zinc. The application of nitrate of silver, in sub- stance or solution, to the bottom of the crack, is an efficient but very painful remedy. Collodion, or the styptic colloid of Prof. Richardson, is useful in protecting the part from irritation. A large number of salves and ointments of different kinds are in popular use in the treatment of excoriated nipples, but are, with few exceptions, more often injurious than otherwise. The compound resin cerate of the U. S. Pharmacopoeia has, under the name of Deshler's salve, acquired in this community a high reputation as a remedy for sore nipples. Whatever substance be employed, it should, for obvious reasons, be carefully washed off before applying the child to the breast. Nipple-shields of lead or other metal are recommended by some authors as a means of protecting the part during the act of suckling. Abscess of the Areola is to be treated by the application of emol- lient poultices, and by the early evacuation of the contained pus. The in- cision made for this purpose should be in a line radiating from the nipple towards the circumference of the breast, so as to avoid wounding any of the milk-vessels—an accident, the occurrence of which might lead to the formation of a troublesome fistula, or to permanent occlusion of the duct. MAMMITIS. 735 Mammitis (Mastitis, Mazoitis, Inflammation of the Breast, Mam- mary Abscess, Gathered Breast).—Inflammation of the breast may occur during any stage of lactation, more rarely during pregnancy, or even at other periods. It is, perhaps, most common a few days after delivery— when it occurs as an exaggeration of the natural raptus, or determination towards the mammary glands, which accompanies the establishment of the flow of milk—and again, towards the end of lactation, when, the functional activity of the glands being exhausted, these organs appear to resent the effort to force a continuance of the secretory act. The occur- rence of this affection is often traceable to exposure to cold, to injury (as from sleeping with the distended breast compressed between the arm and body), to overdistension, from a neglect to suckle the child at proper intervals, or to the irritation produced by a cracked nipple. The symptoms of mammitis vary somewhat according to the seat of the inflammation, whether in the supra-mammary or submammary areo- lar tissue, or in the structure of the gland itself. In supra-mammary inflammation, the symptoms are those of ordinary phlegmonous inflam- mation in any situation; the affection is usually circumscribed, the result- ing abscess rarely (according to Birkett) exceeding one or two inches in diameter. The skin over the seat of inflammation is, in these cases, red from the very beginning of the affection, the redness often preceding the other signs of the disease. The symptoms of submammary inflam- mation are more obscure; the form of the swelling is, however, charac- teristic in these cases, the whole breast being thrust forwards, and assum- ing a conical appearance. This is a more serious affection than that last ' described, suppuration following more constantly, and the abscess some- times discharging itself by numerous openings around the circumference of the gland. In inflammation of the mammary gland itself, one or several lobes may be involved, the swelling in the latter case sometimes presenting a distinctly lobulated appearance. The skin over the inflamed part becomes oedematous, and, when suppuration is impending, assumes a dusky-red and polished appearance. Treatment. — The constitutional treatment of inflammation of the breast consists in the administration of mild laxatives and anodyne diaphoretics, during the early stages of the affection, when there is often much fever and general sympathetic disturbance, followed by tonics, when suppuration has occurred. The patient's diet should be nutri- tious and abundant throughout the whole course of the affection, and malt liquors, or even more powerful stimulants, are often required in the later stages of the disease. An almost infinite variety of topical reme- dies has been recommended, and every nurse, and neighbor of the patient, is usually provided with at least one infallible cure; these volunteered prescriptions are, however, more often adapted to aggravate than to alle- viate the patient's condition. Leeches are advised by many authors, but, beside debilitating the patient by the abstraction of blood, often seem to hasten, rather than to prevent suppuration; if employed at all, they should be applied, as advised by Dewees, below rather than immediately over the affected surface. Rest of the inflamed organ is of the highest importance; to secure this, the breast should be supported in a sling, or in an elastic suspensory bandage (such as is in this city made for the purpose), and the arm should be kept to the side, so as to prevent mo- tion of the pectoral muscle. The application of cataplasms, or of warm, emollient fomentations, is commonly both more soothing to the patient and more efficient than the use of evaporating lotions. Gentle and methodical friction with warm olive oil and laudanum, when it can be 736 DISEASES OF THE BREAST. borne, is a valuable adjuvant to the other remedies employed. Bella- donna plasters are used by many surgeons, and are supposed to arrest the flow of milk; they have, in my own experience, rarely been of much service. As long as there is a prospect of obtaining resolution, the breast should be kept constantly exhausted, either by suckling, or, if this give too much pain, by the use of a breast-pump. When suppuration has occurred, the child should, I think, as a rule, be weaned; few women can, without injury, sustain the drain of a mammary abscess superadded to that of lactation, while the milk furnished under these circumstances is necessarily unsuited for a child's nutriment. When an abscess has formed, the use of poultices should be continued, and, as soon as decided fluctuation is manifested, a free incision should be made, in a line radiating from the nipple to the periphery of the breast. In most instances, the exact spot at which the opening should be made will be indicated by the occurrence of pointing, but should this indication not be present—as will often be the case if the abscess origi- nate in the submammary region—the incision should be made where fluctuation is most distinct, and, if possible, preferably I think at the upper part of the breast; this advice is contrary to that usually given, an opening in the most depending situation being commonly recom- mended ; but the advantage of the superior incision, is that, in the after- dressings, it allows the walls of the abscess to be more closely brought together by strapping. As'prolonged suppuration is undesirable, poulticing should be discon- tinued a few days after the opening of the abscess, and a piece of oiled Fig. 413. , \ Mode of supporting the breast by strapping. lint, or a little simple cerate, laid over the wound. The breast should then be carefully strapped (Fig. 413), strips of adhesive plaster being applied in an imbricated manner, so as to firmly support and gently com- press the whole organ. In some instances, particularly if the case have been neglected in its early stages, several openings form, which may TUMORS OF THE BREAST. 737 persist and degenerate into troublesome sinuses; these may usually be induced to heal by careful strapping, and by the use of stimulating or astringent injections—tonics and concentrated food being at the same time freely ad ministered—and if these means fail, the establishment of a seton (as recommended by Dr. Physick) should be tried, before resorting to the extreme measure of laying open the sinuses with the knife. Chronic or Cold Abscess of the Breast is to be treated by making an opening in a convenient situation, and, if necessary, introducing a drainage tube, the breast being supported by strapping, while the general condition of the patient is improved by the administration of tonics and nutritious food. The arm should be kept to the side and supported in a sling. Encysted Abscess is chiefly interesting on account of its having been frequently mistaken for solid tumor, and excision of the breast having, as a consequence, been unnecessarily performed. The diagnosis may be made by observing that abscess almost invariably originates dur- ing the pregnant or puerperal state, is not distinctly circumscribed, nor freely movable, is accompanied with subcutaneous oedema, and is com- monly elastic, if not positively fluctuating. The exploring needle may be used in any case of doubt, and should always be employed before resorting to excision. The treatment of encysted abscess consists in the evacuation of the contained pus, and the subsequent formation of a seton or the use of stimulating injections, to promote the healing of the cavity. External support should at the same time be afforded by strap- ping. The induration in these cases may persist for a very long period. Neuralgia of the Breast.—This is a distressing affection which may occur in connection with small glandular or other mammary tumors, or may exist independently of any discoverable local lesion. It is, according to Erichsen, commonly associated with uterine derangement. The treatment is that of neuralgia in general; tonics, such as iron and the valerianate of zinc, are usually indicated, and as topical remedies, plasters of belladonna or opium will often be found serviceable. If the neuralgic condition be dependent upon uterine irritation, this must of course receive clue attention. Tumors of the Breast. The female breast is very frequently the seat of tumors, the chief forms of morbid growth of a non-malignant character met with in this situation being the cystic (simple or proliferous) and the glandular, though fibrous or fibro-plastic, cartilaginous, and osseous tumors are likewise occasionally found in the breast, as are also true hydatids, scrofulous and tuberculous deposits, etc. Of the malignant growths, scirrhus is by far the most frequent, encephaloid coming next, and colloid and melanoid cancer being comparatively rare. Cystic Tumors of the Breast.—1. Simple Cysts.—These are com- monly single or unilocular, though multiple or multilocular cysts are also found in the breast. The most common variety is the serous cyst, constituting the Sero-cystic Tumor of Sir B. C. Brodie, but oily cysts fire also sometimes met with in the mammary region. The pathology 47 738 DISEASES OF THE BREAST. and general characters of these growths have already been considered (pp. 461, 462), and it merely remains to be stated that they commonly occur in young and otherwise healthy persons, increase very slowly in size, are rarely painful (except perhaps at the period of the menses), have a globular appearance, and an elastic or even fluctuating feel, are movable, occupy usually a limited portion of the breast, do not implicate the neighboring lymphatic glands, and are rarely attended with re- traction of the nipple, or discoloration of the superjacent skin. If, however, a unilocular cyst be very large, and the skin over it thin and tense, the hue of the contained fluid may be apparent through the integument, or the tumor itself may be translucent, the affection being then sometimes designated Hydrocele of the Breast. If, as sometimes happens, the cyst communicate with a milk duct, pressure may cause a small quantity of fluid to exude from the nipple. Diagnosis.—The diagnosis of simple mammary cysts, if superficial, is attended with little or no difficulty, but if deep-seated these growths may be readily mistaken for cancer. Hence, in any case of doubt, the surgeon should not neglect the use of the exploring needle. Treatment.—If the cyst be single, or unilocular, a cure may sometimes be effected by the application of stimulating embrocations, such as the tincture of camphor with lead-water, or the tincture of iodine. Should these means fail, the cyst may be punctured and a seton established, or stimulating injections, with pressure, may be employed, so as to induce adhesion of the cyst walls; or a free incision may be made, and -the cavity stuffed with lint, so as to convert the cyst into an abscess. Finally, if the cyst wall be thick, the whole tumor may be dissected out, the mammary gland itself being allowed to remain. In cases of multiple, or of multilocular cysts, excision is the only mode of treatment to be recommended; and it may even be proper, in some instances, to remove the whole gland, so as to insure thorough extirpation. 2. Proliferous Cysts with Vascular Intra-cystic Growths.—The breast is the favorite seat of this variety of cyst, which constitutes the Sero- cystic Sarcoma of Sir Benjamin C. Brodie. Its pathology, mode of Fig. 414. Sero-cystic sarcoma. growth, and symptoms, and the means by which it maybe diagnosticated from a cancerous growth, have already been sufficiently referred to (page 463). The only treatment likely to result in a permanent cure, is com- plete excision of the affected breast. GLANDULAR TUMOR OF THE BREAST. 739 Glandular Tumor of the Breast (Adenoid Tumor, Adenocele, Chronic Mammary Tumor).—This affection appears to originate as a proliferous cyst, the intra-cystic growth gradually encroaching upon and filling the cavity of the cyst, which is thus converted into a solid tumor. The glandular tumor usually occurs in young women, and often ac- companies irritation or other derangement of the reproductive organs. It is usually of slow growth .(occasionally, however, increasing very rapidly), commonly painless, except, perhaps, at the menstrual periods, movable, circumscribed, and with a curved outline; it is somewhat nodu- lated, and does not implicate the neighboring lymphatic glands. Though often apparently isolated and unattached, this form of tumor is, accord- ing to Birkett, invariably connected with the tissue of the mammary gland—sometimes by a narrow peduncle—and is inclosed within the fascia of that organ. A section of the growth presents a somewhat granular appearance, and is at first of a bluish-white color, becoming, by exposure to the air, pinkish, and finally quite red. A viscid, glairy, synovia-like fluid maybe sometimes expressed from the cut surface of the tumor, but is very different in character from the "cancer-juice" of scirrhus. By microscopic examination, the chronic mammary tumor is found to consist of gland-structure in various stages of development, Fig. 415. Glandular tumor of the breast: a, portion of normal gland-structure ; b, adenoid new formation ; c, connective and fatty tissue. Magnified 250 diameters. surrounded by an investment of areolar tissue, which divides the growth into minute lobules; the caecal terminations of the gland-tubes contain epithelial scales. These tumors are frequently found to contain cysts. Treatment.—These growths sometimes disappear spontaneously, and this circumstance, together with the fact that their removal has some- times been followed by a development of cancer in situ, should make the surgeon hesitate to recommend excision in any case in which the tumor is indolent and not increasing. Under such circumstances, the treatment should consist simply in the adoption of measures to improve the general health, with the application of sorbefacients and compression. Should, however, the tumor assume a rapid growth, or should its presence be the source of anxiety to the patient, excision may be practised, and usually with excellent results. In such a case, it will commonly be sufficient to remove the tumor itself, with that lobe of the gland to which it is attached. Painful Mammary Tumor (Irritable Tumor of the Breast)__ Two varieties of tumor are embraced under this name, one of an ade- noid or glandular character, and the other a true "painful subcutaneous 740 DISEASES OF THE BREAST. tubercle" (see page 477). The treatment consists in the administration of tonics, with compression, and the local use of anodynes—or in excision, which may be confidently expected to give permanent relief. Cancer of the Breast.—The breast is the favorite seat of Scirrhus, which is also the most frequent form in which cancer occurs in this local- ity. Atrophic Scirrhus is a term used by Collis, and some other writers, for those forms of scirrhous cancer which reduce the organ in which they are seated below the normal size, while the term Lardaceous Scirrhus is used to designate those tumors in which, along with the cancer cells, there is also a deposit of a large quantity of fat—the name aptly indi- cating the brawny feel and appearance (like that of hog's skin) which is observed in these cases. The lardaceous cancer must not be con- founded with the cancer " en cuirasse" (p. 482), which commonly runs a course as chronic as that of the other is acute. Encephaloid of the breast is a much rarer affection than scirrhus, the proportionate number of cases being variously estimated, by different writers, as from one-twentieth to one-fifth. In some cases, the tumor appears, microscopically, to occupy an intermediate position between scirrhus and encephaloid, and to such growths the terms Acute Scirrhus and Firm Medullary Cancer have been applied. Melanoid and Colloid Cancer are also occasionally, but very rarely, found in the breast. Diagnosis—The structure and microscopic appearance of these vari- ous forms of cancer, as well as their course and symptoms, have already been sufficiently described in Chapter XXYL, and I shall, therefore, in this place merely recapitulate those points which may serve to aid in the diagnosis between scirrhus and non-malignant solid mammary tumors— the characters of encephaloid being commonly so plainly marked as to render its recognition a matter of comparative facility. Non-malignant Tumors are somewhat nodulated, not very hard, occasionally partially elastic, movable, and non-ad- herent. Scirrhus, on the other hand, originat- ing as a small nodule, is from the first of a stony hardness, and soon becomes fixed and adherent to subjacent tissues, being evidently infiltrated among the struc- tures in which it is developed. The skin becomes widely involved, having a peculiar pitted or dimpled ap- pearance, from the shortening of various subcutaneous fibres. In an extreme de- gree, this pitting gives the whole breast a brawny or lardaceous appearance. The nipple is commonly retracted, and the superficial veins dilated. The pain is severe, but not continuous, of a lanci- nating or "electric" character. The neighboring lymphatic glands, particularly those in the axilla and above the clavicle, become involved in the dis- ease, which is often attended by a marked state of cachexia. The tumor usually grows pretty rapidly, is attended with ulceration, often of a peculiar character (p. 480), and frequently recurs after ap- parently thorough removal. Non-malignant mammary tumors may "Scirrhus is seldom met with in persons occur at any age, but are most common under forty years of age. in women less than forty years old. Prognosis.—The prognosis of cancer of the breast is, of course, un- favorable. The most rapidly fatal cases are those of encephaloid, and of They are covered with healthy skin, except in the ulcerative stage of the sero- cystic sarcoma, and the skin even then does not appear infiltrated, as in the case of scirrhus. The nipple is rarely retracted, and the superficial veins are not markedly dilated. There is seldom much pain, except in the case of the "irritable tumor,1' and then continuous, and of a neuralgic character. The neighboring lymphatic glands are not involved; there is no tendency to multiplication in internal organs, and, therefore, no cachexia; and the tumor, which grows slowly, rarely recurs, if it have been thoroughly excised. EXCISION OF THE MAMMARY GLAND. 741 lardaceous scirrhus, and the least so, those which assume the atrophic form. The latter are chiefly met with among old persons, and, the course of the disease being chronic, death may ensue from some other cause. In the cuirass-like form of the affection, again, life is often prolonged for a considerable period; in these cases the virulence of the disease appears to be expended mainly upon the skin, the lymphatic glands and internal organs not being implicated until at a comparatively late stage. Treatment.—The only treatment which offers any prospect of per- manent benefit, in cases of mammary cancer, is excision of the tumor, together with the whole mammary gland—though as palliative measures, compression and the application of cold may occasionally be of service (see page 488). If the tumor, though in the region of the breast, do not appear to involve the mammary gland, it will usually be sufficient to remove that portion of this organ which is nearest the cancerous mass—unless the tumor be below or on the sternal side of the gland, when, as the latter becomes infiltrated at an early period, total excision should be practised. Operative measures are not, however, to be indiscriminately resorted to in every instance. Certain cases are totally unsuited for excision:— such are those in which there are multiple tumors; in which there is extensive implication of the lymphatic glands, particularly of those above the clavicle; in which the disease appears to have involved internal organs ; in which there is wide-spread ulceration ; or in which the whole integument of the breast is brawny and lardaceous. The presence of any of these conditions would forbid the hope of being able to effect thorough extirpation, and would therefore render operative interference improper. Nor, again, would excision be, as a rule, advisable, in a case of atrophic or cuirass-like cancer, occurring in an old person, nor in any case in which, from the general condition of the patient, or from other circumstances, the operation would probably be in itself attended with unusual risk. Excluding all these cases, however, there remain a large number—probably a majority—in which early excision is highly de- sirable, and in which the surgeon should urge its performance. The reasons upon which this advice is grounded have already been given (page 489). Slight brawniness of the integument, limited ulceration, moderate adhesion to subjacent structures, or even slight lymphatic implication, though unfavorable circumstances, do not necessarily contra- indicate the operation. While no rule of universal application can be laid down upon this subject, the surgeon will not, I think, have cause to regret his decision, who operates in those cases (and those only) in which it appears practicable to safely extirpate the entire mass of disease. When excision is to be done at all, it should be done as soon as the nature of the case has been ascertained, there being no advantage to be gained by delay. Caustics may be employed in sorhe rare cases, to which the knife may be deemed inapplicable (see page 489). Recurrent growths should be removed as soon as' detected, with the same limita- tions as in the case of the primary tumor. Excision of the Mammary Gland.—The operation is thus per- formed: The patient, being in the recumbent posture, is thoroughly etherized, and her clothing so arranged as fairly to expose the breast and upper extremity. The arm is then held out of the way by an as- sistant, in such a manner as to render tense the fibres of the pectoral muscle. If the tumor be non-malignant and of moderate size, a single incision will suffice; this may be a simple oblique cut in the direction of 742 DISEASES OF THE BREAST. the muscular fibres; or, if more room be required, may be in the form of a double curve, or S. In the removal of malignant growths, however the affected portion of integument must itself be excised; and here two semilunar incisions may be employed, one below and the other above the nipple, which is included between them, or a double S incision (Fio\ 228), or, if the tumor be very large, an oblique incision over its upper Fig. 416. Excision of the breast. part, and two shorter longitudinal incisions meeting below the nipple, which is thus removed with a triangular portion of skin. In other cases, again, the surgeon may prefer a circular or an oval incision around the nipple, as advised by the late Mr. Collis, of Dublin. The particular line of incision is a matter of but small importance, provided that care be taken to remove every part of the integument which appears adherent or infiltrated. Having completed his external incisions, the surgeon dissects rapidly down to the pectoral muscle, and turns up the edge of the mammary gland (Fig. 416), which may then often be separated by the fingers, aided by a few strokes of the knife. In other cases, a portion of the pectoralis itself may require removal, and I have occasionally been obliged to carry the dissection so deep as to expose even the surface of the ribs and the intercostal muscles. When by careful examination of both tumor and wound, the surgeon has satisfied himself that all the diseased structure has been removed, attention should be directed to the state of the axillary glands. It may happen that a single gland is enlarged, but not markedly indurated, and that it is so, apparently, as the result of transmitted irritation, rather than from being itself carcinomatous. Under such circumstances, the axilla should not be interfered with, the gland being watched, however, and, if necessary, subsequently removed by a separate operation. If the axillary glands are evidently involved in the disease, though not so extensively implicated as to forbid operative treatment altogether, it is usually advised that they should be removed, the upper extremity of the incision being extended as far as necessary for this purpose. This is the course which I have myself always pursued, and it is, as mentioned, in accordance with the teaching of most authors. It is but right to add, however, that the late Mr. Collis (for whose opinion I have the highest respect) deprecated incisions into.the axilla in almost all cases, believ- ing that such incisions were apt to be followed by the development of CAUSES OF HERNIA. 743 lardaceous cancer of the arm and side, and that they were likely to hasten the death of the patient. When axillary glands are to be removed, they should as far as possible be enucleated with the fingers and handle of the scalpel, rather than excised—the use of the edge or point of the knife being, in the deep portions of the axilla, attended with considerable risk. If the implicated glands should unfortunately be so deeply attached as not to admit of complete removal, the best that can be done is to draw down the mass and throw a strong ligature around its base, cutting off the part below the seat of strangulation, in hope that the remainder may be destroyed by sloughing. The wound left by the operation of excision of the breast, should be simply dressed. A few ligatures only are commonly required; the lips of the wound are brought together with a few points of suture, or with adhesive strips, a piece of oiled lint, covered with oiled silk, being then applied, and held in place with strips of plaster or a light bandage. The arm should be laid across the chest, so as to relax the parts and thus facilitate union, but should not be closely confined. The mortality from the operation is small, in view of the extent of the wound, being, » even in hospital practice, less than ten per cent. The chief risks are from the development of erysipelas or pyaemia. The Mammary Gland in the Male may occasionally be the seat of disease; thus it has been found hypertrophied, and has been known to furnish a secretion of milk, while it is sometimes the seat of cystic growths, or of scirrhous or medullary cancer. The treatment would be the same as for similar affections in the female. CHAPTER XL. HERNIA. The term Hernia signifies a protrusion of any portion of the viscera through an abnormal opening in the walls of the cavity within which the protruded part is naturally contained. A protrusion through a normal aperture is not a hernia; thus the term is never applied to a protrusion of the bowel through the anus, or of the womb through the vulva. Herniae of the brain, and of the thoracic viscera, have already been con- sidered in previous portions of the volume; and the subject for discus- sion in this place is therefore limited to Abdominal Hernia, or, as it is familiarly called, Rupture. Any part of the abdominal parietes may give passage to a hernia, but rupture is most likely to occur where the muscular and tendinous struc- tures are comparatively weak, as where the spermatic cord or round ligament issues from the abdomen, where the femoral vessels pass into the thigh, or at the umbilicus. Causes op Hernia. The Predisposing Causes of rupture may be divided into such as pertain to the general condition of the patient, as age, sex, etc., and such as pertain to the local condition of the part in which the hernia 744 HERNIA. subsequently occurs : the latter are called by Birkett the Inciting Causes. The Immediate, or Exciting Cause of rupture, when any such can be alleged, is usually some violent exertion, as in lifting, coughing, or straining. General Predisposing Causes.—1. Age—The majority of cases of hernia are developed in infancy, or early adult life; more, that is, before the age of thirty-five years than afterwards. This statement is contrary to the ordinarily received doctrine, but has been clearly estab- lished by the researches of Mr. Kingdon (of the City of London Truss Society) and of Mr. Birkett. As, however, the number of infants and young persons in every community is much larger than that of adults, the relative frequency of hernia is greater as old age approaches. Thus advancing age may be considered a predisposing cause of hernia. 2. Sex.—The male sex is unquestionably more predisposed to the occurrence of hernia than the female, the proportion, for all ages and forms of the disease, being, according to Kingdon, about two to one. The difference is most marked in infancy and early childhood, on ac- count of the frequency of a congenital malformation in the male, which t will be presently referred to. 3. Occupation.—The majority of cases of hernia occur among the labor- ing classes, but there does not appear, according to Kingdon, to be any direct connection traceable between the development of rupture and the pursuit of any particular occupation. 4. Inheritance.—A predisposition to hernia is frequently inherited, the first year of life being that in which the hereditary influence is most marked. The anatomical peculiarities on which the frequent occurrence of hernia at this early age depends, are, (1) imperfect closure of the ventral orifice of the vaginal process of the peritoneum, and persisting patulousness of that canal, and (2) abnormal lengthening of the mesen- tery. The first-named malformation is always, and the second often, probably, of congenital origin ; they will be again referred to under the heading of inciting causes. Local Predisposing or Inciting Causes.—1. Wounds, etc.—The occurrence of hernia is occasionally predisposed to by wounds or subcu- taneous lacerations of the abdominal parietes. Ventral hernia usually results under these circumstances (see page 365), but if the wound be suitably situated, inguinal, or any other form of hernia may ensue. 2. Weakening of the Abdominal Parietes, as the result of previous inflammation, abscess, etc., or from over-distension by the pressure of the gravid uterus, by the accumulation of fat in the omentum or mesen- tery, or by the development of ovarian tumors, or of ascites, may act as a predisposing cause of hernia. 3. A Patulous Condition of the Vaginal Process of the Peritoneum, or of its Ventral Orifice, is a frequent predisposing cause of hernia. It is known that the testicles are, in the earlier periods of foetal life, situated in the lumbar region, whence they gradually descend into the scrotum. During their descent, they are behind and partially invested by the peri- toneum, a prolongation of which membrane accompanies them into the scrotum, where it forms the tunica vaginalis on either side. This vagi- nal process of the peritoneum at first forms one common sac with that of the peritoneum itself, and the communication between them often persists at birth, or even a month or two later. Usually, however, about the period of birth, the vaginal process divides into two portions, by the NOMENCLATURE. 745 contraction of the sheath and the formation of adhesions between its sides, at about the position of the head of the epididymis. The lower portion invests the testicle (forming the tunica vaginalis propria testis), while the upper portion lies in front of the spermatic cord, and consti- tutes the tunica vaginalis propria funiculi. In the normal state, the tunica vaginalis of the testicle continues through life as a closed sac, while the tunica vaginalis of the cord becomes obliterated and converted into a delicate fibrous band. It not unfrequently happens, however, that the funicular portion of the vaginal process persists as a tube of small calibre, closed at both ends, or, more rarely, that either its ventral or testicular orifice, or both, remain patulous. The testicular orifice is, of course, that by which the funicular portion communicates in foetal life with the testicular portion of the vaginal process of the peritoneum, while the ventral orifice is that by which it communicates with the general cavity of the peritoneum, and corresponds in position with the internal abdominal ring. From the above brief anatomical description, it can be readily understood that a patulous state of the vaginal process, or of its ventral orifice, would predispose the person in whom it existed to the occurrence of rupture. 4. A Relaxed and Elongated Condition of the Mesentery acts as a pre- disposing cause of hernia. That the mesentery is actually elongated, in many cases of hernia, can scarcely admit of a doubt—for the bowel could not descend so low as it is observed to do in the scrotum, were its mesenteric attachments not abnormally relaxed—but whether this relax- ation and elongation be a cause or a consequence of hernia, is a different question; that it is often a cause of rupture, is rendered probable, as pointed out by Birkett, by the facts that (1) persons with a hernial sac are more troubled by the descent of a hernia when out of health than at other times; (2) persons of a relaxed frame are more apt than others to become subjects of hernia, as they advance in life; and (3) in middle- aged persons of either sex, affected with hernia, the abdominal viscera generally are less firmly held in place by their peritoneal attachments, than in those who have no disposition to hernia. This elongation of the mesentery may, as just mentioned, be due to a relaxed state of the fibrous tissues, acquired at any period of life, or may probably, in some cases at least, be of congenital origin. 5. The Gradual Stretching and Protrusion of the Parietal Peritoneum at weak parts of the abdominal wall, as the result of frequently repeated muscular exertion, of coughing, of straining at stool, or in urinating, etc., may act as a predisposing cause of hernia, by leading to the ultimate development of a sac or pouch into which the viscera may be received, this pouch then constituting the sac of the hernia. Immediate or Exciting Causes.—In the majority of instances, probably, a hernia is slowly developed, and may not attract the patient's attention until fully formed ; in other cases, however, the rupture occurs suddenly, as the result of a fall, or of some violent muscular effort. Nomenclature. Herniae are classified according to their (1) locality, as inguinal, fem- oral, scrotal, umbilical, etc.; (2) condition, as reducible, irreducible, strangulated, etc.; (3) contents, as intestinal (enterocele), omental (epi- plocele), vesical (cystocele), etc.; and (I) period of development, as con- 746 HERNIA. genital, infantile, etc. The latter mode of classification is, however, incorrect, as many cases of so-called congenital and infantile hernia do not occur until adult life. Structure op a Hernia. A hernia consists essentially of a sac and its contents, the tissues ex- ternal to the sac being the skin, subcutaneous fascia, etc., of the part in which the hernia occurs. In some instances the sac is wholly or partially deficient, as in caecal and vesical herniae, certain congenital umbilical herniae, and in ventral herniae resulting from penetrating wounds. With these exceptions, every hernia has a sac (or peritoneal investment), that part which communicates with the peritoneal cavity being the neck, and that which surrounds the protruded viscera being the body of the sac. Varieties of the Hernial Sac.—There are two distinct varieties of the hernial sac, the congenital and the acquired. 1. The Congenital Sac consists of the patulous vaginal process of peritoneum, or of its funicular portion, and is therefore only met with in those forms of oblique inguinal hernia which are often, though impro- perly, termed congenital and infantile. It may exist through life as a pouch, communicating with the peritoneal cavity, without ever becoming the seat of an actual hernia. 2. The Acquired Sac is slowly developed by the gradual stretching of a portion of the parietal peritoneum, as the result of frequently repeated pressure from within, exercised by the organs which ultimately form the contents of the hernia. This is the form of sac which exists in the ordi- nary oblique and direct inguinal herniae, as well as in femoral hernia, and in those which occur in other regions. The mode of development of the acquired hernial sac has been particu- larly studied by Cloquet and Demeaux, and is well described by Birkett. When the parietal peritoneum first protrudes through the abdominal wall, the widest portion of the sac is that which communicates with the peritoneal cavity, but in the fully formed sac, the neck is smaller than the body, the sac being puckered like the mouth of a purse, by the con- striction of the fibrous or muscular ring through which the hernia has escaped. In this stage of the hernial sac's development, which is called the period of formation, the neck of the sac itself exercises no constric- tion upon the protruded viscus, and the puckering which has been described disappears upon reduction of the hernia, or upon division of the ring of the abdominal wall through which the rupture has occurred. At a later stage, the period of organization, the puckered folds at the neck of the sac adhere together, while at the same time the fat disappears from the adjacent subserous areolar tissue, this becoming converted into an indurated and vascular ring which is said to contain a layer of con- tractile fibres. In this stage, the neck of the sac exercises an essential constricting power, and requires to be divided if the hernia becomes strangulated. The ultimate stage is the period of contraction; as soon as a hernia ceases to descend, the orifice of the sac manifests a disposi- tion to contract, and may even become obliterated, thus accomplishing the cure of the disease—as is occasionally witnessed in the herniae of infants, and more rarely in those of adults. During this stage, the ring which surrounds the neck of the sac becomes thicker, and of a fibrous or cartilaginous hardness. If the hernia protrude in this stage, strangula- tion is very apt to occur , HYDROCELE OR DROPSY OF HERNIAL SAC. 747 The sac of a hernia is thus at first thin and translucent, but often at a later period becomes thick and indurated, and may even become the seat of calcareous degeneration; in other instances, as in cases of large umbilical hernia, the sac may by distension become extremely attenuated. The aperture in the abdominal wall through which a hernia has escaped, eventually assumes a more or less circular outline, and often becomes enlarged; it may become displaced by the weight of the pro- truding viscera, being usually dragged downwards and towards the median line of the body; thus, in an oblique inguinal hernia of long standing, the internal may come to be placed directly behind the external abdominal ring. The superficial tissues frequently become thinned and stretched, but, if a truss have been employed for a long time, may be indu- rated and thickened from the pressure of the pad of the instrument. Contents of the Hernial Sac.—Almost any of the viscera may be occasionally found in herniae, but the parts most usually protruded are the bowel and omentum. The small intestine, and particularly the ilium, is much more frequently involved in a hernia than the large in- testine : only a portion of the calibre of the gut may enter the sac, or a large coil of bowel with its mesenteric attachment. In some very large herniae, almost the whole of the small intestine may descend into the sac. When long protruded, the bowel becomes thickened and contracted, and of a grayish hue externally: its mesentery at the same time becomes hypertrophied and vascular. When the sac of a hernia is habitually occupied by omentum, the latter tissue becomes indurated and thickened, and often matted together into a conical mass, the apex of which cor- responds to the neck of the sac. The omental veins become distended and varicose, and apertures or depressions often exist in the dense mass, into which a knuckle of intestine may slip, and become strangulated. When a hernial sac contains both bowel and omentum, the latter usually protrudes in front of, and may completely surround the gut. Cysts sometimes exist in the protruded omentum, and may, in the operation of herniotomy, confuse the surgeon by their resemblance to knuckles of intestine. In addition to the viscera which are contained in the hernial sac, a certain amount of serous fluid always exists in its interior : under ordinary circumstances the quantity is but small, but if the hernia be- come inflamed or strangulated, may be very much increased. Adhesions often exist in the sac of an old hernia, gluing together the contained viscera, or binding them to the wall of the sac itself: while recent, these adhesions are soft and easily separated, but in cases of long standing become firm and form an impediment to reduction. Loose bodies, consist- ing apparently of detached appendices epiploicae, are occasionally found in the interior of a hernial sac. Hydrocele or Dropsy of a Hernial Sac is the name given to an unusual condition which consists in the accumulation of fluid in the bot- tom of a hernial sac, the communication of which with the abdominal cavity is occluded, either by obliteration of the orifice, or by the formation of adhesions between the wall of the sac and the Viscera Which OCClipy its Upper portion. Cases Hydrocele of hernial sac. 748 HERNIA. of this rare form of disease have been recorded by Pott, Pelletan, Boyer, Lawrence, Curling, Erichsen, and W. F. Atlee, of this city. The treatment consists in evacuating the fluid by means of a trocar and canula. Symptoms op Hernia in General. Fig. 418. The patient often experiences a sensation of weakness in the groin or other region in which a hernia is about to occur, before any protrusion takes place. There is also frequently a decided fulness in the part, which is most marked in the erect posture, or upon contracting the abdominal mus- cles. The hernia, if gradually devel- oped, appears as a small tumor, not larger at first, perhaps, than the tip of the finger, which can be reduced by pressure, and which disappears spon- taneously when the recumbent posture is assumed. In young children, the hernia is often of considerable size when first noticed, and the same is true of those cases of rupture which are suddenly developed as the result of violent exertion; in the latter cases, the formation of the hernia is often at- tended with pain. A fully developed hernia forms a round or oval tumor, usually broader below than above (the neck of the hernia), increasing in size when the patient stands up, holds his breath, or coughs, either subsiding spontaneously when the patient lies down, or being readily reduced within the abdomen by gentle pressure, and re-appearing upon the resumption of the erect posture. When the patient coughs, a distinct impulse may be commonly perceived in the hernial tumor. The symptoms of hernia are somewhat modified by the nature of its contents. Intestinal Hernia or Enterocele.—When the hernia contains bowel only, the tumor is smooth, gurgles under pressure, and is often tympanitic and resonant when percussed. The hernia is often the seat of borborygmus or flatulent rumbling. The impulse on coughing is well marked, and the patient frequently complains of dyspeptic symptoms, and of an uncomfortable dragging feeling. Reduction is attended with gurgling, and with a peculiar, characteristic sensation, which, when once felt, can scarcely be mistaken, and which is spoken of by some writers as the "slip" or "flop" of a hernia. Omental Hernia or Epiplocele.—In these cases, the tumor is irregular and comparatively ilUdefined, having a doughy feel, and with a less distinct impulse on coughing than in the form of the disease last described; reduction is effected gradually, and without the character- istic gurgling sensation which has been referred to. Omental hernia is said to be most frequent on the left side, and is chiefly seen in adults. Scrotal hernia in a child; a, position of left testis. (From a patient of Dr. C. B. Nancrede.) TREATMENT OF REDUCIBLE HERNIA. 749 Mixed Hernia or Entero-Epiplocele.—In these cases the symp- toms of the intestinal and omental herniae are variously combined. Caecal Hernia is of course confined to .the right side, and is com- monly irreducible, from that portion of caecum which is uncovered by peritoneum forming adhesions to the adjacent structures. Herni® of the Stomach or Bladder are of rare occurrence; the former (Gastrocele) has been observed in the inguinal and umbilical regions, and in cases of diaphragmatic rupture; there are no distinctive symptoms by which it can be certainly recognized during life. Hernia of the bladder (Cystocele) is irreducible, and attended with difficult micturition; urine may be made to flow by compressing the tumor. Treatment op Reducible Hernia. The treatment of reducible hernia may be palliative, or may aim at effecting a radical cure. Palliative Treatment.—This consists in preventing the descent of the hernia by the application of a suitable truss or bandage. In cases of umbilical and ventral rupture, an elastic band and pad may be the best means of retention, but a truss is preferable for the ordinary forms of hernia. I do not purpose to enter into any discussion of the com- parative merits of the many forms of truss which are offered by their respective inventors to the profession and the public, but shall merely mention what may be considered the requisites of a good truss. A Truss consists essentially of a pad and a spring; the pad should be firm, slightly convex upon the surface (except in particular cases), of an oval or elongated triangular shape, and sufficiently large to compress not only the aperture through which the hernia escapes, but the whole canal through which it has passed to reach the surface. The pad may be of buckskin, firmly stuffed, of polished wood, or of such other material as may be found by experience to produce least irritation of the skin, some patients in this respect differing from others. In certain cases, in which the ring through which the hernia protrudes is very large, the ordinary convex, oval or triangular pad, may be advantageously replaced by one of a horseshoe or ring shape, as recommended by Mr. J. Wood. As a rule, the plate which forms the back of the pad should be made of the same piece of metal as the spring, while the bearing of the pad should be not directly inwards, but somewhat upwards as well, the particular angle varying according to the shape of the patient's abdo- men. The spring of a truss is made of metal (covered with buckskin or leather), and curved so as to pass around the patient's trunk, just above the rim of the pelvis; it should not touch except at the point of counterpressure, which, in the ordinary single-pad truss, is at the pa- tient's hip, on the opposite side to that of the rupture—and at this point the spring should be beaten thin, curved to fit the part, and suitably padded. The spring should be elastic, and should exercise just enough force to keep the hernia reduced, without pressing so deeply as to cause absorption of the abdominal parietes. From the free end of the spring, a leather strap passes to the pad, thus completing the circle around the patient's pelvis, while, for additional security, another strap may pass from the body of the spring along the fold of the buttock and around 750 HERNIA. the inside of the thigh, to be fastened to a button at the lower edge of the pad. In many cases, particularly in those of persons with fat and pendu- lous abdomens, it is difficult to keep a hernia reduced except by using a spring of such force as to produce great discomfort, beside incurring the risk of encouraging the development of a rupture on the opposite side; under such circumstances, it may be better to employ a double-pad truss (such as Hood's), thus affording support to both sides of the abdo- men. The points of counterpressure, when such an instrument is used, are situated on either side of the spine. The double-pad truss is, of course, necessary in cases of double hernia. Before applying a truss, the hernia should be completely reduced, and the apparatus then adjusted, while the patient is in the recumbent posture; the truss may be left off at night, being removed after the patient is in bed and re-applied before he rises, but should be constantly worn at other times. Every one who is ruptured should be provided with at least two trusses, so that if one break, another may be imme- diately substituted; and it is well to have one' furnished with a plain wooden pad, for use while bathing, etc. If the pad of a truss tend to produce chafing, as is apt to be the case in hot weather, the part should be frequently washed with alum and whiskey, or cologne water, and well dusted with ordinary toilet powder, or lycopodium. The necessity of constantly wearing the truss, and of never permitting the descent of the hernia, cannot be too strongly insisted upon. The only circumstance which should be allowed to prevent the use of the instrument, is the presence of an undescended testis in such a part of the inguinal canal as to render the pressure of the truss-pad unbearable; and even such a case should not be abandoned, without an attempt to effect the desired object by trying various forms of apparatus. As a test for the efficiency of a truss, Erichsen advises that the patient should be directed to cough, while sitting on the edge of a chair, leaning forwards, and with the legs extended and widely separated; if the hernia do not slip down behind the pad under these circumstances, the instrument may be considered satisfactory. Radical Cure of Hernia.—In those cases in which the vaginal pro- cess of the peritoneum constitutes the sac of a hernia (congenital sac), the application of a well-fitting truss will occasionally effect a cure (particu- larly if the patient be an infant), by inducing the formation of adhesions between the opposing sides of the canal, and thus imitating the process of nature in accomplishing the closure of the part. In the other forms of hernia, in which the sac is slowly developed (acquired sac), it may be possible to prevent the formation of the sac by the employment of a truss ; but when once formed, all that can usually be hoped for, in the use of the instrument, is to check the further enlargement of the sac by keeping the hernia constantly reduced. Hence, although when provided with a suitable truss, a person who is ruptured may go through a long life with both safety and comfort, it is not strange that attempts should have been made to effect a radical cure of hernia by other means. Castratioai, excision of the sac, ligation or scarification of its neck, and acupuncturation, have at various times been recommended and prac- tised, but are now matters chiefly of historical interest. The injection of the sac with the tincture of iodine, has been advantageously resorted to by Professor Pancoast, of this city. Gerdy's operation, which consisted in simply invaginating a portion of the sac and superjacent integuments, RADICAL CURE OF HERNIA. 751 by pushing them up with the finger into the canal through which the rupture descended, and holding them there with sutures, while adhesion was promoted by the application of liq. ammoniae to remove the cuticle of the invaginated part, has been revived with various modifications and improvements by Syme, Fayrer, Wutzer, Wells, Davies, Armsby, D. H. Agnew, and others; while another very ingenious procedure, combining invagination with ligation of the neck of the sac, has been devised by J. Wood, of King's College, London. The subcutaneous employment of the silver-wire suture has been recently recommended by Richardson, of New Orleans, and by Chisolm, of Maryland. The more important operations for the radical cure of hernia will be described under the heads of the special forms of the disease for which they are adapted; but it will be convenient to refer, in this place, to the general question of the applicability of such modes of treatment. The objections to any operation for the radical cure of hernia, are (1) the risk by which the procedure is necessarily attended, and (2) the pro- bability of failure by the hernia recurring in spite of the operation. (1.) There is, in the first place, the risk of inflicting direct injury upon important vessels, the peritoneal cavity, or even the bowel itself. A skilful operator could doubtless avoid these accidents, yet the possi- bility of their occurrence should be borne in mind in estimating the dangers of the procedure. But even if no such untoward event as has been referred to mars the progress of the operation, it is evident that in every case there is necessarily a risk of the development of peritonitis; for every operation aims to effect a cure by inducing a certain amount of inflammation in the neck of the sac, and it is impossible to be sure that this inflammation may not spread further than is intended. And, although the statistics of various modes of operating show that but few deaths have actually occurred from peritoneal inflammation, in pro- portion to the number of cases in which the operations have been per- formed, yet, as justly remarked by Birkett, these facts only show that peritonitis is not a necessary consequence of the procedure. (2.) If, however, the chance of a fatal termination is small, the pro- bability of failure is comparatively great. Mr. Wood1 has pointed out that the main cause of failure, in most operations for the radical cure of hernia, lies in the neglect to include the posterior wall of the canal in the part operated on, the rupture sooner or later redescending behind the seat of operation; and hence a prominent feature in his own mode of procedure, consists in drawing forward the posterior wall of the canal, so as to induce its adhesion to the anterior; yet of the sixty cases reported in his work, one ended in death, and eleven in failure; of six more the termination was doubtful; while of the forty-two recoveries, ten had not been heard from since their discharge from hospital—so that the positively ascertained number of permanent recoveries, which he was then able to report, was but little more than half of the number operated upon.2 Another cause of failure, which equally affects every form of operation, is strongly insisted upon by Birkett, though denied by Wood; this is the existence of relaxation and elongation of the mesentery, which will, when present, tend to allow the reproduction of the rupture in the same or another part. 1 On Rupture, etc. London, 1863, p. 147. 8 According to Druitt, however (Surgeon's Vade Mecum, 10th edit.), of 155 cases operated on by Wood up to 1870,113 are to be classed as recoveries, and only 2 proved fatal. 752 HERNIA. Hence it would appear that the most favorable view to be taken of any operation which has been as yet proposed for the radical cure of hernia, is that while not necessarily followed by grave consequences, it is not unattended with risk, and by no means certain to effect the object designed ; and that in consideration of the safe and really satisfactory means of palliation afforded by the use of a truss, the radical treatment must be looked upon as at best an operation of complaisance or expedi- ency. The most favorable cases for operation are probably those of hernia into the vaginal process or its funicular portion, the so-called congenital or infantile cases ; for, as remarked by Birkett, it is almost exclusively in these cases that a natural tendency to spontaneous cure has been observed. The operation is doubtless justifiable in exceptional instances, as when it is found impossible to maintain reduction by means of a truss, or when the occupation of the patient or other causes render the inconvenience of wearing a truss more than ordinarily burden- some; but, though occasionally justifiable, the operation is not, in any case, one to be urged upon the patient, nor to be performed without his fully understanding the uncertainties and dangers of the procedure; and in the immense majority of cases the surgeon will best consult both his own reputation and the good of his patient, by dissuading from any but palliative treatment. Irreducible Hernia. Yarious circumstances may tend to render a hernia irreducible; thus in a rupture of long standing, the neck of the sac, as was mentioned on a previous page, becomes constricted and smaller than its body, the shape of the hernia thus sometimes rendering it irreducible, particularly if the case be one of omental hernia, in which the omentum is matted to- gether into a dense conical mass; again, a hernia may become irreducible from the formation of adhesions between its contents and the interior of the sac, or, in the case of herniae of the caecum or bladder (in which the sac is defective), between those viscera and the surrounding tissues. Symptoms.—An irreducible hernia constantly tends to become larger, and causes inconvenience by its bulk and weight—the latter giv- ing rise to an unpleasant dragging sensation, with perhaps tormina, and disturbance of the digestive functions; moreover, an irreducible hernia is constantly exposed to the risk of becoming inflamed, obstructed, or strangulated. Treatment.—This should consist in preventing the further increase of the hernia, by the adaptation of a truss with a concave pad, or, if the rupture be very large, a " bag truss" or suspensory bandage. B. Cooper, and other surgeons, have succeeded in some instances in converting an irreducible into a reducible hernia, by keeping the patient in bed and on low diet for six or eight weeks, administering at the same time purga- tives, with perhaps mercurial and antimonial preparations, and applying ice, sorbefacient unguents, or compression, to the hernial tumor. This plan could hardly be expected to succeed, unless in cases of omental hernia in which irreducibility was clue solely to the shape of the protruded mass; and the treatment itself is so tedious and annoying, that few patients can be found who are willing to submit to it. Velpeau, Bouchut, Giidi-in, and Pancoast, of this city, have resorted to subcutaneous divi- sion of the external ring or other seat of stricture, in these cases, the OBSTRUCTED OR INCARCERATED HERNIA. 753 operation consisting in making a puncture through the skin and subcuta- neous fascia, introducing a grooved director, which is insinuated beneath the source of constriction, and then dividing the latter with a curved bistoury passed along the groove and made to cut with a gentle rocking motion; it is evident from what was said concerning the development of the hernial sac, that in any case of long standing—and such only are as a rule permanently irreducible—it would be necessary to divide the neck of the sac itself (which would materially increase the danger of the operation), and that even then reduction could not be effected if adhe- sions existed between the sac and its contents. Hence the cases must be very few in number in which a prudent surgeon would feel justified in resorting to this procedure. Inflamed Hernia. Inflammation may attack a previously irreducible hernia, or may itself be the cause of irreducibility. Symptoms.—These are essentially those of local, or in some cases of general peritonitis, with constipation, but not complete obstruction, and occasionally vomiting, but not of a fecal character. The tumor is less tense than that of strangulated hernia, and the protrusion is less closely embraced by the edges of the opening through which it has passed. The inflammation may originate in the hernia, from the pres- sure of an unsuitable truss or from some other local cause, or may be secondary to an inflamed state of the alimentary canal. As the result of inflammation, adhesions are apt to form between the contents and sac of the hernia, rendering it permanently irreducible. Treatment.—The patient should be put to bed, and, if his strength permit, a few leeches may be applied over the hernial tumor. Opium may be pretty freely given, in doses suited to the age of the patient, and if there be any tendency to general peritonitis, the anodyne may be pro- perly combined with calomel. The application of an ice-bag, the skin being protected by the interposition of flannel, will often prove of the greatest service. The administration of cathartics should be strictly prohibited, but the action of the bowels may be solicited by simple ene- mata. The diet should be moderate in amount and unirritating in quality. Littre and Birkett have described a variety of inflamed hernia in which a limited portion of the wall of the bowel becomes adherent to a small hernial sac, inflammation extending to the neighboring viscera, and thus ultimately inducing intestinal obstruction and death. Obstructed or Incarcerated Hernia. A hernia is said to be incarcerated, when the portion of bowel which it contains becomes obstructed by the accumulation of gas, or of solid or liquid fecal matter—a condition which was formerly supposed to be the cause of obstruction in cases of strangulated hernia. This condition is chiefly met with in old persons with chronically irreducible hernise, and may be due to the impaction of a mass of cherry-stones or similar substances in the protruded gut. 48 754 HERNIA. Symptoms.—The symptoms are those of intestinal obstruction— moderate constipation, nausea, eructation, and perhaps vomiting—with- out any of the acute distress which accompanies strangulation; the tumor is painful and flatulent, but not particularly tense, and its gaseous and liquid contents may be sometimes pressed into the neighboring portions of bowel by cautious manipulation, when solid masses of feces may per- haps be recognized by the touch. Treatment.—This consists in the administration of purgative ene- mata, thrown up as far as possible by means of an O'Beirne's tube, so as to promote the natural peristaltic action of the bowels, opium being at the same time given in moderate quantities by the mouth. Ice may be applied to the tumor for a short time, the patient being kept in bed; and a cautious trial of the taxis (as will be presently described) may then be made, so as to at least partially empty the protruded bowel of its contents. When this has been accomplished (but not before), a cathartic may be given by the mouth. Should it be found that by these means the incarceration cannot be overcome, owing to the contracted state of the neck of the sac, it may be necessary to resort to herniotomy, either by the subcutaneous operation described in speaking of irreduci- ble hernia, or by one or other of the methods ordinarily employed in cases of strangulation. It should never be forgotten, however, that incarcerated, unlike strangulated hernia, is essentially a chronic affec- tion, and the surgeon should beware of converting it into one which is acute by a premature resort to the knife. Strangulated Hernia. A hernia is said to be strangulated, when it is so constricted that its circulation is materially interfered with, inflammation and ultimately gangrene of the protruded viscus inevitably resulting, if the strangula- tion be not relieved. If the case be one of enterocele, the function of the strangulated portion qf intestine ceases, and obstruction of the bowel necessarily ensues; but if the omentum or vermiform appendix alone be involved, though there will be constipation, it may not be complete. Causes of Strangulation.—In some cases, the occurrence of stran- gulation is preceded for several hours by a feeling of relaxation and weakness in the bowels, with perhaps a tendency to diarrhoea. Hence, Birkett believes, and probably with reason, that, in some instances at least, mechanical constriction is not the sole cause of strangulation, which may be partially due to a morbid action engendered in the tissues of the bowel itself. Strangulation usually results from the protrusion of an additional portion of intestine into an already existing and per- haps irreducible hernia, or from the descent of a hernia which has been long restrained by a truss into a sac which has reached its ultimate stage of development, that of contraction (see page 746); occasionally, however, a hernia becomes strangulated when first protruded—this form of strangulation commonly occurring as the result of violent effort in young persons, and running a more acute- course than that which occurs in large herniae of long standing. Finally, a hernia which is at first merely obstructed or incarcerated, may eventually become strangulated by the gradual arrest of its venous circulation. STRANGULATED HERNIA. 755 Mechanism of Strangulation.—The occurrence of strangulation was formerly attributed to spasm of the walls of the opening through which the hernia descends; as, however, the tissues which surround the neck of the hernial sac are in most instances fibrous or tendinous, the occurrence of spasm must be considered at least doubtful, though the contractile fibres which are said to have been found in cases of long standing (p. 746) might aid in causing strangulation. The mechanism by which this condition is induced, in most cases, is as follows: a seg- ment of bowel or portion of omentum is suddenly extruded, under the influence of some violent effort, and being immediately compressed by the sides of the opening through which it has escaped, is prevented from returning; or from some morbid action in the alimentary canal generally, or in the peritoneal tissue, a previously existing hernia becomes con- gested, swollen, and temporarily irreducible; or the same effect may be caused by the accumulation of gaseous or fecal matter in the protruded bowel. Whatever be the particular circumstances of the case, the con- tents of the hernial sac become congested, swollen, and oedematous, the disproportion in size between the protruded viscera and the orifice through which they have escaped, becoming momentarily greater. The consffriction may be so tight as to deprive the strangulated part of vitality in a very short time, gangrene thus sometimes occurring in acute cases in the course of a few hours; under other circumstances gangrene is preceded by inflammation—and a patient with this chronic form of strangulation, may die of exhaustion and general peritonitis, without actual sphacelus having occurred. Seat of Constriction.—This may be—1, external to the sac; 2, in the tissue of the sac itself; or 3, entirely within the sac. 1. In cases of recent hernia, in which the sac has not passed beyond the period of Fig. 419. formation (p. 746), strangulation is com- monly due solely to the compression exer- cised by the tissues external to the neck of the sac; this is usually the case in small strangulated herniae which occur as the result of sudden efforts in young persons. 2. In a large number of instances, the neck of the sac itself is the seat of con- striction: this is the case usually when the hernia has existed for a considerable time before the occurrence of strangulation. Occasionally, the seat of constriction may be in the body of the hernial sac, which may present an hour-glass shape, due either to a congenital peculiarity (p. 771), or to the stricture in the neck of the sac, formation of a recent sac above an old one, laid open. the neck of which has undergone contraction. 3. In some rare cases, the seat of constriction is entirely within the hernial sac, being due to the presence of bands of organized lymph; or strangulation may result from a knuckle of intestine being caught in a rent or pocket of omentum, in cases in which both are involved in the hernia. Structural Changes resulting from Strangulation—These are first manifested in the contents of the hernia itself, and subsequently 756 HERNIA. in its sac and other coverings, and in the contents of the abdominal cavity. 1. Changes in Contents of Hernia.—The first effect of strangulation is to produce congestion of the strangulated part, followed more or less quickly by inflammation and gan- Fig. 420. grene. In cases of acute strangula- tion, the bowel may present a distinct groove at the part corresponding to the seat of constriction, and ulcer- ation and perforation may take place at this point. The congested portion of intestine is swollen, of a u leathery" consistency, dark-red or brownish- purple in color, and often dotted with ecchymoses. In the stage of inflam- mation, patches of lymph may be ob- served on the peritoneal surface of the bowel, and the part feels sticky to the touch. As gangrene approaches, the serous covering of the intestine»loses its natural lustre, the gut becomes Gangrene of intestine from strangulation. Soft and doughy, the Color is a gray- ish-black, and the various layers of the bowel become readily separable from each other; ultimately the part gives way, and fecal extravasation occurs, resulting either in death or in the formation of a fecal fistula. Fortunately, before perforation occurs, adhesions have usually sealed the sides of the gut to the neck of the sac, so that the contents of the bowel do not enter the peritoneal cavity. The omentum, in the stage of congestion, presents a good deal of venous engorgement, assuming a reddish hue when inflamed, and becoming purple or grayish-yellow when gangrene supervenes. The fluid of the hernial sac is usually increased in quantity, and assumes a reddish-brown color from the transudation of blood, becoming cloudy, dark, and fetid, upon the occurrence of gangrene. Hemorrhage into the sac is occasionally met with, and, still more rarely, suppuration takes place, probably as the result of injury inflicted by the prolonged employment of the taxis. 2. Changes in Sac and Coverings of Hernia.—The sac and its external coverings become inflamed, if the strangulation be not relieved, the skin over the hernial tumor becoming, on the approach of gangrene, of a reddish-purple hue, tender, doughy, and ultimately emphysematous, from the occurrence of mortification or the escape of gas from the ulcer- ated bowel; finally, if the case be left to itself, sloughing will ensue, when the patient may possibly recover with a fecal fistula. 3. Changes in Abdominal Cavity___The peritoneum always, probably, becomes inflamed when strangulation has persisted for any length of time, the inflammation usually assuming a diffused character, and being attended with the effusion of cloudy serum, and the production of ill- formed lymph or pus.. Symptoms of Strangulated Hernia.—These are either local or constitutional. 1. Local Symptoms.—If the hernia has existed for some time, it will be found, when strangulated, to be larger than usual, and somewhat painful, and if it contain bowel, to be tense, resisting, and semi-elastic to the touch; an omental hernia, however, may be soft and doughy, SYMPTOMS OF STRANGULATED HERNIA. 757 though strangulated; or if, as rarely happens, a recent hernia becomes strangulated behind an old and empty sac, the flaccidity of the latter may mask the tenseness of the former. The hernia is, of course, irre- ducible. There is no. longer any impulse on coughing, the constriction preventing any fresh descent of bowel, and not allowing the shock of coughing to be transmitted to the hernial contents—a fact which sug- gested to Luke an ingenious plan of determining the seat of strangu- lation, by noting the exact point at which the impulse ceased to be felt. The hernia may continue to increase in size, after the occurrence of strangulation, from the effusion of serum into the sac; this is particu- larly observed in cases in which the taxis has been repeatedly, though fruitlessly, employed. On the approach of gangrene, the hernial tumor, as already mentioned, presents the ordinary signs of inflammation, and, in some instances, suppuration or sloughing may ensue. 2. Constitutional Symptoms.—These are referable to obstruction of the intestine, and to subsequent inflammation of the sac and peritoneum. (1.) The symptoms of intestinal obstruction are essentially the same, whatever may be the cause of obstruction ; they consist of griping pains about the umbilicus, a sense of constriction, with flatulence, tympanites, tenesmus, constipation, nausea, and vomiting. There may be one or two passages from the lower bowel after the establishment of strangu- lation, and, if the hernia be altogether omental, there may not be at any time complete constipation. There is also a variation in the degree to which vomiting is present; in some cases early and profuse, in other cases there may be merely slight nausea, so long as the patient is quiet, though even in these instances vomiting may be induced by the admin- istration of liquids. The matter ejected consists at first of the contents of the stomach, next of the gastric fluids, mixed with regurgitated bile, and ultimately of the intestinal contents, the vomiting then being called fecal or stercoraceous. As the patient becomes exhausted, and particu- larly if opium have been freely given, the vomiting may subside; the surgeon should not, however, be deceived by this delusive calm, which is really indicative of a most dangerous condition; the pulse now be- comes feeble, the surface cold, and the extremities shrivelled, while the countenance assumes a pinched and anxious expression. Death may ensue in this stage, or, on the other hand, the extreme relaxation may allow reduction to be readily accomplished. (2.) The symptoms of peritonitis, when tlrls condition is fully developed, are commonly well marked. Often, however, there is but little pain and tenderness, and but for the peculiar small and wiry pulse, and anxious countenance, the existence of peritoneal inflammation might not be recognized. Upon the occurrence of gangrene, the patience falls into a state of collapse: the pain suddenly ceases, the skin is cold and bathed in a clammy sweat, the pulse is weak and running, sometimes intermit- ting, and death may be preceded by slight delirium. The period at which the inflammatory symptoms occur is a matter of some impor- tance. In a case of acute strangulation (pp. 754, 755), such as is met with in young persons as the result of violent exertion, inflammation sets in early, and may terminate in fatal gangrene in the course of a few hours, while, if the strangulation be of a more chronic character, the symptoms of obstruction may last for several days before the occurrence of any serious inflammatory changes; hence, while in the former case an early operation is imperative, in the latter, more time may be properly spent in a trial of other measures. 758 HERNIA. Diagnosis of Strangulation.—A strangulated, may usually be dis- tinguished from an incarcerated hernia, by noting the absence of im- pulse on coughing, the persistent vomiting and stercoraceous character of the matters ejected,'and, in an acute case, the sudden onset of the symptoms. From an inflamed hernia, or from general peritonitis coex- isting with an irreducible hernia, it may be distinguished by observing the character of the vomit and the completeness of the constipation. In a case of merely coincident peritonitis, moreover, the point of greatest tenderness may be at a distance from the hernial sac. The vomiting of pregnancy, if the patient have an irreducible hernia, may simulate stran- gulation, but may be distinguished by observing the nature of the matter ejected (which is never stercoraceous), and the absence of complete con- stipation. The coexistence of an irreducible hernia with intestinal ob- struction from another cause, may deceive the most skilful surgeon, the existence of an impulse on coughing being, in such a case, probably the only symptom to distinguish it from one of strangulation. If there be two or more herniae, one only of which is strangulated, it will probably be found that there is most tension and tenderness about the neck of that which is the seat of constriction. Certain tumors, as, for instance, an inflamed lymphatic gland, occurring in one of the common localities of hernia in connection with the rational symptoms of strangulation, may closely simulate the latter condition, and the true state of the case may be only revealed by making an exploratory incision. Inflammation of an undescended testicle may be distinguished from strangulated hernia, by observing the absence of the gland from the corresponding side of the scrotum. Prognosis.—In cases of acute strangulation (pp. 755, 757), the prognosis is extremely grave, ulceration and gangrene sometimes oc- curring in the course of a few hours. In chronic strangulation, there is less immediate danger, though the affection is always one of a very serious character. It is difficult to estimate properly the death-rate of strangulated hernia, from the fact that the operation, which, in many, if not most, cases, affords the only chance of life, is unfortunately too often postponed until death is inevitable under any circumstances. I cannot subscribe to the dogma, which has been recently promulgated by high authority both at home and abroad, that surgeons generally are too prone to operate in case* of strangulated hernia. I am well con- vinced, on the contrary (and in this view I am sustained by the almost unanimous testimony of hospital surgeons of large experience), that lives are constantly sacrificed by the hesitancy which many medical men feel in resorting to herniotomy; and yet this is an operation which, like tracheotomy, every physician, as well as every surgeon, should feel himself competent to perform. While no one can deprecate more than I do a premature resort to the knife, I firmly believe that many lives would annually be saved, were the profession, as well as the public, more aware of the dangers attending a strangulated hernia, and of the respon- sibility which attaches to him who undertakes its treatment. This much is certain: that every strangulated hernia, if not relieved in a variable, but always brief, period, will almost inevitably cause the death of the patient; and that, if a moderate and cautious employment of the taxis does not afford relief, the sole hope of safety lies in the use of the knife— the operation, moreover, not, as a rule, adding anything to the danger of the case, though, from being postponed until too late, it unfortu- nately often fails to save life. Birkett estimates the proportion of cases lost by delay, as being two-thirds of those who die after the operation, TREATMENT OF STRANGULATED HERNIA. 759 and judiciously advises that the surgeon should not feel himself justified in leaving, for any length of time, a case of strangulated hernia, until the constriction has been, in one way or another, relieved. Even in a case in which the diagnosis is not quite clear, an explora- tory incision may be highly proper, and the oft-repeated rule, " when in doubt, operate," is unquestionably founded on sound surgical principles. Treatment of Strangulated Hernia.—The two principal me- thods employed in the treatment of strangulated hernia are the taxis and herniotomy. There are, besides, certain auxiliary measures, which are employed, either before resorting to or in connection with the taxis. It is of the utmost importance, in regard to treatment, that the surgeon should distinguish between the two conditions which have been referred to as acute and chronic strangulation. In the acute form (which, it may be repeated, usually occurs in young persons, often as the result of sudden and violent exertion, the hernia itself being commonly of small size), but little time is allowed for the employment of expectant treatment; and if the intensity of the consti- tutional disturbance, the restlessness and anxiety of the patient, and the constant vomiting, with pain and other evidences of threatening inflammation, show the case to be one of this class, the surgeon should resort at once to the taxis, aided by the induction of complete anaesthesia, with the understanding that, if a moderate trial of this method prove unavailing, herniotomy is to be immediately proceeded with. If, on the other hand, the case be one of chronic strangulation (which is usually met with in old persons who have long been ruptured, in which the hernia is comparatively large, and in which the symptoms are at first simply those of obstruction), the necessity for immediate action is less urgent. If no vomiting have occurred, or if merely the content's of the stomach have been rejected without there having been any regurgitation from the bowels, it may even be proper to postpone the taxis, and try the effect of rest, position, and cold, with the internal administration of opium. The patient may be placed in bed, with the hips elevated and the knees flexed, the scrotum (in a case of scrotal hernia) being well supported, and an ice-bag, guarded by flannel, applied over the neck of the sac and adjacent parts. The lower bowel may be emptied by the use of an enema, and a full dose of opium or morphia given by the mouth (or by the rectum if there is much nausea), the room being then darkened and the patient left to sleep. Upon the surgeon's return, after an interval of four, six, or eight hours, according to the greater or less urgency of the case, he will often find that either reduc- tion has been spontaneously accomplished, or is readily effected by slight manipulation. It is impossible to lay down any positive rule as to the length of time during which this expectant mode of treatment may be properly employed, but probably twenty-four hours may be given as an extreme limit; at the end of this period, or before (if urgent symptoms should arise), the patient should be thoroughly anaesthetized, and then, if the taxis fail, the surgeon should at once proceed to the operation. The above remarks are based upon the supposition that the surgeon has had the opportunity of directing the treatment of the case from the very beginning. It unfortunately happens, however, that, in many instances, precious time is wasted on account of the ignorance or obsti- nacy of the patient, or still worse, that his condition has been greatly aggravated by ill-judged and, perhaps, violent efforts at reduction by 760 HERNIA. himself or others. The surgeon is often not called to the case until ulceration or gangrene of the gut is impending, if, indeed, it has not already occurred. Under such circumstances, an operation is, of course, the only treatment admissible. In any case, if the matters vomited be colored with bile, showing that intestinal regurgitation has begun, and still more if the vomiting be stercoraceous, no time should be lost in relieving the constriction, and if the taxis have been already fairly tried by another practitioner, it may, under these circumstances, be even proper to operate without its repetition. As justly remarked by Birkett, " The vital importance of liberating the bowel from constriction, at the earliest moment, cannot be overestimated. As upon the speedy accom- plishment of this the salvation of life depends, a little precipitate action may even be forgiven, so hazardous is the position of a patient with the bowel strangulated. But what is the risk attending the operation of exposing the hernial sac, dividing the impediment to the reduction of the hernia, and reducing it, even should the peritoneal sac require to be opened? Practically none. In comparison with that of leaving the bowel strangulated, it is harmless." The Taxis.1 This is the name given to the various manipulations by which the sur- geon endeavors to effect the reduction of a hernia without resorting to any cutting operation. The ordinary and commonly the best mode of apply- ing the taxis is as follows: The patient being thoroughly anaesthetized, in the recumbent posture, with both the shoulders and hips slightly raised, the thighs adducted and flexed (so as to relax the abdominal muscles), and the bladder and rectum emptied, the surgeon fixes the orifice and neck of the hernial sac, by surrounding the corresponding part of the tumor with the thumb and fingers of the left hand, while with the palm and fingers of the right he gently compresses the body of the tumor, so as, if possible, to empty it of some of its gaseous or fluid contents. Then drawing down the tumor a little, so as to dislodge the hernia from the constricting neck of its sac, he attempts, by a combination of gentle kneading and compressing movements, to return the protruding viscera into the abdominal cavity, the line of pressure strictly corresponding to that by which the hernia came down, and that portion of the hernial contents being first replaced which last descended. The success of the manipulation is made apparent by the disappearance of the tumor with the peculiar gurgling and slipping sensation which has been already referred to as characterizing the reduction of a hernia (p. 748). The mode of applying the taxis above described, may be advantage- ously varied in certain cases; thus, if the seat of constriction be not hidden by the thickness of the superincumbent fat, the surgeon may attempt to dilate the hernial aperture, by introducing the tip of the finger or the finger-nail, and drawing the edge of the ring to one side, while pressure on the tumor is maintained with the other hand. This plan, the suggestion of which is attributedto Seutin,is chiefly applicable in cases of femoral hernia, and should be only tried in cases of quite recent strangulation, for if the constricted bowel were already softened by inflammatory changes, the pressure of the finger might possibly lead to serious consequences. In some cases in which the ordinary taxis fails, taxis with inversion may succeed. This consists in drawing the lower 1 From the Greek Ta£if, from Taa-a-r, I arrange or put in order. ADJUVANTS TO THE TAXIS. 761 extremities and body of the patient upwards in a vertical direction, while the shoulders rest on the bed, thus bringing the force of gravity to aid the manipulations of the surgeon. The same end may be some- times attained with less discomfort to the patient, by simply elevating the pelvis, and practising slow and gentle frictions of the abdomen, in a direction from below upwards, so as to encourage the recession of the viscera from the seat of constriction. Again, success may be occasion- ally attained by causing the patient to lie on the side opposite to that of the hernia, by placing him on his elbows or knees, or by directing him to lean forwards over the back of a chair. In a case admitting of procrastination, any or all of these plans may be tried before resorting to severer measures. The taxis should invariably be practised with the utmost caution and gentleness; forcible squeezing and pushing is not at all likely to be pro- ductive of the slightest benefit, while it will almost certainly, by increas- ing the tendency to congestion, hinder reduction, and may not impro- bably lead to serious and perhaps fatal inflammation. The time during which the taxis may be employed should not, as a rule, exceed from a quarter to half an hour on each occasion ; if on its first trial it do not prove successful, and if the urgency of the case admit of delay, a trial should be given to opium, cold applications, etc., in the way already described, the taxis- being renewed after some hours' interval: if the second attempt also fail, herniotomy should ordinarily be at once resorted to. Adjuvants to the Taxis.—Of these the most valuable is un- questionably anaesthesia. Chloroform is preferred to ether by many surgeons, as being less likely to provoke vomiting; but as the fullest effect of the anaesthetic agent is required, ether is probably safer, and will, I believe, be found quite satisfactory. Etherization should be pushed not only until the patient is insensible to pain, but until complete muscular relaxation is induced. Venesection was formerly much em- ployed in these cases, the bleeding being sometimes carried ad deliquium, but since the introduction of anaesthetics is comparatively seldom resorted to; the same may be said of the use of the tobacco enema, an uncertain and dangerous remedy. The warm bath is often an efficient adjuvant to the taxis, and may be properly used in hospitals, or wherever there are facilities for its employment, as a preliminary to the taxis in acute cases. The patient may be kept in a bath of a temperature of about 95° Fahr., until some relaxation or faintness is induced, when he should be wrapped in blankets and immediately etherized. The taxis is then employed, and if this fail, herniotomy. The warm bath is less applicable in cases of chronic strangulation, in which it seems, some- times, to increase the tension and bulk of the hernial tumor. The local application of cold, in the form of an ice-bag guarded by flannel, is often of great use in cases admitting of some hours' delay, in conjunction with a position which insures relaxation of the abdominal walls, and the internal administration of opium (see page 759). Purgatives are very commonly taken by patients on their own responsibility, or by the pre- scription of non-professional advisers, but can exercise only an injurious influence. They may, as already mentioned, be of service in the treat- ment of incarcerated hernia (p. 754), but should be strictly interdicted when actual strangulation exists. A purgative enema of castor oil and oil of turpentine, suspended in gruel or soapsuds, may, however, be pro- perly administered in a case of chronic strangulation, with a view of 762 HERNIA. emptying the bowel below the seat of constriction, and thus, by lessening the distension of the abdomen, facilitating the reduction of the hernia. Management of the Case after Reduction.—The symptoms of strangulation commonly disappear immediately or very soon after the accomplishment of reduction ; all that is then necessary is to apply a compress and bandage to prevent the re-descent of the hernia, and to keep the patient in bed until any constitutional disturbance that may be present has subsided. If the bowels are not moved spontaneously in the course of twenty-four or forty-eight hours, an opening enema may be administered. Persistence of Symptoms after Reduction.—It occasionally happens that, though the hernial tumor has disappeared under the use of the taxis, the symptoms of strangulation still continue: this may arise from the occurrence of what is called reduction in mass (only met with in inguinal hernia); from the gut having been so tightly constricted as to be more or less completely paralyzed, in which case gangrene will pro- bably follow; from the existence of strangulation within the sac (as from the existence of internal adhesions, or from a knuckle of intestine being caught in a pocket of omentum, in a case of entero-epiplocele); or from the coexistence of a second strangulated hernia in another locality. 1. Reduction in Mass (en bloc).—This name is commonly applied to several distinct pathological conditions. (1.) The whole hernia may be pushed back behind the abdominal walk, into a space formed by the separation of these from the parietal perito- neum ; this is a very rare accident, according to Birkett, who believes that more frequently only the neck and mouth of the sac are detached from their external connections, the scrotal tissues being pushed up with the body of the sac, which then lies partially within the inguinal canal. In either case, the strangulation is maintained by the neck of the hernial sac. (2.) The neck of the sac may give way under forcible pressure, the hernia as a consequence escaping into the subserous areolar tissue, where it forms a pouch for itself between the peritoneum and the internal abdominal fascia. (3.) There may be an intra-parietal sac, or rather the sac may consist of two parts which are separated by a contracted portion; if the seat of strangulation be at the ventral orifice, the hernia may be pushed from the outer into the inner or intra-parietal sac (which is situated in the abdominal wall), the tumor as a consequence disappearing, though the strangulation still continues. The occurrence of reduction in mass is not attended with the gurgling sound and sensation which is characteristic of the return of a hernia from its sac into the cavity of the abdomen; and hence, if this sign should in any case be absent, the surgeon would at once suspect that the acci- dent in question had happened. If reduction in mass should have taken place before the surgeon is called to the case, he would be forced to rely mainly upon the history of the accident, in making a diagnosis, though if the whole hernia were within the abdominal wall, he would be aided by observing that there was no fulness of the part such as would be caused by the sac remaining in situ, and that the inguinal canal and abdominal rings were unusually patulous. In the case of rupture of the neck of the sac, or of the existence of an intra-parietal sac, these signs would of course be absent. RUPTURE OF THE INTESTINE. 763 The treatment of reduction in mass consists in directing the patient to cough, so as if possible to cause the re-descent of the hernia (when herni- otomy should be at once performed), or, if this fail, in making an explo- ratory incision, exposing the abdominal ring, prolonging the wound if necessary into the inguinal canal, laying open the sac of the hernia, and dividing the neck of the sac, or other source of constriction. 2. Paralysis of the Bowel.—This condition may be suspected if the symptoms of strangulation continue in spite of reduction attended with the characteristic gurgle, so often referred to. Under these circumstances, the surgeon should wait for a few hours, for it may be that the constric- tion, though sufficient to cause temporary paralysis of the gut, has not impaired its vitality, in which case the vomiting will by degrees lose its stercoraceous character, the tympanites subside, and all the symptoms of strangulation gradually disappear; to operate under such circum- stances, would expose the patient to a totally unnecessary risk. If, how- ever, the symptoms persist with unabated violence for several hours, the best that can be done is to lay open the hernial sac and deal with the gangrenous intestine (if this can be found) in the way which will be presently described, or, as a last resort, to cover the wound with a light poultice, in the hope that when the gut sloughs the patient may recover with a fecal fistula. 3. Internal Strangulation.—The symptoms in this case, if the hernia were inguinal, might be undistinguishable from those of reduction in mass; the hernial sac could, however, always be felt in the inguinal canal, and there would be no undue patulousness of the abdominal rings. The treatment would consist in laying open the sac. and in searching for and removing the cause of constriction, dividing bands of adhesion, and unravelling, as it were, the omentum, by the folds of which the strangula- tion might probably be caused; if it should be found that the seat of con- striction was not within reach, the case being one of internal strangula- tion and the existence of the hernia a mere coincidence, the surgeon would, in my opinion, be justified in extending the incision upwards into the abdominal wall, so as to allow a careful exploration of the adjacent intestine; by such a proceeding, Bryant was enabled to discover and divide a fibrous band which produced internal strangulation, and thus saved his patient's life. 4. Coexistence of another Hernia.—If a second hernia should exist in a state of strangulation (which could be ascertained by a careful examina- tion of the various parts in which herniae may occur), it should of course be at once reduced by the taxis, or, if necessary, by herniotomy. Rupture of the Intestine.—This is the most serious complication which can follow the employment of the taxis, and is only likely to ensue when the force used has been very great; it must not be forgotten, how- ever, that a portion of bowel which has been strangulated,for twenty-four hours or longer, is very much softened, and will give way under much slighter pressure than in its normal condition. The signs by which the occurrence of this accident may be recognized, are sufficiently obvious; the hernia disappears, but without the characteristic gurgle which is per- ceived when reduction is properly accomplished, and the development of intense abdominal pain, with hiccough and collapse, indicates the occur- rence of fecal extravasation into the peritoneal sac. Death is inevitable, unless, as rarely happens, adhesions should have previously shut off the part from the general cavity of the peritoneum, when recovery with a 764 HERNIA. fecal fistula may possibly ensue. The only admissible treatment would consist in laying open the hernial sac, so as to facilitate the latter termination. «•** Herniotomy or Kelotomy. There are two principal modes of operating for the relief of strangu- lated hernia, in one of which the hernial sac is, and in the other of which it is not opened. The latter, which is sometimes known as Petit's ope- ration, is preferable in certain selected cases, and will be referred to in its proper place. Herniotomy Opening the Sac.—The ordinary operation, in which the sac is opened, is thus performed. The patient is thoroughly anaes- thetized, his bladder and Fig. 421. rectum emptied, and the hair removed from the seat of operation. The surgeon makes his first incision, from two to four inches long, through the skin and superficial fascia over the neck of the sac, either by transfixing a fold of inte- gument and cutting from without inwards, or, which I prefer, by simply cutting down as if for the removal of a tumor. After the first incision, the operator should proceed cautiously, picking up each successive layer of tissue with forceps, and notching it, so as to introduce a grooved director, upon which it is then to beslit up; any artery that bleeds should be at once secured. When the sac is reached, it is in the same way picked up (at its anterior and lower part) with delicate forceps or a tenaculum, notched by a light touch of the knife laid flatwise, and then slit up upon a broad director. The sac may be usually recognized by its tension, its rounded, semi-translucent appear- ance, its fibrinous structure, and the arborescent distribution of its ves- sels. A flow of serum commonly marks the opening of the sac. The next step is to divide the source of constriction; this is effected by passing the left forefinger up to the neck of the sac (Fig. 421), and insinuating the nail beneath the tense edge (drawing the coil of intestine slightly downwards, if necessary for' the purpose), and then introducing flatwise, along the palmar surface of the finger, a probe-pointed "hernia-knife" with a lim- ited cutting edge (Fig. 422); by turning the edge forwards, as soon as the blade has entered the stricture, the latter may be readily divided, an incision of from two to three lines being usually quite sufficient. If the stricture will not admit the finger-nail, a grooved director must be substituted. As soon as the constriction is relieved, the surgeon ex- amines the contents of the hernia, dealing with bowel and omentum according to the condition in which each is found; if their state be satis- factory, reduction is cautiously effected, the gut being first returned, and Herniotomy ; searching for the seat of stricture. HERNIOTOMY. 765 the edges of the sac held in place, so as to avoid the accident which has been referred to as reduction in mass. The finger should then be cau- tiously introduced into the abdominal cavity, to make sure that the con- striction has been removed, when the wound may be closed at its upper Fig. 422. Hernia-knife. part with a few stitches, and a compress and bandage applied. The lower part of the wound should always be left open to secure free drain- age, the subsequent dressings being varied according to the exigencies of each particular case. The after-treatment consists in keeping the patient in bed, and under the influence of moderate doses of opium, liquid diet only being allowed for four or five days. If the bowels are not moved spontaneously, a simple enema may be given after forty-eight hours, and repeated when necessary, but the administration of purgatives by the mouth should be avoided. Treatment of Complications.—Yarious complications may arise during the performance of herniotomy or subsequently, the treatment of which must now be briefly considered. Treatment of Intestine.—If the bowel contained in a strangulated hernia be merely congested, it should be gently returned into the abdo- minal cavity, in the way already directed. If it be inflamed, and pre- sent a distinct groove or sulcus corresponding to the seat of constriction, (see page 756), it should be left, after division of the stricture, at or near the orifice of the hernial sac, so that if, as is likely to happen, per- foration ensue, the part will be in the most favorable position for the formation of a fecal fistula. The external wound should be lightly dressed with oiled lint or a poultice. If the bowel be absolutely gan- grenous, it should be slit up and left in situ; to return the gut in this condition would be to insure the occurrence of fecal extravasation, and the development of fatal peritonitis. In every case, the source of con- striction should be freely divided. A wound of the intestine may be accidentally inflicted, either in opening the sac prematurely or in divi- ding the stricture, if a grooved director be used instead of the finger- nail in this part of the operation, the gut spreading over the groove of the instrument, and thus coming in the way of the knife. Hence, if a director be employed, the surgeon should see that it is free from the bowel, and then keep it firmly pressed against the stricture, until the latter has been divided. To avoid the risk of wounding the gut, Rich- ardson, of Dublin, has recently recommended a knife with a broad flange attached to its back, and projecting in front and on either side, thus serving the double purpose of knife and director; a somewhat simi- lar instrument was also employed in the last century by Ledran. The treatment of wounded intestine has been already considered in another portion of the volume (see page 370). Treatment of Omentum.—If the omentum found in the hernial sac be but small in quantity, and unaltered in structure, though congested, it 766 HERNIA. should be returned into the abdominal cavity. If thickened and indu- rated, it should, on the other hand, be left in the sac, as it is apt in this state to become inflamed, and its reduction would probably lead to the development of general peritonitis. If, in addition, the protruded omen- tum be deeply congested, it should, as a rule, be excised, and this should invariably be done if the omentum be inflamed or gangrenous. Exci- sion is effected by transfixing the base of the constricted omentum with a double ligature, tying it in two parts so as to avoid hemorrhage, and then cutting off the mass below the seat of ligation. Retraction of the stump is prevented by bringing the ligatures through the wound, and fixing them on the abdominal wall by means of adhesive strips; the external wound may be closed over the stump, except in the case of gangrene, when it should be left open and simply dressed with a light poultice. It is perhaps scarcely necessary to say that before excising any portion of omentum, it should be thoroughly unravelled, and carefully examined, to make sure that no portion of gut is entangled in its folds. Any cysts that may be found may be treated by simple puncture. Irreducibility after Operation.—It sometimes happens that though the constriction is relieved, the hernia cannot be reduced; this is usually owing to the existence of adhesions between the protruded bowel and the inner surface of the sac, but may occasionally be due to extreme distension of the intestine itself. (1.) The Management of Adhesions depends chiefly on the state of the bowel; if this be in a condition to admit of its being returned into the abdominal cavity, the adhesions should, as a rule, be gently sepa- rated with the finger, or handle of the knife, or, if necessary, cautiously dissected through. In some instances, however, the adhesions may be so broad and firm as to render it proper to leave the intestine unreduced. In case the bowel be ulcerated or gangrenous, the adhesions around the neck of the sac should be scrupulously respected, as upon them depends the prevention of fecal extravasation into the peritoneum. Bands of adhesion passing between the gut or mesentery and the omentum, should be carefully divided, as they may be the real source of constriction (pp. 755, 763); the operation must be done with great care, to avoid the risk of wounding the intestine. (2.) Distension of the Bowel by an accumulation of gas, may impede reduction, particularly if the gut contain a large quantity of indurated fecal matter as well. The treatment consists in making one or more punctures with a very fine trocar, as has been successfully done by Tatum, of London, and by several German surgeons. Hemorrhage.—It sometimes happens that, from an abnormal dis- tribution of a vessel, or from other causes, serious arterial hemorrhage arises when the neck of the hernial sac is divided. The treatment con- sists in enlarging the wound and securing both ends of the bleeding vessel. If the proximity of an artery be suspected, Erichsen advises that the edge of the hernia-knife should be dulled by drawing it over the back of the scalpel; it will then push the artery before it, though still sharp enough to relieve the strangulation. Complications arising during the After-Treatment.—The most im- portant of these are the development of peritonitis, which usually assumes a diffused character, and the formation of a fecal fistula. For the treatment of these conditions, see pages 367 and 371. Sloughing of the hernial sac is a rare occurrence, and one which is very apt to prove fatal; its treatment presents no features calling for special comment. SPECIAL HERNIA. 767 Herniotomy without Opening the Sac (Petit's Operation).— This method was employed in the early part of last century by Petit, and has been particularly advocated by Aston Key, Luke, and other British surgeons. It is now generally acknowledged to be the most eligible procedure when the circumstances of the case allow a choice of operations. It is attended with the obvious advantage of not involving the peritoneum, and of therefore exposing to less risk of the occurrence of peritonitis; but, on the other hand, with the disadvantages of not allowing the surgeon to determine by inspection the condition of the protruded viscera, and of possibly permitting a continuance of strangu- lation by the occurrence of reduction in mass, or by leaving internal adhesions undivided, etc. It is of course only applicable to those cases in which the seat of constriction is external to the sac (p. 755); but as this point cannot always be determined beforehand, this mode of ope- rating should be tried in every instance in which the duration of strangu- lation and the urgency of the symptoms do not contra-indicate its employment. A safe rule is that given by Birkett—to try this method in those cases and those only in which the taxis would be deemed justi- fiable. If after exposing the sac and dividing the tissues external to its neck, the hernia be found still irreducible, or (in the case of an old irreducible hernia, recently strangulated) the symptoms of strangulation still continue, it is easy to open the sac and complete the operation in the ordinary way. Petit's method is particularly applicable in cases of femoral and um- bilical hernia; but should be attempted in those of inguinal hernia as well. It is especially desirable to avoid opening the sac in large herniae which have been long irreducible, and in which strangulation is due to the protrusion of a fresh portion of gut. The statistics of this operation are very favorable, the mortality being, according to the figures given by Erichsen, but 23.5 per cent., as com- pared with a mortality of 47.7 per cent, after the ordinary operation. It must be remembered, however, that Petit's method is only resorted to in selected cases. Gay's Modification of Petit's Method consists in making a small opening near the neck of the sac, introducing the finger to search for the seat of constriction, and upon the finger a concealed bistoury, the point of which is cautiously insinuated between the neck of the sac and the stricture; by then protruding the blade of the instrument, division is effected. This method will be again referred to in speaking of femoral hernia, to which it is chiefly applicable. CHAPTER XLI. SPECIAL HERNIAE. The following classification of the various forms of abdominal hernia, according to their locality and anatomical peculiarities, is based upon that given by Birkett, in his excellent monograph in Holmes's System of Surgery, but is modified and slightly extended, in the hope that it will thus be more readily understood by the student. 768 SPECIAL HERNIA. CLASSIFICATION OF HERNI.E. Hernia in the Epigastric Region. 1. Diaphragmatic. 2. Epigastric. Hernia in the Mesogastric Region. 1. Ventral. [This form may also occur in otber regions.] 2. Umbilical. 3. Lumbar. Herniae in the Hypogastric Region. I. Inguinal. 1. Oblique. f Hernial of sudden development. {a.) Into the vaginal process of peritoneum. {b.) Into funicular portion of vaginal process. (1.) In the';male. ■ (c.) Inguino-crural, etc. Hernice of gradual development. {a.) Inguino-scrotal. (&.) Encysted. (2 \ In the female i (ffl-> Intothe caiial of Nuck. {,.) in tne lemaie. | ^ Inguin0.labial# 2. Direct. II. Femoral or Crural. III. Pelvic. 1. Anterior Obturator. !(1.) Perineal. (2.) Pudendal. (3.) Vaginal. 3. Posterior Ischiatic. The pathology and treatment of each of these forms of hernia are now to be briefly considered. Diaphragmatic Hernia. In this rare form of hernia, some of the abdominal viscera protrude into the thoracic cavity. The protrusion may occur through one of the diaphragmatic orifices which has undergone dilatation, through an aper- ture resulting from congenital defect of development, or, which is most common, through a laceration or wound of the part. The affection is seldom recognized during life, the symptoms being necessarily of a very equivocal nature; even if strangulation should occur, the diagnosis from other forms of intestinal obstruction could rarely be made out, and the treatment, consequently, would be chiefly expectant. Epigastric Hernia. In this variety of the disease, the protrusion occurs in or near the linea alba, between the ensiform cartilage and the umbilicus. Reduction is usually easy. The treatment consists in the application of a pad and elastic bandage. If strangulation occur, and herniotomy be required, care must be taken to divide the stricture by an incision made in the direction of the long axis of the body, and exactly in the mesian line, so as to avoid wounding the epigastric artery. This variety of rupture may be properly considered as a form of Ventral hernia, though the latter term is here applied more particularly to similar herniae in the mesogastric region. VENTRAL AND UMBILICAL HERNIA. 769 Ventral Hernia. This may occur in the linea alba or lineae semilunares, or indeed in any part of the abdominal wall. It may result from rupture of the abdominal muscles (p. 365), from wounds, or from stretching of the fibrous tissue in the median line—due to over-exertion, to distension from pregnancy, etc., or to weakening of the part by the discharge of an abscess. The diagnosis can readily be made if the hernia be reducible, but under other circumstances the affection may be mistaken for a cold abscess, an enlarged lymphatic gland, or a cystic or fatty tumor, from any of which, however, it maybe distinguished by careful palpation and inquiry into the history of the case. The treatment consists in the appli- cation of a suitable truss or bandage. Strangulation rarely occurs in this form of hernia. Umbilical Hernia. (Exomphalos, Omphalocele, Ruptured Navel.) In this variety of hernia, the protrusion occurs through, or in close proximity to, the umbilical ring or navel. Occasionally congenital, it is more commonly acquired, appearing usually during the early months of infancy, but sometimes not until adult life; it is probable, however, that in many, if not most, of the latter cases, the umbilical ring has been patulous since birth, or at least never firmly closed. In congenital cases, the hernia has, it is said, been strangulated by the application of the ligature to the umbilical cord. In infancy both sexes are equally liable to this form of hernia, but in adult life it is much more common in women, owing to the influence of pregnancy in distending and stretching the walls of the female abdomen. The sac of an umbilical hernia is always of the acquired variety (see page 746). Symptoms.—In infancy, the hernia appears as a smooth, tense, rounded tumor, varying in size from that of a marble to that of a small orange, easily reducible, and reappearing spontaneously when the child struggles or cries. In adult life, the hernia often attains a very large size, is irregular in shape, and, in parts at least, doughy to the touch; it usually contains both bowel and omentum, the latter being often indu- rated, hypertrophied, and adherent to the sac. The hernial tumor varies in shape in different cases, but most commonly tends to hang- downwards in front of the abdomen; in a remarkable case which was under my care some years ago, the tumor, when the patient was in a sitting posture, rested on the chair between her thighs. The coverings of an umbilical hernia are in most cases very thin (consisting merely of skin, fascia, and sac), and are often closely connected together. The fascia sometimes presents perforations, through which a knuckle of intestine may protrude and become strangulated. Umbilical hernia in the adult is usually irreducible, or at least not completely reducible, often becomes incarcerated, and is not rarely subject to strangulation, this accident being comparatively infrequent in the case of children. In some instances, double and even triple umbilical herniae have been observed in the same individual. Treatment.—In infants, it is usually possible to effect a cure by the use, for some months, of a compress of cork or metal, held in place by 49 770 SPECIAL HERNIA. means of a suitable bandage ; or, which I prefer, by the simple applica- tion of a couple of broad strips of adhesive plaster, as advised by Fergusson. The strips should be renewed from time to time as they become detached by washing. If the umbilical aperture be very large, and particularly in the case of adults (if the hernia is reducible), the ring pad devised by J. Wood may be advantageously employed. For irreducible umbilical hernia, a concave pad or bag-truss, held in place by an elastic bandage, will afford the best means of retention. Radical Cure.—Various operations for the radical cure of umbilical hernia have been suggested and practised by Desault, Barwell, Heath, Lee, and other surgeons, the method which has attained most favor being probably that recommended by J. Wood, of London. This operation consists in approximating subcutaneously the tendinous margins of the aperture through which the protrusion has occurred, by means of pins bent at a right angle, which are introduced in opposite directions and then twisted together, or by means of two or more wire sutures intro- duced with a curved needle, and secured over a superimposed roll of lint. The operation is more likely to succeed in children than in adults, but, even in them, is believed by Mr. Wood to be of service, if not in obliterating, at least in diminishing the size of the hernial aperture, and thus facilitating subsequent retention with a truss. Herniotomy .—It is very important, in the operation for strangulated umbilical hernia, to relieve the constriction without opening the sac, particularly if this be of large size—its implication in the wound being, under these circumstances, apt to be followed by a fatal result; hence, as the coverings of the hernia are commonly very thin, the surgeon should proceed with great caution in their division. The hernia being drawn down and thus made tense, an incision two or three inches long is to be made over the neck of the tumor at its upper part, and usually in the median line; the skin and fascia being divided, the finger-nail or director is slipped under the margin of the ring, which is then nicked in an up- ward direction. If the symptoms of strangulation persist, the hernial sac must be opened, and any internal source of constriction divided. The omentum, if closely adherent to the inner surface of the sac (as is often the case), should be left undisturbed, the gut being carefully re- turned, and the wound closed with sutures. The after-treatment con- sists in the application of a broad compress and bandage, and (if the sac have been opened) the adoption of means to combat the peritonitis which may be expected to follow. Fergusson recommends, instead of the median incision above described, one at the side of the tumor's neck, as in Gay's method of operating for femoral hernia (see page 784). Lumbar Hernia. In this very rare form of hernia, the protrusion occurs in the loin, between the crest of the ilium and the last rib. Two cases are mentioned by Birkett, in one of which the hernia was of traumatic origin. Inguinal Hernia. This is the most common variety of rupture, inguinal constituting about two-thirds of the whole number of herniae observed in both sexes. OBLIQUE INGUINAL HERNIA IN THE MALE. 771 In oblique inguinal hernia, the Pig- 423. protruding viscera pass through both the internal and external abdominal rings, traversing thus the whole length of the inguinal canal; in direct inguinal hernia, the viscera pass only through the external abdominal ring. The oblique variety is sometimes called external, because in it the neck of the hernial sac is placed to the outer side of the internal epigas- tric artery, the direct inguinal hernia receiving the name of in- ternal, because in it the neck of the sac is to the inner side of the same vessel. An oblique inguinal hernia, in which the protrusion is still within the limits of the in- guinal canal, is called a bubono- cele, or an incomplete or intersti- tial hernia; while one in which the protrusion has passed the external ring is called a complete hernia, and, when it occupies the scrotum, an oscheocele, or scrotal hernia. Inguinal hernia; ou the right side oblique, on the left direct, a. The hernial sac. b. The epigastric artery. I. Oblique Inguinal Hernia in the Male. Of this we may recognize five varieties, three of which are suddenly developed, as the result, usually, of violent exertion, and in which a congenital defect allows the production of the hernia, while the other two are gradually developed. The distinction is of importance, as the former offer a better prospect of radical cure, while, at the same time, if strangulated, they are less apt to yield to the taxis than the latter. 1. Hernia into the Vaginal Process of the Peritoneum.—This is the variety ordinarily spoken of as congenital. As a matter of fact, however, the hernia, though most common in infancy, is occasionally not developed until late in life—it being not the disease, but the anatomical peculiarity which allows its occurrence, that is congenital. The vaginal process of peritoneum remaining patulous (pp. 744, 746), the hernia (which is suddenly developed) descends at once into the scrotum, where it lies in contact with and surrounds the testicle. In some cases, how- ever, the hernia may descend into a patulous vaginal process, while the testis itself is retained in or immediately outside of the inguinal canal, or even within the abdominal cavity; in the former instances the hernia would, but in the latter instance would not be in contact with the gland. The sac, in this variety of hernia, is the vaginal process itself, its mouth corresponding with the position of the internal abdominal ring, and its neck occupying the inguinal canal, which is not shortened by the ap- proximation of the internal and external rings, as in the ordinary oblique inguinal hernia of slow formation. A sub-variety of the hernia into the vaginal process, is the hour-glass-shaped hernia, in which a constriction or narrowing of the hernial sac (vaginal process) exists at some point 772 SPECIAL HERNIA. between the position of the testis and that of the external abdominal ring. Fisr. 424. Hernia into vaginal process of peritoneum. Fig. 425. 2. Hernia into the Funicular Portion of the Vaginal Pro- cess.—This variety of hernia (which is sometimes called "infantile," in contradistinction to the last mentioned or so-called "congenital" hernia), is of frequent occurrence. It is suddenly developed, and though common in infancy, often does not make its appearance until adult life. The sac is the funicular portion of the vaginal process of the peritoneum (pp. 745, 746), and the hernia, when it reaches the scrotum, lies above and separate from the testis, which is inclosed in its own proper tunic. 3. Inguino-Crural Hernia.—This is the name proposed by Holthouse for cases of suddenly developed oblique inguinal hernia, in which, owing to the non-descent of the testicle, or to other causes, the hernia, instead of passing down into the scrotum (or labium, in the case of a woman), protrudes outwards along the fold of the groin, presenting somewhat the appearance of a femoral hernia.1 Similar to these, are the cases in which prolongations of the hernial sac (vaginal process) extend in various directions within the abdominal walls, constituting the intra-parietal or inter-muscular herniae of English authors, and the ^hernies en bissac" of French surgeons. 1 See a case reported by Prof. Parker, of New York, in Am. Med. Times, Sept. 1862, and Am. Journal of Med. Sciences, Oct. 1862, p. 568. Hernia into funicular portion of vaginal process. COVERINGS OF OBLIQUE INGUINAL HERNIA. 773 Common inguino-scrotal hernia. 4. Inguino-Scrotal Hernia of Slow Formation.—This is the common form of oblique inguinal hernia in persons past the middle period of life; the hernia " points" at the internal ab- Fig. 426. dominal ring, forming a small circumscribed swelling, which is most prominent when the patient is erect, and which transmits an impulse when he coughs. As the hernia de- scends through the inguinal canal, it pushes before it the parietal layer of peritoneum, thus forming its own sac by a process of gradual distension. In this situation, it forms a somewhat elongated tumor (Bu- bonocele), lying parallel to the line of Poupart's ligament, and usually in front of the spermatic cord. When the hernia makes its appearance at the external abdominal ring, it forms a tumor of a some- what globular shape, which, however, becomes more or less pyriform as the protrusion descends into the scrotum. Scrotal herniae often attain an enormous size, hanging perhaps as low as the knee; in such cases the hernia is commonly irreducible. In the descent of the hernia, the internal and external rings are approximated, thus shortening the inguinal canal, through which, when the hernia is reduced, the finger may be readily passed (invaginating the coverings of the hernia) within the abdominal cavity. This is not usually practicable in the suddenly developed herniae, in which the inguinal canal maintains its normal length. 5. Encysted Hernia.—This is the " encysted hernia of the tunica vaginalis" of Cooper, and the " infantile hernia" of Hey, of Leeds. It is a hernia of slow formation, and is therefore to be distinguished from the ordinary " infantile hernia" into the funicular portion of the vagi- nal process. The peculiarity of this form of hernia consists in the persistence of the testicular orifice of the funicular portion of the vaginal process of peritoneum, the ventral orifice being closed (p. 745); as a consequence of this con- genital defect, the tunica vaginalis testis extends up to the external abdominal ring, and the her- nia, forming its own sac from the parietal peri- toneum, protrudes into the tunica vaginalis, which is therefore first cut into when an opera- tion is required in a case of this kind. This variety of hernia is very rare, and is seldom recognized before the parts are exposed in herniotomy. Coverings of Oblique Inguinal Hernia.— Encysted hernia. These are (1) the skin, (2) the superficial fascia, (3) the external spermatic or intercolumnar fascia, (4) the cremasteric fascia, containing fibres derived from the internal oblique muscle, (5) the Fig. 427. 774 SPECIAL HERNIAE. fascia propria, internal spermatic, or infundibuliform fascia, correspond- ing to the fascia transversalis, and (6) the sac, which may consist of a dilatation of the parietal peritoneum, or of part or all of the vaginal pro- cess. In the encysted hernia, there is apparently a double sac, the true sac being surrounded by both layers of the tunica vaginalis testis; hence, in laying open the sac of an encysted hernia, three layers of serous membrane are divided. Though the six coverings above mentioned are properly described by systematic writers, it is seldom in practice that they can be individually recognized, the third, fourth, and fifth being commonly blended together so as to be indistinguishable. Relations of Oblique Inguinal Hernia.—The spermatic cord is almost invariably behind the hernia, its component parts being commonly together, but occasionally separated; more rarely the various structures of the cord may be spread out in front of the hernia. The position of the testicle corresponds with that of the cord, lying below and behind the hernia, or very rarely in front of it; the hernia and testis are in contact in the so-called congenital hernia (into the vaginal process) and in the inguino-crural variety, but in all others are separate. The epigastric artery lies to the inner side of and behind the neck of the hernia; it is, in ingnino-scrotal herniae of long standing, somewhat deflected from its normal oblique course, by the shortening of the inguinal canal, and then passes upwards and slightly inwards beneath the outer border of the rectus abdominis muscle. II. Oblique Inguinal Hernia in the Female. Of this we may recognize two varieties, one of sudden development, in which the hernia descends into the. canal of Nuck, this variety corre- sponding with the hernia into the vaginal process of the male (" con- genital" hernia), and one of gradual development, the inguino-labial, corresponding to the ordinary inguino-scrotal hernia of the male. When, in a case of hernia into the canal of Nuck, the protrusion extends ob- liquely outwards in the line of Poupart's ligament, the hernia may be properly called inguino-crural. The coverings and relations of these herniae are the same as in the corresponding herniae of the male, substi- tuting merely round ligament for spermatic cord, and labium pudendi for scrotum. Hernia into the Canal of Nuck is the commonest form of hernia met with in girls, and, with the exception of umbilical hernia, is the only form which occurs in female infants. It is in these cases, according to Kingdon, not unusual to find the ovary in contact with the hernia. Inguino-Labial Hernia, contrary to the commonly received notion, is almost as frequent in women as femoral hernia. The symptoms are very much those of the inguino-scrotal hernia of the male, except that the tumor rarely attains so large a size, and is less pyriform in shape. The neck of the hernia is, besides, larger and narrower than in the cor- responding hernia of the male. III. Direct Inguinal Hernia. This occurs in both sexes. The direct inguinal hernia is always gra- dually developed, except in the contingency of a traumatic laceration of DIAGNOSIS OF INGUINAL HERNIA. 775 the structures immediately behind the external abdominal ring, when a hernia may suddenly protrude. The hernia " points" behind the external abdominal ring, and escapes through the space known as Hesselbach's triangle, usually pushing before itself, or separating the fibres of, the conjoined tendon, but occasionally passing to the outer side of the latter. Leaving the external ring, the hernia reaches the upper portion of the scrotum, where it forms a tumor which is more globular in form than that of an oblique inguinal hernia. The long axis of the sac, more- over, is parallel to the median line of the body, and its neck close to the outer border of the rectus muscle—not curving outwards in the line of Poupart's ligament, as in the case of a hernia which has traversed the entire length of the inguinal canal. Coverings of Direct Inguinal Hernia.—These vary according to the particular part of the triangle of Hesselbach through which the hernia protrudes. In the common form of direct inguinal hernia the coverings are (1) skin, (2) superficial fascia, (3) intercolumnar fascia, (4) fibres of the conjoined tendon, (5) transversalis fascia, and (6) the sac. In the comparatively rare instances in which the protrusion occurs to the outer side of the conjoined tendon, the latter does not furnish any part of the investments of the hernia, which then carries with it a portion of the cremasteric fascia, as in the case of the oblique inguinal hernia. Relations.—The spermatic cord (or round ligament) passes along the outer and posterior side of the hernial sac, while the epigastric ar- tery also courses along the outer side of the sac, arching above the neck of the latter to reach the sheath of the rectus muscle. Anomalous Inguinal Herniae.—It occasionally, though very rarely, happens that an inguinal hernia escapes, not through the ex- ternal abdominal ring, but through an abnormal opening in the aponeu- rosis of the external oblique muscle, close to the ring. In such a case the spermatic cord would not be in direct contact with the hernia. Diagnosis of Inguinal Hernia. From Femoral Hernia, an inguinal hernia may be distinguished by observing (1) that it invariably protrudes above the line of Poupart's ligament, anel (2) that the external abdominal ring (through which an inguinal hernia escapes) lies to the inner side of the pubic spine. Hence, if the neck of the sac be found outside of this prominence, it may be inferred that the hernia is not inguinal. The Differential Diagnosis between the various forms of inguinal hernia, may usually be made by investigating the history of the case, and by attention to the symptoms which have been described as characterizing the several varieties of the affection. In other instances, however, and particularly in case of stran- gulation, the surgeon may be unable to say positively even whether the hernia is oblique or direct. Inguinal Hernia which has not descended into the Scrotum is to be distinguished from abscess, hydrocele or haematocele of the cord, tumor of the cord, adenitis, and undescended testis. (1.) Abscess arising within the pelvis and pointing in the course of the inguinal canal is reducible, and may transmit an impulse when the 776 SPECIAL HERNIA. patient coughs, but can be distinguished from hernia by its fluctuating character, and by the absence of gurgling in reduction. (2.) Hydrocele of the Cord may be distinguished by its elastic, semi- fluctuating character, its translucency if low down, the impossibility of complete reduction within the abdominal cavity, and the absence of gurgling. The same signs may, in the female, serve for the diagnosis from hernia, of a serous cyst, which sometimes occupies the canal of Nuck (Hydrocele of the Round Ligament). (3.) Haematocele of the Cord may be recognized by the existence of fluctuation and ecchymosis, by the impossibility of complete reduction, and by the absence of gurgling. (4.) Tumors of the Cord have a well-defined outline, transmit no impulse on coughing, and are irreducible. (5.) Enlarged Lymphatic Glands are commonly situated below Pou- part's ligament; but when a single gland is above, and inflamed, the case may be mistaken for one of strangulated hernia, the diagnosis perhaps being only cleared up by an exploratory incision. (6.) An Undescended Testis occupying the inguinal canal may be dis- tinguished from hernia by the impossibility of reduction, the absence of gurgling, the peculiar sickening sensation caused by pressure, and the fact that there is no testicle in the scrotum of that side. The difficulty is greater when the undescended testis is inflamed, but here (unless a strangulated hernia coexist) the diagnosis may be made by attention to the points already mentioned, and by noting the character of the vomit- ing, which in the case of an inflamed testis is not persistent, and never stercoraceous. Scrotal Hernia is to be distinguished from hydrocele of the tunica vaginalis, haematocele, varicocele, and tumors of the testis. (1.) Hydrocele is to be distinguished by its translucency, its tense and semi-elastic character, its irreducibility, and the absence of impulse on coughing; it begins at the bottom of the scrotum, instead of at the top, as is the case with hernia, and is distinctly circumscribed, the cord being readily perceptible above it. If a hydrocele of the cord coexist, the diagnosis is more difficult. Congenital hydrocele, in which the commu- nication between the tunica vaginalis and peritoneum persists, though reducible by pressure, may be distinguished by the absence of gurgling, and by the gradual manner in which the tumor reappears when the pres- sure is removed. Hernia and hydrocele may coexist, in which case the hydrocele is usually in front, and each tumor presents its own character- istic peculiarities. (2.) Haematocele may be distinguished by its history (of traumatic origin), its irreducibility, the absence of impulse and gurgling, and the distinctness with which the cord may be felt above. (3.) Varicocele may be distinguished from hernia by making the patient lie down and by elevating the scrotum, when the tumor, if a varicocele, will disappear slowly and without gurgling; if now the surgeon press gently on the external abdominal ring, and direct the patient to rise, the tumor, if a varicocele, will be slowly reproduced, beginning at the bottom of the scrotum, but, if a hernia, will not reappear; if, on the other hand, mode- rately firm pressure be made upon the cord below the external ring, so as to take off the weight of the superincumbent column of blood, and thus prevent distension of the spermatic veins, the tumor, if a varicocele, will not be reproduced, whereas a hernia will slip down alongside of the finger. TREATMENT OF INGUINAL HERNIA. 777 (4.) Tumors of the Testis may be distinguished by their rounded shape and solid feel, by the absence of impulse or gurgling, by their irreducibility, and by the nou-implication of the cord and inguinal canal. Treatment of Inguinal Hernia. The Palliative Treatment of oblique inguinal hernia consists, when the rupture is reducible, in the application of a truss, the pad of which should be of an elongated shape, and should press upon the whole extent of the inguinal canal and upon the internal abdominal ring. In applying a truss for hernia into the vaginal process, in a child, great care must be taken not to press injuriously upon the testis, if this have not fully descended. For direct inguinal hernia, a truss is required which shall support the abdominal parietes behind the external abdominal ring ; a good instrument for the purpose is that with an " ovoid-ring pad," as employed by Mr. John Wood. For irreducible inguinal hernia of either form, a hollow pad, or suspensory or bag-truss, is to be applied. Radical Cure.—Of the numerous ingenious operations which have been devised for the radical treatment of inguinal hernia, I shall describe but four, viz.: 1, Wutzer's; 2, Syme's and Fayrer's (which are essentially the same); 3, Agnew's; and 4, J. Wood's. 1. Wutzer's Method consists in invaginating a plug of scrotum in the inguinal canal, and endeavoring to fix it there by exciting inflammation in the neck of the sac. The patient is placed in a supine posture, the rectum and bladder being empty, the affected part carefully shaved, and the hernia thoroughly reduced. Invagination is effected by pushing up a cone of the scrotal tissues with the left forefinger, which is introduced within the internal ring; an oiled, hollow, boxwood cylinder (Fig. 428, C) is next carefully introduced as the finger is withdrawn, so as to main- Fig. 428. C C / A £ c Wutzer's apparatus or radical cure of hernia. tain invagination; along the inner surface of this cylinder, a flexible needle (A), gilt to prevent corrosion, is passed by means of a movable handle, and thrust through the scrotum, hernial sac, anterior wall of the inguinal canal, and tissues of the groin, the operation being completed by the application externally of a concave boxwood case or roof (B), the curve of which corresponds to that of the cylinder, and which passes over the point of the needle and is held in place by means of a screw at the other end. The apparatus is kept in place for about a week, the invaginated plug being subsequently supported by a roll of lint and a spica bandage ; the patient is kept in bed about three weeks, and should wear a light truss for several months afterwards. 2. Syme's Method is a modification of the above, and is thus described by its author: " Instead of a complicated machine for distending the 778 SPECIAL HERNIA. invaginated integument, I employed a piece of bougie or gutta-percha, to one end of which was attached a strong double thread. The plug thus prepared and smeared with cantharides ointment, was drawn into its place by the threads, which, by means of a curved needle guided on the finger fairly within the ring, were passed, at the distance of rather more than an inch from each other, through all the textures to the surface, where they were tied firmly together on a piece of bougie, to prevent undue pressure on the skin." The plug is left in position ten days, and the patient kept in bed a fortnight longer. Prof. Fayrer's Method differs from Syme's, merely in the substitution of an oiled wooden plug for that of gutta-percha; in the fact that the ligatures (which are of silk), though introduced at different points, are brought out through the same aperture in the groin, where they are tied over a piece of wood or ivory; and in the withdrawal of the plug in from two to six days. Thirty-eight cases operated on in this way by Fayrer gave twenty-four cures (the perma- nence of which was, however, not ascertained), while twenty-five cases operated on by Wutzer's plan gave the smaller proportion of fourteen cures. 3. Agnew's Method.—For this operation, a special instrument is re- quired, which resembles a bivalve speculum, and consists of two semi- cylindrical blades with handles, Fig. 429. with two grooves on the inner or mob^ concave surface of each blade, and ^/§|§lSS§B§5^g[^ a rod and screw to regulate the de- ^^^Z#^^^^^^H mm gree to which the blades are sepa- ^ t~^s**ias!«3^?*? rated. An incision 2£ inches long ^gp^fpS^ ""*""■*■"--—/ is made over the scrotum, pass- ^KP^^ ing downwards from a point three- . ,. . ., ., J.,1„„0„fW,i. fourths of an inch below the external Agnews instrument for the radical cure of hernia. , . . abdominal ring; the subjacent tis- sues are separated from the skin of the scrotum by the finger, introduced through the incision, and then invaginated, the "speculum" being made to replace the finger, as in Wutzer's operation. The blades of the instru- ment are then separated, and a long-handled needle, armed with a silver wire, passed along one of the grooves of the lower blade, thrust through the intervening structures, and brought out on the surface of the body over the internal ring; the needle is then unthreaded and withdrawn, rethreaded with the other end of the wire, and passed along the second groove, to be brought out at the same aperture as before. Both ends of the wire are then drawn tight and twisted over a roll of lint. A short needle is next armed with a silk ligature, and passed across the inguinal canal between the blades of the speculum at three points, near the sum- mit, at the middle, and just above the external ring; these threads are loosely tied, the speculum removed, and the operation completed by the application of a compress and bandage. The silver wire is removed after seven or eight days, and the silk threads (which are to be, from time to time, tightened) allowed to cut their way out by ulceration; the patient is kept in bed for about three weeks, and subsequently furnished with a light truss. This operation, which I have seen most skilfully performed by Prof. Agnew, was first employed by that surgeon in1864; it is known to have been successful in at least seven cases up to Octo- ber, 1870. . Wood's Method.—The most important feature of Mr. Wood's various operations consists, as has been already mentioned, in applying sutures in such a way as to effect compression and closure of the tendinous RADICAL CURE OF INGUINAL HERNIA. 779 sides of the hernial canal in its whole length. The instruments required are, (1) a strongly-curved needle, eyed near the point, and mounted in a firm handle; (2) a knife somewhat resembling a tenotome; (3) a strong, hempen thread, or silvered copper wire; and (4) a compress, which, if the thread be used, is to be made of boxwood, glass, or porcelain. (1.) Operation with Thread.—The patient being anaesthetized, and the rupture thoroughly reduced, a small scrotal incision is made over or below the fundus of the hernial sac, and the skin and fascia separated over an area two or more inches in diameter, by means of the knife in- troduced flatwise. The knees of the patient are then brought together, and elevated so as to relax the structures of the groin, and the detached fascia invaginated with the forefinger which is pushed well up into the inguinal canal, with the nail directed backwards. The finger being hooked forwards, so as to raise the lower border of the internal oblique muscle, and with it the conjoined tendon, the unarmed needle, well oiled, is passed up on the pubic side of the finger, pushed deeply through the tendon at its most salient part, made to traverse the internal pillar of the superficial ring obliquely upwards and inwards, and finally brought through the skin, which is first drawn inwards and upwards as much as its deep attachments will allow. One end of the thread is then passed through the eye of the needle, which is quickly withdrawn, leaving the other end of the thread in the puncture. The finger is next placed be- hind the external pillar of the superficial ring, close to Poupart's liga- ment, opposite the internal hernial opening, in the groove between the spermatic cord and the ligament. The finger is again raised, stretching the aponeurosis, and the needle (which is now armed) passed between the point of the finger and Poupart's ligament, pushed through the lat- ter, and brought out at the same opening as before; a loop of the thread is this time left in the puncture, and the needle carrying the free end again withdrawn. The finger is now placed on the inner side of the spermatic cord, just above the pubic spine, and pressed firmly upon the conjoined tendon, pushing this backwards and the cord outwards, so as to feel the border of the rectus tendon. Into the tendinous layer of the triangular aponeurosis covering this part of the rectus, the needle is then deeply thrust, turned obliquely towards the surface, and a third time brought out through the original puncture, which now contains both ends of the thread and an intermediate loop; two portions of thread thus cross the hernial canal, invaginated fascia, and sac, closely embracing but not including the spermatic cord, and joining together the front and back walls of the canal. The compress is placed obliquely over the canal, the free ends of thread and the loop crossed and firmly drawn in opposite directions, and the whole then secured by passing one end of the thread through the loop and tying it back to the other end in a "bow-knot." The operation is completed by the application of pads of lint and a spica bandage. The knot is untied and the compress removed, from the third to the seventh day, the threads being allowed to remain as setons as long as may be deemed necessary. (2.) Operation with Wire.—The preliminary steps are the same as when the thread is used, but in passing the needle for the second time it is unarmed, and withdrawn armed with the other end of the wire, thus leaving a loop above and bringing both free extremities out at the scro- tal incision below: the hernial sac and the fascia covering it opposite the scrotal aperture are then pinched up with the finger and thumb, and the cord slipped back as in the operation for varicocele, when the needle is passed (entering and emerging through the scrotal wound) from without 780 SPECIAL HERNIA. inwards and a little upwards, immediately in front of the spermatic cord; it is now armed with one of the ends of wire (either will answer the purpose) and withdrawn; the next step is to straighten and draw down the ends of wire until the loop is near the skin, where it is held while the ends are twisted together with three or four turns, the inclosed sac and fascia being thus twisted and held between the ends of wire. The loop is now drawn upwards, so as to effect complete invagination of the twisted sac and scrotal fascia, and in its turn twisted down into the groin puncture; the ends of wire are then cut off about three inches from the surface and bent into a hook which is carried upwards to meet the loop, both being locked together over a compress of lint, and the whole covered with a spica bandage. The wire may be untwisted about the eighth or tenth day, and removed about the fourteenth. (3.) Operation with Pins.—For small ruptures in children, particu- larly for ruptures into the vaginal process, Mr. Wood resorts to the use of pins bent at a right angle; these are passed in opposite directions, one through the conjoined tendon and internal pillar, and the other through the external pillar of the ring, the hernial sac being transfixed by both pins, which are then twisted together. The pins •are withdrawn from the second to the tenth day. The statistics of the operations for the radical cure of inguinal hernia performed by Mr. Wood himself, have already been given (page 751); 22 cases operated on by one or other of his methods, which are tabu- lated in the Report of the Boston City Hospital, gave 3 recoveries, 3 "fair results," 2 deaths, and 14 failures. Taxis for Inguinal Hernia.—In employing the taxis, in a case of inguinal hernia, the pressure must be applied strictly in the direction Fig. 430. Incision for strangulated inguinal hernia. of the inguinal canal, i. e. obliquely upwards and outwards. It must, however, be remembered, that in a case of inguino-scrotal hernia of long standing, the direction of the canal itself becomes changed, by the approximation of the abdominal rings. Herniotomy.—An incision of from two to four inches in length is made in the direction of the long axis of the tumor (Fig. 430), so that the position of the external ring will be a little above the middle of the wound: the various coverings of the hernia are then carefully divided, until the FEMORAL OR CRURAL HERNIA. 781 director or tip of the finger can be insinuated beneath the edge of the ring, when, if this be found to exercise any constriction, it is to be incised in an upward direction, in a line parallel to the linea alba. The taxis may be then gently employed, when it will occasionally happen that reduction can be effected without further trouble, but if such is not the case, the internal ring is to be explored and similarly dealt with: in the majority of instances, however, the stricture is in the neck of the sac itself, and an opening must then be made of sufficient size to allow the introduction of the finger, which is passed up to the seat of obstruction, a hernia-knife following and nicking the stricture in the way described at page 764. It is a well-established rule that the incision in this part of the operation is to be made directly upwards, in a line parallel to the linea alba, so that whether the rupture be of the oblique or direct variety (and this cannot always be determined beforehand), the epigastric artery may escape injury. Femoral or Crural Hernia. (Merocele.) In this form of hernia, which is more common in women than in men, the protrusion takes place beneath Poupart's ligament, and almost invariably to the inner side of the femoral vein. Descending through the femoral ring, the hernia pushes before it the parietal layer of peri- toneum (thus forming its own sac), with the dense layer of areolar Fis 1, Femoral hernia ; 2, femoral vein ; 3, femoral artery, giving off, 4, common trunk of epigastric and Obturator arteries, and 5, epigastric artery ; 6, spermatic cord. tissue which normally closes the ring and is known as the septum crurale; passing downwards along the crural canal, in the inner com- partment of the sheath of the femoral vessels, the hernia changes its course upon arriving at the saphenous opening, and, turning forwards, Pushes before it the cribriform fascia, and curves upwards on to the fal- cnorm process of the fascia lata and lower portion of the external 782 SPECIAL HERNIA. oblique tendon, lying at this point beneath the superficial fascia and skin. Varieties.—Several varieties of femoral hernia are described by systematic writers. Thus, when the rupture is still within the crural canal it is called incomplete, being complete when it has passed the saphenous opening. Another division is founded upon the relations of the sac to the internal epigastric and obliterated umbilical arteries, the common form, in which the mouth of the sac lies between these vessels, being called middle crural hernia, and the rare varieties in which it lies to the outer side of the epigastric, or to the inner side of the umbilical artery, being called, respectively, external and internal crural hernia. LeGendre has described four rare varieties, to which Birkett has added a fifth: these are, (1) the pectineal crural, or hernia of Cloquet, in which, after passing the femoral ring, the hernia turns within and behind the femoral vessels, resting on the pectineus muscle; (2) the hernia through Gimbernat's ligament, or hernia of Laugier, the anatomical peculiarities of which are sufficiently expressed by its name; (3) the hernia with a diverticulum through the cribriform fascia, or hernia of Hesselbach, in which the hernia protrudes through several openings in the cribriform fascia, getting thus a lobulated appearance; (4) the hernia with a diver- ticulum through the superficial fascia, or hernia of Cooper, which, mutatis mutandis, is similar to that last mentioned; and (5) the hernia external to the femoral vessels, or hernia of Partridge. Coverings.—The coverings of an ordinary complete femoral hernia are (1) skin, (2) superficial fascia, (3) cribriform fascia, (4) crural sheath, (5) septum crurale, and (6) sac. The septum crurale and. adjacent por- tion of the crural sheath are commonly matted together, constituting the fascia propria of Cooper. The coverings of an incomplete femoral hernia are the same, substituting the falciform process of the fascia lata for the cribriform fascia. Relations.—The femoral vein lies close to the outer side of the hernia, and separated from it merely by a septum of the crural sheath, the epigastric artery is above and to its outer side, while the spermatic cord or round ligament passes almost immediately above it on the inner % side. The obturator artery, when, as not unfrequently happens, it arises from the external iliac, common femoral, or epigastric, instead of from the internal iliac artery (as in the normal condition), usually descends on the outer side of the crural ring to reach the obturator foramen, but occasionally skirts along the free border of Gimbernat's ligament, when it would almost completely encircle the neck of the hernial sac. In the rare cases in which the hernia escapes externally to the femoral vessels, the circumflex ilii artery would lie to the outer side of the sac. Diagnosis.—Femoral hernia seldom attains a large size, appearing usually as a firm, tense, rounded tumor, on the inner side of the femoral vessels, and invariably originating below Poupart's ligament—though it frequently passes above that structure, as it curves upwards after emer- ging from the saphenous opening. When of large size, the appearances are somewhat different, the tumor then being often soft and doughy, even though strangulated. The diagnosis of crural from inguinal hernia, can always be made by observing the relations of the neck of the hernia to Poupart's ligament and the spine of the pubes, as pointed out at TREATMENT OF FEMORAL HERNIA. 783 page 775. Obturator hernia can be distinguished by noting its deep situation and the freedom of the femoral ring. Enlarged lymphatic glands may be mistaken for crural hernia, but can usually be distin- guished by observing that there is more than one tumor, and that there is no impulse on coughing, and by attention to the history and progress of the case. As, however, a strangulated femoral hernia may exist behind an enlarged gland, in any case of doubt an exploratory incision should be made. The same course may be necessary if symptoms of strangulation occur in a case in which a fatty or cystic growth occupies the region of the femoral ring. For the diagnosis of crural hernia from psoas abscess, see page 633. A dilated and varicose condition of the saphena vein may be distinguished by the absence of gurgling on reduc- tion, and by the return of the tumor when the patient stands up, even though pressure be made at the crural ring. Treatment of Femoral Hernia.—The Palliative Treatment consists in the application of a well-fitting truss, which, in ordinary cases, should be furnished with a small and convex pad, made to press just below Poupart's ligament and a little to the outside of the pubic spine, in the line of the crural canal. If, however, as is sometimes the case, the whole crural arch be much relaxed, a large and rather flat pad is preferable, in order to press Poupart's ligament against the body of the pubes, and thus approximate the walls of the canal. A hollow pad or bag-truss must be employed if the hernia is irreducible. Radical Cure.—Mr. Wood has described an operation in which wire is used in the same manner as in his second method of treating inguinal hernia, and by which "that part of the tendinous crural arch which overrides the neck of the sac is drawn backwards and downwards, and becomes adherent to the pubic portion of the fascia lata." Cheever, of Boston, has recorded one case in which this plan was resorted to without any permanent benefit, but no extended statistics of the opera- tion have, I believe, as yet been published. Taxis.—In applying the taxis in a case of femoral hernia, the thigh of the affected side should be strongly flexed, rotated inwards, and car- ried well across the opposite limb, so as to relax the crural arch. Pres- sure is to be made in accordance with the direction of the descent of the hernia, viz., first downwards, so as to clear the falciform process, then backwards, and finally upwards in the line of the crural canal. The taxis is less likely to succeed in femoral than in inguinal hernia, and the proportion of cases requiring herniotomy is therefore greater. More- over, there is less time for delay, as strangulation in crural rupture is commonly of the acute variety (see p. 759). Herniotomy.—The external incision may vary according to the fancy of the operator, some surgeons preferring a single longitudinal incision, others one which is oblique and parallel to Poupart's ligament, while still others combine both, thus, r"* ""J , or make a slightly curved cut over the pubic side of the neck of the tumor, reaching one )iich above and one or two below the crural arch. The superficial cover- •ngs having been divided, the condensed layer formed by the septum crurale and crural sheath (fascia propria) is cautiously opened, so as to expose without wounding the sac. The finger is then passed up 784 SPECIAL HERNIA. below the fascia propria, and the nail, or the extremity of a grooved director, insinuated under the sharp edges of Gimbernat's ligament and the falciform process, at their point of junction (Hey's ligament), the hernia-knife being then introduced and made to cut upwards and inwards for a space not exceeding two lines. If reduction cannot now be effected, any constricting fibres of the fascia propria which may have been left Fig. 432. Incision for strangulated femoral hernia. are to be carefully severed, when, if the hernia be still irreducible, the sac must be opened, and the stricture sought for and divided, with the precautions described on a previous page. It is sometimes possible to relieve the strangulation by nicking Gimbernat's and Hey's ligament outside of the fascia propria. In the majority of instances, however, the stricture is in this structure itself, requiring it to be laid open in the man- ner above described. The. fascia propria, when much thickened and con- gested, may be mistaken for the hernial sac, or for a mass of omentum. It has not, however, the arborescent arrangement of vessels which cha- racterizes the former, and is more rounded and uniform in appearance than the latter. The direction in which the stricture is to be divided, whether the sac be opened or not, is invariably upwards and inwards. An outward incision might wound the femoral vein, one upwards and outwards the epigastric artery, and one directly upwards the spermatic cord, while an inward incision would divide Gimbernat's ligament only, and therefore probably fail to relieve the constriction. The only pos- sible risk, in the incision upwards and inwards, is of wounding the obtu- rator artery, in the rare cases in which this vessel winds around the neck of the sac (page 782). This danger may be obviated by slightly blunting the edge of the hernia-knife, which will then push the vessel before it, while it will still be sharp enough to divide the fibrous bands which impede reduction. As already mentioned, a very limited incision is sufficient. Should the obturator artery be accidentally wounded, hemor- rhage from either end must be arrested by torsion, or, if this fail, by the application of a ligature. Herniotomy by Gay's Method.—An incision of about an inch in length is to be made on the inner side of the tumor, near the neck of the sac, and the various tissues cautiously divided until a concealed bistoury can be introduced flatwise between the neck of the sac and the inner margin OBTURATOR HERNIA. 785 of the crural ring. The edge of the knife is then turned towards the pubes, when, by projecting the blade, the stricture is readily divided. The small lateral incision, which is practised in this mode of operating, is highly commended by Sir William Fergusson, who declares that he rarely employs any other. This distinguished surgeon, however, ap- parently completes the operation with the ordinary hernia-knife, instead of with the bistouri cachee, as originally advised by Gay. Obturator Hernia. In this rare form of hernia, which was first described by Garengeot, the protrusion takes place through the obturator foramen, forming in some cases a well-marked tumor in Scarpa's triangle, though, in other instances, not even the slightest fulness of the part has been perceptible. The affection is commoner in women than in men, and the hernial sac (which is one of gradual development) is always small, not unfrequently containing a portion only of the calibre of the bowel. Obturator hernia is occasionally complicated by the coexistence of femoral or inguinal hernia, and in a case recorded by Hilton, the sac of an obturator hernia was found on either side of the body. The position occupied by an obturator hernia is in Scarpa's triangle, behind and somewhat to the inner side of the femoral vessels, and to the outer side of the adductor longus tendon; the hernial tumor is covered by the pectineus muscle. Diagnosis.—When the protrusion is perceptible, the case may be diagnosticated from one of femoral rupture by observing the position of the tumor in relation to the femoral artery and body of the pubes— these structures lying behind the tumor in the case of a crural, but in front of it in the case of an obturator hernia. When no swelling is observable, the symptoms of strangulation being at the same time present, the diagnosis of obturator hernia may be made, according to Birkett, by attending to the following particulars: (1) there is often a history of colicky pains previously felt in the pelvic region, sometimes relieved with an accompanying sensation of something having slipped back into the abdomen ; (2) the evidences of strangulation may be pre- ceded by a sudden and violent pain at the inner and upper part of the thigh; (3) cramp in the abdominal muscles, rather than pain within the abdomen, may be complained of, obviously due to reflected irritation from the cutaneous filaments of the obturator nerve; (4) pain in the course of the distribution of the obturator nerve—a very significant symptom, the value of which was first pointed out by Howship—may be induced or increased by rotating the thigh outwards, and thus putting the obturator muscles on the stretch; (5) pain may be elicited by making pressure over the external outlet of the obturator canal, comparing the effect on either side of the body; and (6) pain may be elicited by pressing on the pelvic outlet of the canal with the finger introduced into the vagina or rectum. Treatment.—If the hernial tumor be perceptible, an attempt may be made to effect reduction by means of the taxis; but if this fail, or if there be reason to suspect the existence of strangulated obturator hernia, though no swelling can be recognized, an exploratory operation should at once be resorted to. A longitudinal incision about three inches m extent may be made, beginning a little above Poupart's ligament, and passing downwards on the inner side of the femoral vessels. The 50 786 SPECIAL HERNIA. pectineus muscle being divided, and the fibres of the obturator separated with the director or handle of the knife, the sac of the hernia, if there be one, will be exposed. The taxis should now be tried again, when, if still unsuccessful, the sac should be opened, and the stricture cau- tiously divided in an upward direction. Birkett has collected twenty- five recorded cases of strangulated obturator hernia, in fourteen of which the nature of the affection was not discovered until after the patient's death, while in one the symptoms disappeared spontaneously without treatment. Of the ten cases recognized during life and submitted to treatment, four recovered and six died. The taxis was employed in two cases, with one recovery; and herniotomy in six cases, with three re- coveries. In one case the diagnosis was not made until after the per- formance of gastrotomy (the patient dying), and in another, in which the integuments were becoming gangrenous when the case was first seen, the patient died the day after the establishment of a fecal fistula. Perineal Hernia. In this form of rupture, the protrusion occupies the perineum, and is placed, usually, between the rectum and prostate in the male, and be- tween the rectum and vagina in the female, but, occasionally, on one or other side of the anus. Perineal hernia, which is more common in women than in men, is readily reducible, and may be kept within the pelvic cavity by the use of a pad and T bandage. Pudendal or Labial Hernia. In this variety, the hernia occupies one of the labia majora, descending between the vagina and the ramus of the ischium. Pudendal hernia is to be diagnosticated from inguino-labial and from femoral rupture, and from cysts of the labium and of the canal of Nuck, the so-called hydro- cele of that part. From inguino-labial hernia, it may be distinguished by the parallelism of its axis to that of the vagina, by the non-implica- tion of the inguinal canal, by its rounded rather than pyriform shape, and by its position alongside of the ramus of the ischium instead of over the body of the pubes; from femoral hernia, by the position of the neck of the hernial sac as regards the ramus of the ischium, this bone lying externally in the case of pudendal, and internally in the case of crural rupture; and from cystic growths, by their irreducibility, their tense and resisting character, their gradual increase in size, and, in many instances, the possibility of completely isolating them with the fingers. The treatment consists in the introduction of a suitable pessary, or in the application of an elastic bandage. Should strangulation occur and herniotomy be required, the stricture should be divided in an inward direction. Vaginal Hernia. The protrusion occupies either the anterior or posterior wall of the vagina, and may produce discomfort by compressing either the rectum or urethra. The treatment consists in the use of a suitable pessary or elastic bandage, and in the employment of the catheter, if there is any difficulty in evacuating the contents of the bladder. intestinal obstruction. 787 Ischiatic or Sciatic Hernia. The hernia protrudes through the sciatic notch, usually below but some- times above the pyriformis muscle, and projects beneath the gluteus inaximus. The treatment consists in the application of a pad and elas- tic bandage; should herniotomy be required, the stricture should be divided, as recommended by Sir Astley Cooper, in a forward direction. CHAPTER XLII. DISEASES OF INTESTINAL CANAL. Intestinal Obstruction. Obstruction to the passage of fecal matter along the intestinal canal may be due to various causes, some of which produce acute symptoms and often terminate life in the course of a few days, while others act com- paratively slowly—the obstruction in these cases not unfrequently yield- ing spontaneously, and even when proving fatal, not doing so for a con- siderable period; hence the customary division of cases of intestinal obstruction into two classes, the acute and chronic, a division which is convenient for purposes of study, and will therefore be retained, though in practice cases will often be met with which are on the border line between the two varieties, the acute forms of obstruction sometimes, as well remarked by Pollock, subsiding into the chronic, while, on the other hand, the chronic cases may at any moment become acute. Acute Intestinal Obstruction.— The most frequent causes of this form of obstruction are (1) congenital malforma- tions; (2) the impaction of foreign bodies, gall-stones, etc.; (3) invagination or intus- susception—the upper segment of bowel commonly slipping within the grasp of the lower, like the finger of a glove when it is taken from the hand—though occasionally the lower .segment is in- vaginated into the upper, constituting retrograde intussusception; (4) twisting of the bowel upon itself—volvulus—com- monly connected with abnormal elonga- tion of the mesenteric attachment of the affected gut; and (5) internal stran- gxdation, due to the binding down of % the bowel by a diverticulum, or by a band of organized lymph, to the protrusion of the gut through an aperture in the mesen- tery or omentum, etc. Symptoms of acute obstruction may also occur in the course of inflammatory affections of the abdo- men, such as peritonitis or typhlitis, or (as already mentioned) in cases of chronic Fig. 433. Internal strangulation by a diverticulum 788 DISEASES OF INTESTINAL CANAL. obstruction, especially from cancerous disease of the bowel. Spasm, without organic change, is considered by some authors to be capable of producing acute obstruction; but though the possibility of such an event may not be denied, its occurrence must be extremely rare.1 Symptoms of Acute Obstruction.—These are usually well marked; the patient commonly experiences intense pain, often referred to a particular spot, accompanied with great vital depression, and occasionally absolute syncope. Vomiting, at first of the gastric, and subsequently of the intes- tinal contents, and complete constipation, quickly supervene, -the abdomen at the same time becoming tender, swollen, and tympanitic, and the inter- ference with normal peristalsis causing the bowels to roll over each other with loud borborygmus and gurgling ; the motions of the intestine, if the abdominal parietes be thin, may be felt or even seen externally, and may sometimes be observed to cease suddenly at some particular point which corresponds to the seat of obstruction. Unless relief be speedily obtained, death ensues—either from simple exhaustion, or more commonly from peritonitis, gangrene, or both—the duration of the case rarely exceeding a week or ten days; in cases of intussusception, the invaginated portion of gut is occasionally separated by sloughing, and discharged per anum, the continuity of the bowel being maintained by previously formed adhe- sions, and spontaneous recovery thus following. Chronic Obstruction.—The most common causes of this variety of obstruction are (1) fecal accumulations; (2) stricture of the bowel, often of a malignant character ; (3) inflammatory changes in the bowel, result- ing from injury; (4) chronic peritonitis (often tuberculous), or abdominal abscesses; and (5) abdominal tumors of various kinds, which may com- press and thus obstruct the adjacent portions of intestipe. Symptoms.—In the case of chronic obstruction, constipation is the most prominent symptom; there is seldom any acute pain, and compara- tively slight constitutional disturbance, while the vomiting is not constant and does not assume a stercoraceous character until much later than in cases of the acute variety. Abdominal distension, though ultimately well marked, is slowly developed, and life may be prolonged for six weeks or more, recovery even being sometimes obtained after the persistence of complete obstruction for this period of time. Statistics of Intestinal Obstruction.—The statistics of intestinal obstruction were particularly investigated by the late Dr. W. Brinton, who found, from an analysis of 12,000 post-mortem examinations taken promiscuously,that, excluding hernia, intestinal obstruction caused death in one out of 280 cases. Of the fatal cases of obstructed bowel, about 43 per cent, were clue to the existence of intussusception; 31|per cent, to internal strangulation (by bands, etc.) ; 17^ per cent, to strictures, or to tumors implicating the intestinal wall; and 8 per cent, to twisting of the gut upon itself. The locality of the lesion was (in the case of intussusception) the junction of ilium and caecum in 56 per cent., the ilium alone in 28 per cent., the jejunum in 4 per cent., and the colon in 12 per cent, of the whole number of instances. In obstruction from internal strangulation (by bands, etc.), the part affected was the small intestine in 95 per cent. of all cases; while, on the other hand, strictures and twistings involved 1 Strangulated hernia, which is perhaps the most frequent cause of acute intesti- nal obstruction, is treated of in Chap. XL., and is therefore omitted here. INTESTINAL OBSTRUCTION. 789 the large intestine in 88 per cent, of all cases. The sexes are almost equally liable to most of the causes of intestinal obstruction, but im- pacted gall-stones are four times as common in women as in men. Diagnosis.—It is of the utmost importance, in undertaking the treatment of a case of intestinal obstruction, to ascertain (1) whether it belongs to the acute or to the chronic variety, and (2) to what cause the obstruction is due. From Dr. Brinton's statistics, quoted above, it will be seen that of acute (fatal) cases rather more than half (43 to 39^-) are due to intussusception, while of the remainder, about four-fifths are due to internal strangulation ; and as the treatment of these conditions is not the same, their diagnosis becomes a matter of great interest. Intussusception is by far the most frequent cause of obstruction met with among infants and young children, and is sometimes traceable to the disturbance created by polypi of the bowel, by intestinal worms, or even by masses of undigested food; it is especially characterized by a constant desire to go to stool, and by the discharge from the rectum of mucus, with liquid or coagulated blood. The perpetual desire to defecate is considered by Pollock almost pathognomonic of invagination. Ster- coraceous vomiting is not so uniformly present in this, as in other varie- ties of acute obstruction. In many cases, if the abdominal wall be thin, an elongated tumor, the shape of which has been compared to that of a sausage, may be distinctly felt by palpation, usually at the left side, and, in children at least, the invaginated gut may often be felt by the introduction of the finger into the rectum. Internal Strangulation is most common in the periods of adolescence and early adult or middle life. Its most characteristic symptom is the occurrence of intense prostration or syncope. Twisting of the Bowel is usually an affection of advanced life, and commonly involves the sigmoid flexure of the colon, its next most fre- quent seat being in the neighborhood of the ileo-caecal valve. True knotting of the bowel has been observed in two cases, one recorded by Parker, and one by M. W. Taylor. In obstruction from twisting, the abdomen is, according to Erichsen, unevenly distended, one side being flattened while the other is tympanitic. Strictures or Tumors (causing chronic obstruction) affect the lower bowel much more commonly than the upper, and the diagnosis can usually be made by inquiring into the history of the case, and by an examination per anum. The history of the case will likewise serve for the purpose of diagnosis, should acute symptoms suddenly supervene under these circumstances. In order to determine what part of the intestinal canal is the seat of obstruction, it is to be borne in mind that when the symptoms are acute, the lesion (unless the case be one of twisting of the gut) is usually situated in the upper bowel, while chronic obstruction commonly involves the large intestine. Obstruction below the descending colon can gene- rally be recognized by careful exploration of the rectum. The period at which stercoraceous vomiting occurs is earlier in proportion to the greater proximity of the seat of obstruction to the pylorus ; moreover, the higher the point at which peristalsis is arrested, the less, as a rule (according to Hilton, Bird, and Barlow), is the amount of urine secreted. Finally, careful palpation of the abdomen may, if the parietes be thin, serve to point out more or less exactly the point at which the bowel is obstructed. 790 DISEASES OF INTESTINAL CANAL. Treatment of Intestinal Obstruction. Certain indications are common to all cases of intestinal obstruction.1 Bearing in mind that the most desperate cases sometimes terminate in spontaneous recovery, the surgeon should in the first place endeavor to obviate the tendency to death by relieving pain, diminishing peristaltic action, preventing distension, and maintaining the patient's strength. The first and second objects are best accomplished by the free adminis- tration of opium (which Brinton says may be sometimes advantageously combined with belladonna), and preferably in the solid form. From half a grain to a grain of the Extractum opii of the U. S. Pharmacopoeia, may be given every three or four hours, or at such intervals as may be thought proper. The third and fourth objects are to be accomplished by the administration of concentrated food in small quantities and at fre- quent intervals. It is obviously desirable that, in order to prevent dis- tension, the bulk of food, and especially of liquid, introduced into the stomach, should be as small as possible, and for the same reason the exhibition of purgatives by the mouth should be strictly interdicted. Large and repeated enemata of warm water, or, which Head prefers, warm oil, administered through a long tube, are, on the other hand, of the greatest value, serving in different cases to effect disintegration of fecal accumulations, to alter the position of the bowel and thus cause the dis- appearance of a twist, or even possibly to relieve, intussusception by pushing up the invaginated gut: the last-mentioned result could, how- ever, only be attained in very recent cases, on account of the rapid for- mation of adhesions between the two portions of intestine which are involved. Inflation of the large intestine with air, introduced through the rectum by means of a long tube and stomach-pump, has occasionally proved successful in relieving the'obstruction when all other measures have failed, and should certainly, I think, be resorted to in such cases. The administration of calomel, in combination with opium, might be proper in case peritonitis should be developed at an early period; but under other circumstances should be avoided, as tending by its cathartic action to increase the distension of the bowel. The special treatment of congenital malformations of the anus or rectum, of stricture or tumor involving the large intestine, and of ab- dominal abscess or tumor, compressing, though not directly implicating the bowel—any of which conditions may lead to intestinal obstruction— will be considered in future pages. But, supposing that the case is one of acute obstruction, resulting from either intussusception, internal strangulation, twisting, stricture of the small intestine, or the impac- tion of a foreign body, and that the course of treatment which has been recommended has been tried and failed, what is to be done ? There is no time for delay, for these cases as a rule soon terminate fatally, and if any operation is to be done, it should not be postponed until the patient is at the point of death. Gastrotomy, or, to speak more accurately, Laparotomy,2 the laying 1 It is perhaps scarcely necessary to say that in every case of intestinal obstruc- tion, the surgeon should make a careful examination of all the localities in which hernia is apt to occur. 2 It would be better, I think, to reserve the term gastrotomy for the operation of opening the stomach to remove a foreign body (p. 372), designating the operation of abdominal section, in general, by the word laparotomy (from Xawapa, the soft part of the body below the ribs). GASTROTOMY FOR INTESTINAL OBSTRUCTION. 791 open of the abdominal cavity in order to search for and if possible remove the source of obstruction, has been resorted to in these cases, and is, I think, justifiable under certain circumstances. If, however, the case be one of intussusception (and this is, as has been seen, the cause of obstruction in the majority of acute cases), the surgeon will, in my judgment, best consult the interests of his patient by declining operative interference. My reasons for this opinion are, that (1) the tender age of many of the subjects of invagination renders them peculiarly ill adapted to support so grave an operation; (2) the operation, which is always one of a very serious nature, is particularly so in these cases, on account of the almost constant existence of peritonitis as a complication; (3) the attempt to dislodge the invaginated bowel is very apt to fail, from the existence of adhesions; and (4) there is a fair probability of spon- taneous recovery after sloughing of the invaginated gut. The latter point may be illustrated by the following statistics: Of twenty-four cases quoted by Pollock, from Hinton, of Blaina, thirteen terminated fatally without any relief having been obtained, while in the other eleven the invaginated pieces of intestine sloughed, and were evacuated per anum; in two of these death quickly followed, but in the other nine the patients made complete recoveries. Haven, of Boston, has collected fifty-nine cases, in twelve of which sloughing of the invaginated portion occurred, with two deaths and ten recoveries ; while J. Lewis Smith, of New York, has collected fifty cases, of which seven recovered in the same manner. The most elaborate statistics of intussusception with which I am acquainted are those of Duchaussoy, who has collected one hundred and thirty-five cases, with twenty-nine recoveries and one hundred and six deaths. It is but right to add that gastrotomy has occasionally proved successful in these cases, as in three instances mentioned by Haven, and in two out of five referred to by Adelmann. In cases of acute obstruction due to causes other than intussusception, there can be no doubt, I think, that gastrotomy is justifiable, should other measures fail to give relief in the course of two or at most three days. There is, under such circumstances, no reasonable prospect of spontaneous recovery, and the only hope, of cure in a case of persistent internal strangulation, which, next to invagination, is by far the most common lesion found in cases of acute obstruction, is in the employment of operative measures before the occurrence of general peritonitis or gan- grene. Even in these cases, however, it may be well, before resorting to the knife, to try, as advised by Brinton, the effect of one or more tobacco enemata. Gastrotomy or Laparotomy is thus performed: The patient, tho- roughly etherized, is placed in the recumbent posture, his buttocks being brought to the foot of the operating table, and the contents of his bladder evacuated by catheterization; the temperature of the room should be previously raised to at least 70° Fahr. The surgeon may cut down directly upon the seat of obstruction, if the point at which this exists has been accurately determined, but should, under other circum- stances, make his incision strictly in the median line, the wound ex- tending from an inch below the umbilicus, longitudinally downwards for about four inches. . The dissection is cautiously carried down to the peritoneum, in which membrane a small opening is then made, and enlarged as much as maybe necessary with a probe-pointed bistoury introduced upon the finger as a director. Search is next to be made for the seat of obstruction, by carefully tracing downwards that portion of 792 DISEASES OF INTESTINAL CANAL. the bowel which is found distended. The source of strangulation having been discovered, the constriction is to be relieved, by the division or separation of bands or organized adhesions, or by withdrawing the strangulated gut from any pocket or fissure in which it may have been caught. If it should be found that the case is one of volvulus, the bowel may be carefully untwisted and replaced in its normal position. If the obstruction be due to the impaction of a foreign body or a gall- stone, the gut may be opened and the offending substance removed, the case being subsequently treated as one of wounded intestine (see page 370). If a stricture of the intestine be# found (very rare except in the lower bowel, when a different operation* would be indicated), the best that can be done is to lay open the gut above the stricture, and attach the margins of the aperture thus made to the edges of the ex- ternal wound, in hope that the patient may recover Avith a fecal fistula. The same course should be pursued if the case be found to" be one of intussusception, and if the firmness of the adhesions should prevent the relief of the invagination. Unless it be designed to attempt the establishment of a fecal fistula, the external wound should be immediately closed, upon the completion of the operation ; the afterrtreatment consists in the adoption of means to combat the peritonitis which may be expected to arise. The statistics of gastrotomy for intestinal obstruction have been in- vestigated by Adelmann, who finds that thirty-three cases gave fifteen recoveries and eighteen deaths. OPERATION FOB Cases. Recovered. Died. Volvulus.........4 2 2 Strangulation continuing after reduction of hernia .7 5 2 Invagination........5 2 3 Foreign bodies . . . . . . . .3 2 1 Prolapsus of small intestine through rupture of rectum.........2 0 2 . Strangulation by bands ...... 8 2 6 Tumors and hypertrophy . . . . . .4 2 2 Aggregate . . . . .33 15 18 Enterotomy for Acute Obstruction.—The operation which has just been described, is that which I would recommend in cases of acute intestinal obstruction in which interference is deemed necessary. Other surgeons, however, prefer a resort to Enterotomy, making an incision in the right iliac region, and opening the first coil of intestine which presents itself, so as to establish a fecal fistula. This operation would doubtless involve less interference with the peritoneal cavity than laparotomy, but could not be expected to afford permanent relief in cases of internal strangulation, while in cases of intussusception, no operation should in my judgment be performed, for the reasons already mentioned. Puncture of the Bowel with a delicate trocar is recommended by Prof. Gross, as a means of affording relief by allowing the escape of gas from the distended bowel. Operations for Chronic Obstruction; Colotomy.—In most instances, the cause of the obstruction in chronic cases can be detected by careful rectal exploration, when very simple treatment will often suf- fice to give relief; thus, if an accumulation of hardened and impacted feces be found in the lower bowel, repeated enemata must be employed, so as to soften and disintegrate the mass, removal being, if necessary, LUMBAR COLOTOMY. 793 aided by the use of the finger, or, which is certainly more agreeable to the operator, a lithotomy scoop, or the handle of a teaspoon. In cases of obstruction dependent on uterine or ovarian disease, the surgeon should address his treatment to the organs primarily implicated. The cases of chronic obstruction demanding operative relief are chiefly those dependent on stricture of the rectum, whether malignant or otherwise, and the operation employed in these cases consists in the establishment of an artificial anus by opening the colon (colotomy), the part of the gut usually selected for this procedure being the sigmoid flexure. The Ope- ration of colotomy may also be occasionally required in certain cases of malformation of the lower bowel, of ulceration or cancerous disease of the rectum (even if unattended by obstruction), and of recto-vaginal or recto-vesical fistula. Colotomy may be performed by opening the sigmoid flexure in the left iliac region (as originally suggested by Littre, in 1710); the caecum in the right iliac region (Pillore, 1776); the sigmoid flexure in the left lumbar region (Callisen, 1796); the transverse colon in the umbilical region. (Fine, 1797); or, finally, the caecum in the right lumbar region. Callisen's or Amussat's Operation.—The operation which is generally resorted to in the present day, and which is certainly the best in cases of chronic obstruction from stricture, etc., was suggested by Callisen and subsequently improved by Amussat, and consists in opening the colon in the left lumbar region—Left Lumbar Colotomy; the following directions for its performance are given by Allingham, and are founded upon the experience derived from more than fifty dissections, and from a large number of operations performed by that surgeon. Anaesthesia having been induced, the patient is fixed in the* prone position with a slight inclination towards the right side, a hard pillow being placed under the left side so as to render the loin tense and prominent. To determine the exact position of the colon, a point on the crest of the ilium, midway between the anterior superior and posterior superior spinous processes, is marked with iodine paint, the colon in the normal condition being always situated half an inch behind the point thus "Fi*. 434. marked. The surgeon then, stand- ing in front of the patient, makes an incision of at least four inches, midway between the last rib and the crest of the ilium, the centre of the wound corresponding ex- actly with the point which has been marked. The wound may be transverse, as recommended by Amussat, or oblique, down- wards and forwards in the course of the ribs, as preferred by Bryant. The Various tissues are Incision in left lumbar region, in Amussat's operation. carefully divided to the full extent of the external wound, until the lumbar fascia and edge of the quadratus lumborum muscle have been reached; the former being cut through, the colon immediately presents itself, and may commonly be recognized, even if undistended, by the appearance of one of its longitudinal bands. The operation is completed by introducing with a curved needle strong silken sutures, by means of which the gut is drawn to the surface, when it is incised in the direction of its long axis, to the extent of about 794: DISEASES OF INTESTINAL CANAL. an inch; the margins of the intestinal aperture are then stitched to the edges of the external wound, the sutures being retained until they begin to cut their way through by ulceration. The great advantage of this operation over Littre's, is in the fact that the abdominal cavity is not opened, the colon being approached on that side which is uncovered by peritoneum; the operation is comparatively easy when the bowel is distended with feces, but under opposite circum- stances (as when performed for stricture without obstruction) may be attended with considerable difficulty; it is a good plan in such a case to administer a full injection before beginning the operation, so as, if pos- sible, to render the position of the colon more apparent. Some inconve- nience is usually at first experienced from prolapse of the bowel through the artificial anus, but, as the tissues contract, the tendency to protru- sion diminishes, and it may be ultimately necessary to adopt means to prevent the orifice from closing. To avoid the escape of fecal matter at inconvenient times, the patient should wear an obturator of ivory or other suitable material, attached to a gutta-percha plate, and held in posi- tion with a truss or bandage. If the disease for which the operation is performed be situated above the sigmoid flexure, the caecum should be opened in the right lumbar region by a similar procedure to that which has been described. Littre's Operation is a more simple procedure than Amussat's, parti- cularly in children. It consists in making an incision from two to three inches in length, parallel to and a little above the line of Poupart's ligament, and midway between the anterior superior spinous process of the ilium and the spine of the pubes. The various tissues, including the peritoneum, are cautiously divided upon a grooved director, when the colon is drawn forwards and opened as in Amussat's method. This operation is usually performed on the left side, opening the sigmoid flexure, but may also be practised on the right side, opening the caecum. With regard to the statistics of these operations, it may be mentioned that Mr. Hawkins,1 from an analysis of all the cases which he was able to collect up to the end of 1851, came to the conclusion that the propor- tion of recoveries after Amussat's operation was decidedly greater than after Littre's. Mr. Hawkins's tables contain 17 cases in which the peri- toneum was opened, with 7 recoveries and 10 deaths, and 31 in which the peritoneum was not opened, with 17 recoveries and 14 deaths. Mr. Curling's experience in lumbar colotomy is perhaps as large as that of any other living surgeon; of 16 cases reported by himself and his col- leagues,2 10 were successful, while 6 terminated fatally—though in some of these great relief was temporarily afforded. Mr. Allingham's3 expe- rience has been equally satisfactory; of 10 terminated cases reported by this surgeon, 6 are fairly regarded as successful, great relief was afforded in 3 more, and death resulted from the operation in only 1 instance. When colotomy is performed for malignant disease of the rectum, permanent recovery cannot, of course, be anticipated, but even as a means of affording temporary comfort, the operation should, in my judgment, be unhesitatingly resorted to in suitable cases. I would advise its performance (provided there were no special contra-indica- tions) in any case of chronic obstruction from disease of the lower ' Med.-Chirurg. Trans., vol. xxxv. 2 Lond. Hosp. Reports, vols. ii. and iv. 9 St. Thomas's Hosp. Reports, K S., vol. i. MALFORMATIONS OF THE ANUS AND RECTUM. 795 bowel, in which no benefit had resulted from a fair trial of judicious medical treatment. Malformations of the Anus and Rectum. The surgeon is not unfrequently called upon to attempt the relief of congenital malformations of the lower bowel, which, unless remedied by operation, will inevitably lead to fatal intestinal obstruction. Partial Occlusion of the Anus.—In this condition the anus, though not entirely occluded, yet presents so minute an orifice as not to permit the free escape of feces. The diagnosis of this from the more serious conditions which will be presently described, can be made by careful inspection, which will reveal a passage admitting the introduc- tion of a probe. The treatment consists in enlarging the orifice by making radiating incisions with a probe-pointed knife, dilatation being subsequently maintained by the occasional use of a bougie. Complete Occlusion of the Anus.—In this variety of malforma- tion the anus is closed by a membrane of greater or less thickness, through which the meconium may be seen, and which bulges when the child struggles or cries. The treatment consists in making a crucial incision, excising the flaps thus formed, and bringing the skin and mu- cous membrane together with fine stitches—a bougie being passed from time to time to maintain the opening in a patulous condition. Imperforate Anus.—Here the anus is completely absent, its normal position being occupied by a dense fibro-cellular mass, from a quarter of an inch to an inch in thickness, behind which the rectum terminates in a blind pouch. The treatment consists in making an incision of about Fig. 435. Imperforate anus. an inch in length, forwards from the coccyx, in the direction of the raphe of the perineum. The wound is then cautiously deepened, in the median line, following the curve of the sacrum until the gut is reached, when a free opening is to be made, and the meconium evacu- 796 DISEASES OF INTESTINAL CANAL. ated. The mucous lining of the rectum is then to be drawn downwards (if possible) to the external wound, and attached to the skin with sutures. The use of bougies is subsequently required to maintain dilatation. Occlusion of the Rectum.—The anus is well formed, and the nature of the case isj therefore, probably not suspected until after the development of symptoms of intestinal obstruction, when the diagnosis may be readily made by the introduction of the finger or a probe, the instrument coming in contact with a bulging membranous septum, from half an inch to an inch above the anal orifice. The treatment con- sists in making a small incision to evacuate the meconium, the wound being subsequently dilated with dressing-forceps or enlarged with a con- cealed bistoury. The use of the bougie must be continued daily for some months. Imperforate Rectum. — In this condition the whole rectum is wanting, the anus being usually likewise imperforate. The colon ter- minates in a dilated pouch, in Fig. 436. the iliac fossa, or opposite the promontory of the sacrum. The diagnosis of this condition from that of imperforate anus, is al- ways difficulty and often impos- sible. It may in some cases be facilitated by careful palpation of the abdomen, or (as sug- gested by Holmes) by introduc- ing a sound into the bladder (or vagina, if the patient be a fe- male), when, if the instrument impinge directly on the poste- rior wall of the pelvis, it may be inferred that the rectum is to- tally absent. In the treatment of these cases the surgeon has three operations to choose from, viz., (1) cautious dissection up- wards from the perineum (as recommended for imperforate anus), (2) Littre's operation of opening the colon in the iliac region, and (3) lumbar coloto- my by the method of Callisen and Amussat. The perineal operation is preferable in any case in which it is not evident that the bowel cannot be reached in this direction. It is performed in the manner already described, great care being taken not to wound the bladder, vagina, peritoneum, or iliac vessels. If the gut can be reached, its mucous lining should, if pos- sible, be drawn downwards and attached to the edges of the external wound—as otherwise, apart from the danger attending the passage of the meconium over a raw surface, the artificial canal will be apt to contract into a narrow and troublesome sinus. If, however, it be evident that no attempt to reach the bowel from the Imperforate rectum. MALFORMATIONS OF THE ANUS AND RECTUM. 797 perineum could succeed, or if the attempt has been made and has failed, the only remaining course of treatment is to open the colon by one or other of the methods already described. I cannot subscribe to the doc- trine that it is more merciful to abandon a child to certain death, than to strive to save his life by the formation of an artificial anus; on the con- trary, it is in my judgment the surgeon's duty, in these cases, to urge the performance of this operation, on the same principles as those which guide him to recommend tracheotomy in a case of occlusion of the larynx, or amputation in one of hopeless disorganization of a limb. With regard to the particular mode of opening the colon in these cases, some difference of opinion exists. Amussat's operation in the left lumbar region is usually preferred, but is less apt to succeed in these cases than in those of chronic obstruction in adults, on account of the frequent ex- istence in infants of a long meso-colon, which, by allowing the bowel to float, as it were, may render it impossible, to complete the operation without opening the peritoneum; hence Erichsen is disposed to think that it may be better in these cases to open the csecum on the right side, instead of the descending colon on the left. Mr. Holmes, whose opinion On all subjects relating to the surgery of childhood is of the greatest value, gives a decided preference to Littre's operation, because (1) the operation is easier, the abdominal wall in the infant being thin, while the fat and other tissues of the loin are very deep ; (-2) the colon often can- not be reached from the loin without opening the peritoneum, and (3) the descending colon, in cases of imperforate rectum, is often so short that it might not be reached at all by Amussat's operation, unless the incision were made so high as to endanger the kidney; hence Mr. Holmes recom- mends colotomy from the left groin. Finally, Huguier advises that the colon should be opened by an incision in the iliac region of the right side. The course which I would myself recommend, in the event of the perineal operation being found impracticable, would be to attempt to reach the descending colon in the left lumbar region, unless the distension of the abdomen on the right side, while it was flaccid on the left, should indi- cate the absence of the sigmoid flexure—when it would doubtless be better to open the caecum, as suggested by Erichsen. Congenital Malformations with Abnormal Openings in other Parts.—The several varieties of malformation which have been described, may be complicated by the existence of an abnormal commu- nication between the gut and other parts; thus the bowel may open into the bladder or urethra, or into the vagina, according to the sex of the infant, or upon the surface of the body, sometimes at a considerable distance from the natural position of the anus. The treatment of such cases consists in restoring the natural passage (if possible), when the abnormal opening will usually heal of itself, or, if not, may be closed at some future time by a plastic operation. When the gut opens into the vagina, the treatment may be facilitated by intro- ducing a director through the fistulous orifice, and carrying it downwards towards the perineum; its point may then be cut down upon, and the skin and mucous membrane stitched together in the way already described. Should the bowel communicate with the bladder or urethra, the case may be one of greater difficulty ; if, in such a case, the natural passage cannot be restored, a free perineal incision should be made, as in the ope- ration for lithotomy, laying open the neck of the bladder or membranous portion of the urethra, whichever may be involved, so as to afford a direct outlet for the meconium and feces. If the gut open on the surface 798 DISEASES OF INTESTINAL CANAL. of the body, the question of operative interference turns on the position of the abnormal opening; if this be in a situation in which no particular inconvenience would result from the deformity (as immediately in front of the coccyx), or, on the other hand, in such a locality as to render it probable that a great part of the large intestine is absent (as in the iliac or umbilical region), the safest plan will be to decline an operation, merely dilating the abnormal aperture so as to prevent fecal accumula- tion ; if, however, the gut open in the anterior part of the perineum, or in the scrotum, the rectum will be found at a short distance beneath the integument, and may be readily reached by an incision in the ordinary position of the anus. Before operating in any of the more complicated cases of rectal mal- formation, it may be well, if the symptoms of the case are not urgent, to wait a day in order to allow the gut to become distended, as it will then be more easily reached than if it be in a flaccid condition. Stricture and Tumors of the Rectum and Anus. Any part of the large intestine may be the seat of stricture, but it is by far most commonly met with an inch or two above the anus, or just below the junction of the rec- Fig. 437. turn and sigmoid flexure of the colon. Three forms of rectal stricture may be de- scribed, viz., the simple, the warty, and the malignant. Simple or Fibrous Stricture. — The constric- tion (which appears to be due to the presence of an ad- ventitious structure of a fibrous character) is usually seated in the submucous are- olar tissue, but more rarely in the muscular coat, or even in the mucous lining of the bowel. The extent of the stricture* varies from a few lines to an inch or more, the whole calibre of the gut being commonly involved, though not unfrequently the indura- tion and thickening are most marked on one side. The causes of this form of stric- ture are chiefly inflammation or ulceration of the part, whether arising from chronic dysentery, from wounds, from the irritation caused by fe- cal accumulations or foreign bodies, or from the contact In other instances, stricture ot Fibrous stricture of the rectum. of gonorrhoeal or leucorrhcea! discharges. the rectum may follow the cicatrization of a chancroid, or may occur as STRICTURE OF THE RECTUM. 799 a syphilitic lesion, almost invariably, in this case, as a secondary or tertiary phenomenon. The fibrous stricture appears to be more common in women than in men. Symptoms.—The symptoms of stricture of the rectum are difficult and painful defecation (the feces being flattened and ribbon-like, or passed in the form of scybala, mingled with mucus and perhaps blood), followed by various dyspeptic phenomena, and ultimately by the evidences of intestinal obstruction. Abscesses not unfrequently form in the areolar tissue around the gut, and communicate with the bowel either above or below the stricture, opening into the vagina, in the perineum, or in the gluteal region, and giving rise to intractable fistulae, which contribute much to the discomfort and exhaustion of the patient. In other cases, the formation of fistulas is due to the escape of fecal matter, through ulcerations of the bowel above the seat of stricture. The more solid portions of the feces are detained above the stricture, the gut at this point becoming dilated into the form of a pouch; while the more liquid portions mingled with mucus or muco-pus find their way through the con- tracted part, leading the patient not unfrequently to complain of diar- rhoea. "When intestinal obstruction occurs, its symptoms may be gradu- ally developed, or may be suddenly manifested owing to the complete occlusion of the gut by the lodgement of a fish-bone or other foreign body. Diagnosis.—The diagnosis of stricture of the rectum, when the seat of constriction is within three or four inches of the anus, can usually be readily made by digital examination, the finger being well oiled, and passed with the utmost gentleness. When the stricture is at a higher point, it may often be brought within reach by directing the patient to bear down, or by making the examination while he is in the upright posture. The introduction of a bougie is not of much value for diag- nostic purposes, as it is apt to catch in some of the folds of the rectum, or to strike the promontory of the sacrum, and thus lead to error. In making a digital examination, the surgeon should bear in mind that the rectum may be compressed by objects external to itself, as an enlarged prostate, a retroverted uterus, various forms of tumor, enlarged lym- phatic glands, abscesses, etc. Treatment—The treatment of rectal stricture is both general and local. The general treatment consists in maintaining the state of the patient's health, in keeping the bowels in a soluble condition by regula- tion of the diet and the administration of mild laxatives or emollient enemata, and in relieving pain by the use of opium, particularly in the form of suppositories. Iodide of potassium would be indicated in a case of syphilitic origin. The local treatment consists in endeavoring to restore the part to its normal calibre by the cautious employment of oiled bougies of gradually increasing sizes ; and in obstinate cases, espe- cially if of traumatic origin, by making slight radiating incisions, with a blunt-pointed bistoury. Rectal bougies are ordinarily best made of India-rubber, and should invariably be used with the greatest caution, lest laceration, or even perforation of the bowel, ensue. A bougie, of such a size as to be firmly grasped by the stricture, should be chosen, and may be introduced every third or fourth day, being left in for fifteen or twenty minutes on each occasion. After its withdrawal an opium suppository should be inserted, if possible above the stricture. If inci- sions are required, the knife should be introduced, guided and guarded by the left forefinger, the stricture being simply notched at several points. A bougie may then be passed, and followed in a few minutes by an opium suppository, the patient being kept at rest for a day or two 800 DISEASES OF INTESTINAL CANAL. subsequently. Various ingenious modes of effecting rapid dilatation have been proposed by surgeons, but are, I believe, more dangerous, and not more satisfactory, than the use of the simple bougie, which, though it may perhaps never accomplish an absolute cure of rectal stricture, affords in many instances very decided relief. Should symptoms of intestinal obstruction come on, an attempt should be made to relieve the patient by the administration of copious enemata, etc. (p. 790), or, if necessary, by opening the colon, either in the left or right loin, according to the seat of constriction. Warty Stricture.—A peculiar form of rectal stricture, which might be appropriately called warty, has been described by Brodie, Curling, H. Lee, and others, in which numerous ex- Fig. 438. crescences, resembling condylomata, oc- cupy the margin of the anus and the inte- rior of the gut, below the seat of stricture. These cases are believed by Gosselin to be of syphilitic origin. The profuse muco- purulent discharge, which is the most an- noying complication of this form of stric- ture, may be somewhat controlled by the use of astringent injections and the appli- cation of a solution of nitrate of silver. Malignant Stricture.—In this form of stricture, the obstruction is due to a can- cerous (usually scirrhous or encephaloid) growth, which may originate as an inde- pendent tumor, or as an infiltration in the tissues of the bowel. The symptoms do not at first materially differ from those of simple stricture, though the diagnosis can be made by digital examination, the indu- ration of the malignant growth being of an irregular and nodulated character. When ulceration occurs, the act of defecation is commonly attended with great pain and a burning sensation, extending to the loins and thighs, the discharges containing a con- siderable quantity of pus and blood. Di- gital examination at this time reveals a soft, fungous mass, and the finger is with- drawn smeared with blood. As the cancer- ous tumor grows, it frequently involves neighboring parts, as the vagina or blad- der, giving rise, perhaps, to vesico-rectal or vagino-rectal fistulas, and thus rendering the patient additionally miserable. By compressing the iliac veins, the tumor causes oedema of the lower extremities. Death may ensue from gradual exhaustion, at the end, perhaps, of three or four years, or at an earlier period from the occurrence of intestinal obstruction. The treatment must be merely palliative, any attempts to excise or tear away the malignant growth being totally unjustifiable, and usually Malignant stricture of the rectum. RECTAL FISTULA. 801 leading to a speedy death from peritonitis or hemorrhage. Pain is to be alleviated by the free use of anodynes (by suppository or otherwise), and fecal accumulation to be prevented by the occasional use of laxa- tives. Emollient enemata may sometimes afford relief, but great care must be taken, in their employment, not to inflict injury on the bowel. Bougies may be cautiously employed before ulceration has begun, but at a later period could only be productive of mischief. Finally, lumbar colotomy may be properly resorted to, either to relieve obstruction or to obviate the suffering caused by the passage of feces over the ulcerated surface. Malignant Disease of the Anus.—This, when primary, is com- monly of an epitheliomatous character, though the anus may become secondarily involved in cases of cancer of the rectum. Epithelioma of the anus, if recognized at an early period, may occasionally be excised with advantage, the diseased part being held up by two tenacula, which are then freely dissected out, as advised by H. Lee; but in a more ad- vanced stage of the affection, palliative treatment is alone justifiable. Here, as in cancer of the rectum, great comfort may be occasionally afforded by a resort to lumbar colotomy. Non-malignant Tumors of the Rectum.—These are commonly of a fibrous or fibro-cellular nature, occasionally sessile, but more often pedunculated, constituting the affection known as polypus of the rectum. Rectal polypus is most common in children (though rare at any age), and may, unless the examination is made with care, be mistaken for a hemorrhoidal tumor, or for a prolapse of the mucous coat of the bowel. The polypus often protrudes through the anus at the time of defecation, and is frequently attended with hemorrhage; it may exist as a compli- cation of the painful ulcer or fissure of the rectum. The treatment consists in the application of a firm ligature, so as to strangulate the growth, which is then to be pushed up, and an opium suppository ad- ministered. The strangulated mass becomes detached, and is passed at stool in the course of a few days. Excision should be avoided on account of the risk of hemorrhage. Sessile growths may be treated in the same way (the base being trans- fixed by a double ligature and tied in two halves), or may be more speedily removed by means of the ecraseur. A very vascular tumor of papillary or a villous character has been described as occurring in the rectum by Quain, H. Smith, and other writers. It is attended with constant, and sometimes profuse, hemorrhage, which gradually exhausts the patient. Repeated applications of strong nitric acid effected a cure in the case observed by Mr. Smith. Rectal Fistula. The rectum may communicate with the bladder or urethra in the male, and with the vagina in the female. Recto-Vesical and Recto-Urethral Fistulas may depend upon congenital malformation, or may be caused by ulceration, usually of a malignant character, or by wounds accidentally inflicted, as in the ope- ration of lithotomy. Recto-urethral fistula may also be due to the careless use of a bougie, or to the bursting of a prostatic abscess. The symptoms are sufficiently evident; urine escapes into the gut, and by 802 DISEASES OF INTESTINAL CANAL. flowing over the nates produces excoriation; while if the opening be large, fecal matter may enter the bladder, giving rise to cystitis and vesical tenesmus. When the fistula is due to the ulceration of a malic- nant growth, little can be done in the way of treatment, beyond the adoption of mere palliative measures, lumbar colotomy being justifiable when the feces escape into the bladder. In other cases, however, an attempt may be made to close the fistula, if small, by occasionally touch- ing the part with nitrate of silver or with the galvanic cautery, while if more extensive, a plastic operation may be tried, the fistula being exposed by means of a duck-billed speculum, and its edges pared and brought together in a transverse direction; the bladder should be sub- sequently kept empty by the frequent use of a gum-elastic catheter, and the bowels locked up by means of opium suppositories. The patients in these cases should be taught, before the operation, to introduce the catheter for themselves, so that there may be no occasion for urine to flow over the wound until cicatrization is completed. Advantage may be sometimes derived from keeping the patient in the prone position, and in one instance Sir H. Thompson succeeded in effecting a cure by this alone. As a last resort, a large staff may be introduced into the urethra, and the sphincter ani divided upon this so as to lay the parts freely open; the patient should then be placed in the prone position, and a catheter retained in the bladder while the wound is allowed to heal by granulation. Recto-Vaginal Fistula may depend upon congenital deformity, or upon abscess or ulceration affecting the recto-vaginal septum; but its most frequent cause probably is injury received during parturition. The treatment consists in cauterization (if the fistula be small), or in the closure of the opening by means of a plastic operation, which is thus performed: The contents of the rectum and bladder having been evacu- ated, the patient is thoroughly etherized and secured in the lithotomy position; the fistula is next exposed by drawing upwards the anterior wall of the vagina with a duck-billed speculum, and the edges obliquely pared—the vaginal mucous membrane being dissected off in an extent of four lines around the aperture; a sufficient number of deep and super- ficial sutures are then introduced to bring the freshened edges of the fistula accurately together in a transverse direction. Copeland, Brown, and Erichsen advise that the sphincter ani sjiould be divided, so as to prevent the contraction of this part from interfering with the healing process. The sutures may be of silk, or (which is better) of silver, or flexible iron wire; if of silk, they should be removed about the sixth day, but if of metal, maybe allowed to remain several days longer. The bowels should be locked up with opium for nearly a fortnight. Other modes of treatment consist in laying open the recto-vaginal septum below the fistula by incision, the parts being allowed to heal by granulation, or in introducing a ligature which is daily tightened until it cuts its way through. The late J. R. Barton, of this city, and, more recently, Taylor, of New York, have recommended simple division of the sphincter ani, as in the treatment of fistula in ano; this mode of treatment is also appli- cable to cases in which the gut communicates by a fistulous track with one of the labia majora, constituting Recto-labial Fistula. Entero-Vaginal Fistula, in which the small intestine opens into the vagina, its communication with the lower bowel being interrupted, is a rare condition which obviously does not admit of operative relief. FISTULA IN ANO. 803 Fistula in Ano. This common and distressing affection consists in an abnormal com- munication between the rectum and some point on the external surface, usually in the space between the anus and the tuberosity of the ischium. Causes.—Fistula in ano may originate in, ulceration and perforation of the mucous membrane of the gut, as the result of the irritation pro- duced by fecal accumulations (as in rectal stricture), or by foreign bodies, such as fish-bones or grape-seeds ; it may also be traceable to an abscess which occurs externally to the bowel, in the ischio-rectal fossa, and is caused by injuries, such as blows or kicks upon the anus, or by expo- sure to cold, as from sitting upon wet grass or stones, or arises from suppuration around the prostate, or in a lymphatic gland. Varieties.—Three forms are recognized by systematic writers, viz., (1) the complete fistula, in which there are two openings, one in the gut, and one on the surface of the body ; (2) the incomplete external fistula, in which there is no inner opening, though the fistulous track can usually be traced to just beneath the mucous membrane; and (3) the incomplete internal fistula, in which the sinus communicates with the gut, but not with the external surface. The second and third varieties are also spoken of as blind fistulae. Fig. 439. Symptoms.—The position of the external orifice is usually marked by a prominent papilla or granula- tion, while the internal opening can be felt by the finger in the rectum, or may be seen by the aid of the rectal speculum (Fig. 439). There is a discharge of thin pus from the fistula, producing excoriation of the surrounding parts, which are commonly thickened and indurated. The fistula sometimes runs a pretty straight course, but is often tortuous and bent upon itself, being superficial from the external orifice to the margin of the sphincter, and then passing up deeply alongside of the bowel. There may be several sinuses opening externally, but all communicating with the same principal track ; or there may be two or more independent fistulae in the same case. Occasionally a slight form of fistula is met with, which opens at the R6Ctai speculum. margin of the anus within the position of the sphincter; but in the true "fistula in ano," the external orifice is an inch or more distant from the anus, while the track of the fistula passes through, or more frequently quite outside of the sphincter. Diagnosis.—This can readily be made by introducing a probe through the external opening, while the finger is placed in the rectum; the track of the fistula can thus be traced with a little trouble to its internal opening, which will almost invariably be found just above the internal sphincter, though a sinus may extend some distance further up the bowel. If there be no internal opening, the probe can be felt in the same locality, immediately beneath the mucous lining of the gut. In cases of blind internal fistula a bent probe may be introduced through the inner opening (which may be brought into view by the aid of the speculum) and carried downwards in the direction of the fistulous track; 804 DISEASES OF INTESTINAL CANAL. in these cases, too, pressure on the external surface will cause an escape of pus into the bowel. It must be remembered that every sinus in the neighborhood of the anus is not necessarily a fistula in ano; it may, for instance, be connected with caries or necrosis of the tuber ischii, or may communicate with an abscess, which may arise within the pelvis, or may proceed from the hip-joint. Treatment.—The formation of a fistula in ano may sometimes be prevented by the dilatation with bougies of any rectal stricture that may exist, and by the prompt treatment of inflammation or abscess in the ischio-rectal space. If the surgeon be called in before suppuration has actually occurred, the formation of an ischio-rectal abscess may perhaps be arrested by the assiduous use of poultices or warm fomentations, but if matter be present, it should be at once evacuated by a sufficiently free and deep incision, when the part may possibly heal without forming a communication with the gut. The treatment of fistula in ano may consist (1) in the employment of stimulating applications, such as nitrate of silver or the tincture of iodine; (2) in the use of a ligature, tied so as to strangulate the tissues intervening between the fistula and the surface of the body, and tightened every few days until it cuts its way through by ulceration; and (3) in incision, or the "operation for fistula." The first and second methods are chiefly applicable to those cases in which, from the constitutional condition of the patient, or from his fear of the knife, any cutting operation is contra-indicated. There is some difference of opinion among surgeons as to the pro- priety of operating for fistula in ano in the case of phthisical patients, many writers deprecating interference under these circumstances, on the ground that the fistula acts a useful part as a source of revulsion or counter-irritation, while others advise the operation, in the belief that every additional drain upon the system must be injurious. It seems to me that this question should be decided, in each individual case, accord- ing to the stage and extent of the constitutional affection, and the degree of annoyance caused by the local disease. In a case of advanced phthisis, unless the discomfort produced by the fistula were unusually great, it would doubtless be more prudent to decline an operation—but under other circumstances, a different course may be proper. The mere existence of tubercle is not in itself a contra-indication, and there is in many instances reason to hope that by curing the local affection, the progress of the constitutional disease maybe retarded, if not completely arrested. When fistula in ano is dependent upon stricture of the rectum, no operation for the relief of the fistula should be performed until the stricture has been properly dilated, and if the stricture be of a malig- nant character, the operation is positively contra-indicated. The Operation for Fistula in Ano consists in dividing the sphincter, with the tissues between the external orifice of the fistula and the anus. I am not in the habit of giving ether in this operation, unless the patient particularly desire it, but there is no objection to its use, and it should always be employed if there are several external openings, rendering the operation unusually complicated and tedious. The rectum having been emptied by an enema, the patient is placed on the side corresponding to that of the fistula, with his buttocks at the edge of the bed or table, and held apart by an assistant. If there be several sinuses communicating with one fistula, these should be laid open on a grooved director; but FISSURES AND ULCERS OF THE ANUS. 805 in the majority of instances there is but a single external opening. Through this the surgeon introduces his director, slightly bent at the extremity, and passes it up in the track of the fistula until it projects through the internal opening into the gut, where it can be felt by the forefinger1 inserted into the rectum. The internal opening of the fistula will almost invariably be found just above the sphincter ani, even though the fistula itself extend some distance further along the bowel; if, however, no opening be found here, one should be made by thrusting the director through the rectal mucous membrane, it being quite unnecessary and not very safe to extend the incision higher up. The point of the director being felt in the rectum, is to be hooked down by the finger and brought out through the anus, thus raising the sphincter and other parts to be divided upon the groove of the instrument, which is then cut loose by a single stroke with a sharp scalpel. The whole surface of the wound should then be wiped with the solid stick of nitrate of silver, so as to check oozing, and, by making a superficial eschar, prevent premature adhesion of the edges. A strip of oiled lint is finally laid in the wound, which is allowed to heal by granulation, a probe being occasionally passed between its edges to prevent their uniting superficially and thus reproducing the fistula. The patient should be kept in bed for a'few days after the operation, the bowels being locked up by opium for about forty-eight hours, when a full dose of castor oil may be administered. I have never met with troublesome hemorrhage either during or after this operation, but if it should occur (as it may, if the incision be carried too high, from wound of the hemorrhoidal vessels), it must be controlled by compression or by styptics, or, if a bleeding vessel can be found, by the application of a ligature. If the fistula be of the blind internal variety, an external opening must be made by cutting upon the point of a director introduced from within, the subsequent steps of the operation being conducted in the way already described. Other modes of operating are frequently resorted to, but the principle is the same in all. Gross and Allingham, after passing the director, cut from within outwards with a curved bistoury introduced along the groove of the instrument, while many other surgeons, and perhaps the majority, employ a probe-pointed bistoury, and dispense with the director alto- gether. Brodie, and more recently W. Cooke, have preferred to divide the sphincter with scissors, while others, again, use the "syringotome," or as Syme not inaptly called it, the "probe-razor." If there should be more than one fistula, there would be reason to fear that a multiple division of the sphincter might entail subsequent fecal incontinence. Hence, in such a case, the ligature might be used in prefer- ence-to the knife, or the knife might be used on one side and the ligature on the other. Fissures and Ulcers op the Anus. Several distinct affections are often included under these names. 1. Fissures, Chaps, or Cracks, may exist in the thin skin around the anus, without at all implicating the mucous membrane. These may 1 In making digital examinations of either rectum or vagina, the finger should be well oiled, and the depressions around the nail filled with soap, or simple cerate, so as to prevent the adhesion of any offensive substance. 806 DISEASES OF INTESTINAL CANAL. follow upon herpetic or eczematous eruptions of the part, or may be produced by the acridity of the intestinal discharges, want of cleanli- ness, etc. In their worst form, these fissures or chaps constitute the rhagades often seen in prostitutes, and therefore commonly supposed to be of syphilitic origin, though it is probable that, in many instances, they are due rather to the irritating contact of vaginal discharges, and to a neglect of ablutions. Though these fissures are productive of a great deal of annoyance by the itching and smarting which they occa- sion, they are not attended by the intense burning pain which character- izes the affection which will next be described, and though they may, like it, cause suffering during the act of defecation, this suffering is of comparatively brief duration. The treatment consists in the enforce- ment of scrupulous cleanliness, and in the application of stimulating and slightly astringent washes or ointments, with attention to the state of the bowels and the administration of arsenic or other alteratives, as indicated by the general condition of the patient. Among the most useful local applications are solutions of nitrate of silver (gr. v-x to f|j) or borax, the oxide of zinc or tar ointments of the U. S. Pharmacopoeia, and the citrine ointment diluted to an eighth of its officinal strength. If mucous patches or vegetations exist, they must be treated as directed in previous chapters (pp. 444, 456, 495). 2. The True Fissure of the Anus, or, as it should, in many instances, rather be called, the Painful Ulcer of the Anus, is a small ulcer situated at or within the margin of the anus, and in the grasp, as it were, of the sphincter. It appears, when at the margin of the anus, as a linear ulcer or fissure (whence its name), but, when within the gut, may be seen, by dilating the sphincter with the speculum, to be of an elongated oval shape, rarely exceeding half an inch in length by a quarter of an inch in breadth. The fissure is not unfrequently concealed by a small reddish pile or fold of skin, while the painful ulcer may he com- plicated by the existence of a rectal polypus. Symptoms.—The symptoms of this affection are sufficiently charac- teristic. The patient experiences an intense burning pain, beginning at the time of or shortly after the act of defecation, and continuing with- out alleviation for several hours subsequently. The severity of the pain induces the patient to postpone going to stool as long as possible, thus causing an artificial costiveness which only aggravates his condition. The feces themselves may be streaked with blood or pus on the side corresponding to the seat of the ulcer. There is always a spasmodic contraction of the sphincter ani, attended with tenesmus, and often with a discharge of slimy mucus, and there is frequently great sympathetic disturbance of the urinary apparatus, or of the uterus, occasioning an error in diagnosis by directing attention to these organs. The true nature of the case may, however, always be detected by digital or ocular examination, aided, if necessary, by anaesthesia and the use of the spec- ulum. The fissure or ulcer may occupy any part of the circumference of the anus, but is commonly found posteriorly. Treatment.—In slight cases, a cure may be sometimes effected by the application of nitrate of silver and the use of anodyne and astringent lotions, ointments, or suppositories, but in the majority of instances a trifling operation will be necessary. Boyer, who first accurately de- scribed this affection, divided the whole sphincter, thus effectually put- ting the part at rest and allowing the ulcer to heal; but this procedure is now known to be unnecessarily severe, and the practice of modern HEMORRHOIDS. 807 surgeons is simply to divide the floor of the ulcer and the muscular fibres immediately beneath it. The rectum being emptied by an enema, the surgeon introduces upon his left forefinger, which serves as a director, a straight, narrow, probe-pointed knife, and, beginning above the upper margin of the ulcer, cuts quickly downwards, fairly dividing in a longi- tudinal direction the whole ulcerated surface through its centre. In some cases it may be more convenient to expose the ulcer by means of a fenestrated speculum, the incision being made through the aperture of the instrument. The after-treatment consists in the application of a little oiled lint and the introduction of an opium suppository. Recamier, and more recently Yan Buren, of New York, have recom- mended, instead of the incision of the ulcer, forcible dilatation or partial rupture of the sphincter, accomplished by introducing both thumbs back to back into the rectum, and then widely separating them. I do not know that this procedure is any less painful than the incision, while it is, I think, less certain to effect a permanent cure. 3. Chronic Ulcer of the Rectum.—Extensive ulceration of the rectum, above the sphincter, may result from dysentery, from the irrita- tion caused by foreign bodies or hardened feces, or from the incautious use of bougies or enema-tubes. The symptoms are pain, not, however, usually very severe, with a muco-purulent discharge. The ulcers may be felt by digital examination, or seen by the aid of the speculum. The treatment consists in the employment of anodyne and astringent lotions or suppositories, with attention to the state of the digestive functions. Advantage may be sometimes derived from the internal use of the con- fection of black pepper, which has acquired a reputation under the name of Ward's paste. Hemorrhoids. Hemorrhoids, or piles, are tumors met with at or within the verge of the anus, consisting essentially of a hypertrophy and infiltration of the mucous or muco-cutaneous and subjacent areolar tissues, with a varicose dilatation of branches of the hemorrhoidal veins; in some instances rupture of a vein occurs, with extravasation of blood into the subcu- taneous tissues, while in other cases there appears to be a new develop- ment of arterial capillaries, the pile being then of a vascular, spongy, and almost erectile character, and its mucous covering having an ulcerated, granular, or somewhat villous appearance. Piles are classified according to their situation, into external and internal, and, according to the presence or absence of hemorrhage, into open or bleeding, and blind piles. The ordinary bleeding pile is that form of internal hemorrhoid in which the arterial element predominates, and is sometimes called from its shape the globular pile, in contradistinction to the longitudinal or fleshy pile, which is rarely attended by hemorrhage. Causes of Hemorrhoids.—Any circumstance which impedes the returning current from the hemorrhoidal plexus of veins, or which encourages a flow of blood to the rectum, tends to promote the forma- tion of piles; hence a sedentary life, luxurious habits, occupations which require much standing (as that of a barber), disorders of the alimentary canal, or of the liver, the presence of abdominal tumors, the pregnant state, constipation, the straining due to urethral stricture or prostatic enlargement, inordinate sexual indulgence, etc., may all act as causes 808 DISEASES OF INTESTINAL CANAL. of hemorrhoids. Piles may occur at-any age, but are most common during the periods of adolescence and later adult life. They occur with about equal frequency in either sex. The first step in the formation of a pile, either external or internal, is dilatation of a hemorrhoidal vein, soon followed, if the disease persists, by hypertrophy and infiltration of the superincumbent tissues ; when the pile is unirritatecl or indolent, it may appear to consist merely of a fold of skin or mucous membrane and areolar tissue, but when from any cause the hemorrhoid is inflamed, it becomes swollen and tense, and is evidently filled with fluid or coagulated blood. After a succession of such attacks, the pile forms a distinct tumor, sometimes of considerable size, which, even in its indolent state, gives a good deal of annoyance by its bulk and the sensation of weight which it occasions. External Piles.—In the indolent state these appear as small tumors or radiating folds, occupying the verge of the anus external to the sphincter, and covered with the-thin integument of the part. They give rise to a feeling of heat and fulness about the anus, particularly after defecation, and may be attended with some itching, but do not usually cause a great deal of inconvenience. When inflamed, however, they become excessively painful, the pain radiating in various directions and being much aggravated by exercise, or even by the assumption of the erect posture; they are often accompanied by an intolerable itching and burning, with violent tenesmus, depriving the patient of sleep, and for the time being rendering life almost a burden. If examined in this con- dition—which constitutes an "attack of the piles"—the hemorrhoidal tumors will be found ten.se and swollen, extending up within the grasp of the sphincter, and thus becoming partially covered with mucous mem- brane (extero-internal piles). Their color, which in the uninflamed state was nearly that of the surrounding integument, is now of a deep purplish- red hue. The hemorrhoidal tumor occasionally suppurates, but more commonly returns gradually to its previous indolent state, becoming, however, larger and more indurated with each successive attack of inflam- mation. When piles are large and numerous, the skin between them may undergo maceration, giving rise to a sero-purulent discharge which sometimes produces troublesome excoriation. " External piles are rarely attended by bleeding, but Syme and others have recorded cases of pro- fuse rectal hemorrhage, in which no internal piles could be found, and in which entire relief was afforded by the removal of pendulous flaps of skin which surrounded the anus. The diagnosis of external piles is made with little difficulty; the only affections with which they are liable to be confounded are vegetations and mucous patches, but these can be distinguished by observing that they are not like piles solely confined to the anal region. External hemorrhoids often coexist with the painful ulcer of the anus, or with fistula in ano. Internal Piles.—These are situated entirely within the sphincter, and are therefore covered with mucous membrane. As already men- tioned, there are two principal varieties, the longitudinal or fleshy pile, which in structure corresponds pretty closely with the external hemorrhoid, except that the venous element is more prominent, and the globular, vascular, or granular pile, which is characterized by the development of a congeries of arterial capillaries. The former variety has a broad base, is firm and elastic to the touch, and of a reddish-brown INTERNAL PILES. 809 color; the latter may be either sessile or pjo- 440 pedunculated, is at first of a bluish hue (resembling a varicose vein), but ultimately assumes its characteristic red color, and vil- lous or strawberry-like appearance. Internal piles may exist just within the sphincter, or an inch or two higher up; occasionally the hemorrhoidal tumors form a double circle, one above the other. The symptoms of in- ternal piles are similar to those of external hemorrhoids, but there is more distress, from the tumors frequently protruding during defecation and being caught or grasped by the sphincter, thus causing great pain and tenesmus. The frequent protrusion of the piles ultimately leads to general prolapse of the mucous coat of the rectum, while the constant irritation of the part gives rise to a discharge of thin mucus, which exco- riates the skin around the anus, and is often sufficiently abundant to soil the patient's clothes. Bleeding from the Rectum, or the Hemor- rhoidal Flux, is a most Characteristic Symp- Protruding hemorrhoids. torn of internal piles; it may accompany either form of the disease, though by far most common in connection with that in which there are isolated tumors with a granular, strawberry-like surface. In most instances, blood of an arterial hue appears to issue directly from the surface of the pile, but occasionally there is general oozing from the congested mucous membrane, or a copious stream may be poured from an ulcerated opening in a dilated vein. The amount of blood varies, in different cases, from a few drops to many ounces—enough in some instances to produce excessive and even fatal anaemia and exhaustion. The bleeding may be continuous, or intermittent—recurring sometimes at regular intervals. The occurrence of the hemorrhoidal flux is not unfrequently preceded for some clays by an increase of the ordinary symptoms of piles, constituting what the older writers called the Hem- orrhoidal Effort: in these cases, the loss of blood seems often to act beneficially both by giving local relief and by acting as a derivative, and perhaps preventing serious visceral congestions. The hemorrhoidal flux sometimes alternates vicariously with the menstrual flow. The pain in a severe case of internal piles is not limited to the rectum, but radiates to the loins, sacrum, hips, and thighs, and marked sympathetic irritation is frequently developed in the urino-genitary organs. Internal, like ex- ternal piles, may become inflamed, and ultimately subside into an indo- lent condition, persisting as hard and incompressible tumors containing clotted blood; the clot occasionally undergoes a calcareous change and becomes converted into a phlebolite or vein-stone. In other instances, the piles protrude and are strangulated by the sphincter, eventually sloughing off, and thus undergoing a spontaneous cure. Internal hemorrhoids are to be diagnosticated from prolapsus, and from polypus of the rectum : in complete prolapse of the rectum (a very rare affection), the smooth character of the mucous membrane and the cylindrical form of the protrusion will enable the surgeon to make the diagnosis, while the common form of prolapse, in which the mucous 810 DISEASES OF INTESTINAL CANAL. membrane alone is implicated, may usually be distinguished from piles by its annular form, and by the absence of distinct tumors. The two affections, however, often coexist in the same patient. Rectal polypus may be recognized by its being solitary and of comparatively large size. The diagnosis of bleeding piles from other sources of intestinal hemor- rhage may be made by observing that the blood in the hemorrhoidal flux is bright, liquid, and spread over, rather than mingled with, the feces, whereas blood entering the bowel at a higher point will be dark, partially clotted, and mingled more or less intimately with the other contents of the intestinal canal. Internal hemorrhoids sometimes exist in cases of fistula in ano, and may prove a troublesome complication in the treat- ment of that affection, by protruding^n the wound after the operation. Treatment op Hemorrhoids. Constitutional Treatment.—This consists in endeavoring to im- prove the general health, by the administration of nutritious food and tonics if the patient be of relaxed or debilitated frame, or by regulating the diet and partially cutting off the supply of animal food under oppo- site circumstances: highly seasoned dishes and alcoholic stimulants should be particularly avoided. Any habits that predispose to the disease should be given up, and the patient should daily take moderate but not fatiguing exercise in the open air. If any special cause of the affection can be detected (as urethral stricture), this must of course be appropriately treated. In every case the bowels should be kept in a soluble condition by the administration of mild laxatives, such as castor oil, the compound rhubarb pill, copaiba, the confections of black pepper or senna, the mineral waters of Saratoga or Kissingen, etc. Enemata of cold or tepid water, as most agreeable to the patient, are sometimes of service. Local Treatment.—The local treatment may be palliative or radi- cal : the former will, in many instances, suffice to give very great com- fort to the patient, and may in mild cases even effect a permanent cure; it is often the only plan which is applicable in the latter stages of preg- nancy, or in extreme old age. The radical cure, or that by operation, should, however, usually be advised whenever the hemorrhoidal tumors have become permanent, leading to more or less constant inconvenience and suffering, and particularly in cases of bleeding piles, in which the amount of blood lost tends to render the patient anaemic. If, on the other hand, the hemorrhoidal flux be slight and not productive of much annoyance, it may, in some instances, be wiser not to interfere, for, as already mentioned, there is reason to believe that the loss of blood in these cases sometimes acts beneficially as a derivative. The Palliative Treatment consists in the topical use of various astringents and anodynes, and in the practice of frequent ablutions, so as to insure perfect cleanliness. Sponging with cold water, or the em- ployment of the cold douche, should be resorted to night and morning, and after each fecal evacuation. For internal piles, weak astringent injections (as of alum, or of the Tinct. ferri chloridi, ten drops to the ounce) may be applied, and are particularly useful in cases complicated with prolapsus. Whenever the piles protrude, they should be carefully replaced. In other cases great comfort may be derived from the use of opium combined with acetate of lead or tannic acid, in the form of sup- OPERATIVE TREATMENT OF HEMORRHOIDS. 811 positories. The same or similar remedies may be used for external piles, in the form of ointments. A good combination is one containing equal parts of the gall and stramonium ointments of the tJ. S. Pharmacopoeia. To relieve the itching which attends either form of piles, the best remedy, according to my experience, is the Ung. hydrargyri nitratis, diluted in the proportion of one part to seven. When piles become inflamed, the patient should be put to bed and the part constantly fomented or poul- ticed, while the bowels are moved with mild laxatives. Leeches may sometimes be applied around, but not over, the hemorrhoidal tumors, and if a pile be tense and evidently filled with coagulated blood, a punc- ture may be made with a lancet or sharp bistoury, and the clot turned out. An ice-bag may be substituted for the warm applications, if more agreeable to the patient. As a rule, no operative treatment should be instituted while the piles are in a state of inflammation, though, as the operation can be rendered painless by anaesthesia, it need not be post- poned if there be any reason to the contrary. The Radical or Operative Treatment of Hemorrhoids may consist in excision, ligation, or the application of caustics. 1. Excision is chiefly adapted to the treatment of external piles. For the removal of these, it is sufficient to seize each pile with broad- bladed ring-forceps (Fig. 441), and cut it off with scissors curved upon Fig. 441. Ring-forceps for piles. the flat, treating in the same way any loose folds of skin that may exist around the anus. If the piles be altogether external (covered with skin only), there is no risk of troublesome hemorrhage, anel any bleeding that may occur can be readily controlled by pressure or torsion. If, however, Fig. 442. Smith's clamp for piles. as is often the case, the piles be partly covered with mucous membrane (extero-internal), the hemorrhage may be quite profuse, and it is then much better to use the ligature in the way which will be presently 812 DISEASES OF INTESTINAL CANAL. described, notching first with the scissors the cutaneous surface of the hemorrhoidal tumor, and applying the ligature in the groove thus made. Care must be taken,'in the excision of external piles, not to remove too much skin, lest the contraction which occurs in the healing process should result in the formation of a troublesome anal stricture. In order to render excision a safe mode of treatment for internal piles, a plan which originated with Cusack, of Dublin, may be employed. In this, which is called the Operation by Clamp and Cautery, the base of the hemorrhoidal tumor is closely compressed between the blades of clamp-forceps, and, the pile being then cut off with scissors, bleeding is prevented by applying to the stump or pedicle strong nitric acid or the hot iron. Instruments for this operation have been devised by H. Lee, Wood, and others, the best, probably, being that in- Fig. 443. troduced by H. Smith, of King's College Hospital. The blades of this apparatus (Fig. 442) fit accurately together with a tongue and groove, and the compres- sion of the pedicle is effected by means of a screw which unites the handles. Plates of ivory are fixed to the outer surfaces and edges of the blades, so as to pre- vent the heat of the cautery-iron from reaching the surrounding parts. This operation, which Mr. Smith also employs in cases of prolapse of the rectum, is said to be attended with very little pain, and to be followed by quicker convalescence than the operation of ligation. 2. Ligation is the method usually employed for the treatment of internal piles, and is that which I myself am in the habit of adopting. The patient should take a dose of castor oil the night before, and have his lower bowel thoroughly washed out by means of an enema on the morning of the operation. Though it is not absolutely necessary, it is usually better for him to be etherized. If the piles do not protrude, they may be made to do so by administering a warm water enema, which will bring them down as it is ejected from the rectum. The patient being placed on his side and turned slightly over on his belly, while the nates are widely separated by an assistant, the surgeon seizes each tumor with the ring-forceps and transfixes its base with a double ligature, introduced by means of a naevus-needle, or, which is better for the purpose, the needle known as Bushe's (Fig. 443). The needle being detached, the pile is effectually strangulated by tying the ligatures on either side. The ends of the ligatures are then cut short, when the bulk of the strangulated pile may be lessened by cutting off its summit at a safe distance from the point of ligation. If, however, the hemorrhoid arise from some distance up the rec- tum, it is safer not to use the scissors, but to push the whole strangulated mass above the sphincter. When all the internal piles have been thus ligated, and any external ones that may exist ex- cised, an opium suppository should be placed in the rectum, and the patient returned to bed, with cold water dressing constantly applied to Bushe's needle and needle-carrier. PROLAPSUS OF THE RECTUM. 813 the anus. The bowels should be kept locked up for four or five days, after which a free evacuation may be secured by the administration of castor oil. The ligatures become detached usually within a week, leav- ing small granulating surfaces, which soon heal under the occasional application of nitrate of silver. The operation is sometimes followed by strangury, or even by retention of urine, requiring the administration of a warm bath, or possibly the use of the catheter. In cases of internal piles complicated with prolapsus, the ecraseur may be occasionally used with advantage, as it produces more contraction than the ligature. The instrument should be very slowly worked, as otherwise its employment is apt to be followed by hemorrhage. The ligation of piles is not entirely free from danger, being, in some cases, followed by erysipelas, pyaemia, phlebitis, or tetanus. I have, fortunately, never as yet seen a fatal result from the operation in my own practice, though I nearly lost one case from erysipelas. In two cases, however, which occurred in the wards of my colleagues, a few years ago, tetanus ensued, with a fatal termination. 3. The Application of Caustic is particularly suited for those piles in which the arterial element is predominant, and which may be recognized by their granular or strawberry-like appearance. This mode of treatment, which was introduced by Houston, of Dublin, is now chiefly advocated by H. Lee, Fergusson, and H. Smith ; it is more apt to succeed when the piles are sessile than when they are pedunculated. The caustic used is the strong nitric acid, which is conveniently applied with a smooth piece of wood or a glass brush through a fenestrated glass speculum; as soon as the pile is well coated with the acid, it should be wiped with a piece of lint dipped in oil, or in a paste of prepared chalk and water. A thin slough is formed, the detachment of which leaves a healthy granulating surface which soon heals. The great advantage of this mode of treatment is, according to H. Smith, that it does not require the patient to keep the house after the operation. If the acid be carefully applied, so as not to touch the skin, it causes very little pain; but its use is not absolutely free from risk, one case referred to by Erichsen having terminated fatally from erysipelas. Prolapsus op the Rectum. This occurs under two forms—the partial and the complete. In partial prolapsus of the rectum, the mucous membrane of the gut is alone involved in the protrusion, though the submucous areolar tissue is commonly thickened and elongated. In complete prolapsus, all the tissues of the gut are involved, the bowel being actually invaginated, and protruding sometimes to the extent of several inches. Causes.—The causes of prolapse of the rectum are, (1) a relaxed and weakened state of the tissues in general, such as is met with in feeble children or in debilitated adults; (2) chronic irritation of the rectal mucous membrane, such as results from dysentery or from the presence of internal piles; and (3) reflected irritation dependent upon diseases of other organs, such as urethral stricture, prostatic enlarge- ment, vesical calculus, or exstrophy of the bladder. Symptoms.—The protrusion occurs, at first, only after defecation, aud perhaps only when the bowels are unduly relaxed; but as the 814 DISEASES OF INTESTINAL CANAL. disease progresses, the prolapse becomes more constant, coming down when the patient stands or walks, and being with difficulty kept in place. In the partial form of prolapse the mucous membrane forms a red or purplish ring, somewhat elongated in shape, and continuous with the mucous coating of the sphincter; in the complete prolapse the gut is Fig. 444. Fig. 445. Partial prolapsus of rectum. Section of complete prolapsus of rectum. invaginated through the sphincter, between which and the protruded bowel a distinct groove may always be recognized. The complete pro- lapse forms an elongated cylindrical tumor, of the ordinary color of mucous membrane, presenting a smooth and even surface in the child, but being usually somewhat convoluted and rugose in the adult. When the protrusion is down, there is a sensation of weight and dragging, with some pain (not, however, very intense), and sympathetic vesical dis- turbance. In a case of recent prolapsus of either form, strangulation may occur, leading perhaps to sloughing, and possibly spontaneous cure; but in cases of long standing the sphincter is commonly much relaxed, facilitating both the descent and the reduction of the protrusion. Diagnosis.—The diagnosis of prolapsus of the rectum is usually made without difficulty ; the complete form of the affection can, indeed, scarcely be mistaken for anything else, while partial prolapse is only likely to be confounded with internal piles, with which it is very often complicated, but from which it may be distinguished by the annular character of the protrusion, and by the absence of distinct tumors. Treatment.—The first step in the treatment of prolapse of the rectum is to effect reduction ; this may usually be readily effected by placing the patient on his side, and gently but firmly compressing and pushing up the gut with the hand, protected with a soft cloth dipped in oil. If the sphincter be much dilated, both hands maybe required—one to fix the part, while compression is made with the other. When strangu- lation occurs, reduction may be, if necessary, facilitated by incising the mucous membrane, if the prolapse be of the partial variety, or by dividing the sphincter, if complete invagination have occurred. After reduction, the part may be supported with a pad and bandage. In order to prevent a recurrence of the prolapse, the bowels should be kept in a soluble condition by the administration of laxatives, such as were re- INFLAMMATION OF THE RECTAL POUCHES. 815 commended for piles. The descent of the gut while at stool should be prevented by avoiding straining, and by having the bowels moved while in the recumbent position, or even while standing—protrusion being less apt to occur in either of these than in the ordinary sitting posture. With children a kneeling posture is preferable, and the nurse may, as advised by MacCormac and H. Smith, be directed to draw the skin of the anus forcibly to one side during the act of defecation, so as to cause contraction of the sphincter, and thus prevent the gut from protruding. In mild cases, a cure may often be obtained by attention to these points, and by the local use of astringents in the form of injections or sup- positories. If the prolapse be due to sympathetic irritation from stric- ture, calculus, etc., these affections must, of course, be properly treated, when the rectal complication will commonly subside of itself. Operative Treatment.—In cases of extensive and inveterate pro- lapsus, especially in adults, something more may be required. Excision of the muco-cutaneous folds around the anus, ligation of two or more folds of mucous membrane, the application of caustics, and the operation by clamp and cautery, are the chief modes of treatment. 1. Excision is effected simply by cutting off with curved scissors the radiating flaps of integument around the anal orifice, the subsequent contraction often sufficing to effect a cure; if the incision involve the mucous membrane, a stitch or two should be inserted so as to guard against hemorrhage. 2. Ligation is effected by seizing with ring-forceps a portion of the prolapsed mucous membrane, and tying it firmly with a single ligature: it is usually sufficient to apply one ligature on either side, but more may be required if the prolapse be extensive. The parts should then be carefully returned through the sphincter, and an opium suppository introduced. 3. Caustic, the strong nitric acid being the best, may be applied through a fenestrated speculum, as directed in the case of piles, or to the pro- truded gut, before reduction, as advised by Allingham. 4. The Clamp and Cautery method is perhaps the best mode of treat- ment. Longitudinal folds of mucous membrane are to be seized with Smith's clamp and cut off with scissors, the pedi- cle being then seared with a hot iron. 5. Excision of a V-shaped Segment of the sphincter on one or both sides has been occa- sionally practised, but is a severe mode of treat- ment, and may be followed by fecal inconti- nence. Finally, in cases in which operative interference is not deemed advisable, great comfort may be afforded by the adaptation of a well-fitting anal truss or supporter, such as shown in Fig. 446. Inflammation op the Rectal Pouches. The pouches or lacunae of the rectum are sometimes much enlarged, chiefly in old people, becoming distended with fecal matter, and as a consequence inflamed or ulcerated, and causing intense itching, and often severe pain, unaccompanied, however, by spasm of the sphincter. This affection was first described by Physick, under the name of Encysted Rectum, and is called by Gross, Sacciform Disease of the Anus. The 816 DISEASES OF THE ABDOMINAL ORGANS. diagnosis is readily made by exploring the rectum with a blunt hook or a probe bent at its end. The treatment consists in drawing down suc- cessively each pouch that is affected, and excising the mucous fold at its base with curved scissors. Neuralgia op the Anus. This usually occurs as a symptom of some local lesion (as painful ulcer of the rectum), but may exist independently. The treatment in such cases is very unsatisfactory; the free use of quinia and the local application of belladonna are perhaps the best remedies. Pruritus or Itching of the Anus. This is probably always symptomatic, but occasions so much distress as to be worthy of special mention. It may be due to hemorrhoids, to the presence of intestinal parasites, to papular or other eruptions in the neighborhood of the anus, or to uterine displacement. The treatment consists in the removal of the cause, if this can be ascertained, in atten- tion to the state of the bowels, in the use of frequent ablutions, and in the employment (somewhat empirically, it must be confessed) of various washes or ointments. The dilute citrine ointment is perhaps the best remedy for itching piles, while for the pruritus dependent on cutaneous eruptions of the part, the tar and iodide of sulphur ointments of the U. S. Pharmacopoeia will often be found useful. Curling speaks highly of an ointment containing chloroform and oxide of zinc, and of a wash of sulphuret of potassium and lime-water (3J-f^viij). Chlorinated lotions or weak solutions of hydrocyanic acid may also be employed. Arsenic is often of service as an internal remedy, and may be conveniently given in the form of arsenious acid, combined in a pill with iron and quinia. CHAPTEE XLIII. DISEASES OF THE ABDOMINAL ORGANS AND VARIOUS OPERA- TIONS ON THE ABDOMEN. Paracentesis Abdominis. Paracentesis abdominis, or "the operation of tapping," is not unfre- quently required in cases of ascites and ovarian dropsy. The circum- stances which in any particular case indicate or contra-indicate this operation, are discussed in works on the Practice of Medicine or on the Diseases Peculiar to Women, and it will, therefore, only be necessary to describe in these pages the manual procedure itself. The bladder having been emptied, the patient sits on the edge of the bed, or lies on either side, a broad four-tailed flannel bandage being laid over the upper part of the abdomen, and the ends crossed behind, and firmly held by an assistant. The surgeon makes a short incision in the median line about an inch and a half below the umbilicus, dividing the superficial structures, and then with a quick motion thrusts in a full-sized trocar and canula; the trocar being withdrawn, the fluid is allowed to OVARIAN TUMORS. 817 escape, and is collected in suitable basins or pails. "While the flow con- tinues, the bandage should be continually tightened, so as to compress the abdomen and prevent the occurrence of syncope. Should the canula become clogged, it may be freed from obstruction by introducing Fig. 447. Tapping the abdomen. a director or flexible catheter. When all the fluid has been evacuated, the canula is withdrawn and the wound closed with a broad adhesive strip, the abdomen being supported with a firm compress and bandage. The steps of the operation as above described may be occasionally varied; thus, if the abdominal parietes be tense and thin, the trocar may be thrust in at once, without a preliminary incision, the instrument being- hindered from penetrating too far by the operator's finger placed about half an inch from the point, while the canula may, if preferred, be pro- vided with a stopcock and flexible tube, as in the operation of para- centesis thoracis. The puncture in the median line is to be adopted in cases of ascites, and indeed in every instance, unless the unilateral cha- racter of the swelling should indicate the choice of another locality, when the puncture may be made in the corresponding linea semilunaris. When, as usually happens, the operation has to be repeated, the second punc- ture should be made a few lines above or below the cicatrix of the first. The operation of tapping is rarely attended by any unpleasant results ; it may occasionally, however, be followed by the development of a low form of peritonitis, and in cases of dropsy from malignant disease, the- wound of puncture may become the seat of secondary deposits. It might seem unnecessary to caution the surgeon against mistaking pregnancy for abdominal or ovarian dropsy, but for the fact that tappino- has occasionally been incautiously employed under such circumstances,. with an unfortunate result that can be readily imagined. Ovarian Tumors. I do not purpose entering into any prolonged discussion of the symptoms, diagnosis, and therapeutics of ovarian disease, for these sub- jects belong more to the special domain of Gynaecology than to that of Surgery; it will be sufficient to enumerate the principal affections with which ovarian tumors are likely to be confounded, and to describe briefly the various operative procedures which are employed in their treatment.1 1 In the following pages I have drawn freely from Prof. T. Gaillard Tliomas's excellent " Practical Treatise on the Diseases of Women,™ Phila., 1869. 52 818 DISEASES of THE ABDOMINAL ORGANS. Diagnosis.—Fecal Accumulations in the caecum or other parts of the large intestine have been mistaken for ovarian tumors; the diagnosis may commonly be made by digital examination per vaginam, the fecal tumor imparting a characteristic doughy sensation'to the touch. Pregnancy, either normal or extra-uterine, is usually attended with such obvious symptoms as to prevent the possibility of mistake, and in any case of doubt, a brief delay will serve to clear up the diagnosis. Fibro-muscular Tumors of the Uterus can usually be distinguished from ovarian growths, by observing that in cases of the former there is commonly uterine hemorrhage and leucorrhcea; the uterine sound or probe enters* further than in the normal state; the tumor, which is often Fig. 448. Sims's uterine probe, smallest size. multiple, is usually hard, and by vaginal exploration is found to be irregular in outline and continuous with the uterus; and, finally, if the uterus be moved by means of the sound, the tumor moves with it. On the other hand, in a case of ovarian tumor, there is neither monorrhagia nor leucorrhcea; the uterine sound enters only to the normal distance; the tumor, which is usually solitary, often fluctuates, and is smooth and not continuous with the uterus; and, finally, the uterus can be moved without the tumor moving with it. It is to be noted, with regard to the last diagnostic point, that it is the uterus and not the tumor which must be movable; for the upper part of a solid uterine growth may be mova- ble, while its base is so tightly wedged in the superior strait of the pelvis, that no motion can be communicated to the mass through the uterine sound. Ascites can commonly be distinguished by the character of the tume- faction, which in abdominal dropsy is uniform, but in ovarian disease is localized at first to one or other iliac fossa; by the flattening of the abdomen, in the recumbent posture, owing to the ascitic fluid gravitating to the sides of the peritoneal cavity; by the change in the line of dulness upon variation in the patient's position ; by the resonance anteriorly when the patient lies on her back, owing to the intestines floating upward; by the prominence of the recto-vesical pouch, in which fluctua- tion can be detected by the finger introduced into the vagina; by the presence of a distinct wave when the patient rolls in bed; and by the coexistence of signs of disease of the heart, liver, or kidney, the skm being often harsh and jaundiced, and the feet oedematous at an early period of the affection. In dropsy from disease of the ovary, on the other hand, beside the local character of the swelling in the early stages, it is found that, owing to the fact of the fluid being contained in a tense cyst, there is no flattening of the abdomen nor anterior resonance in the supine posture; little or no variation in the line of dulness; no promi- nence of Douglas's cul-de-sac; no abdominal wave when the patient rolls TREATMENT OF OVARIAN TUMORS. 819 in bed; and no evidence (except by a coincidence) of disease of other viscera. Finally, in a doubtful case, the diagnosis may be made by ex- amining the fluid withdrawn by tapping, which, if the disease be ovarian, will probably be found to contain altered blood-cells, epithelial scales, masses of granular matter, oil globules, and crystals of cholestearine. Cystic Disease of the Broad Ligament so closely resembles that of the ovary, that a diagnosis is frequently impossible, though if the fluid removed by tapping were found to be non-albuminous and like that of ascites, there would be strong reason for believing that the ovary was not implicated. Other abnormal conditions may be occasionally mistaken for ovarian tumors, such as hydatids, uterine distension from retention of the men- strual secretion, accumulations of fat in the omentum or abdominal walls, partial contractions of the recti muscles, and cysts of the kidney or spleen. Though the diagnosis of ovarian tumors can, in most instances, be made with tolerable certainty, by careful and repeated examination, yet cases occasionally occur which completely baffle the most cautious observer, and it has repeatedly happened that the operation of ovari- otomy has been undertaken in cases in which no ovarian tumor could be found, the morbid growth being perhaps connected with the uterus, kidney, spleen, or omentum; or more rarely there being no tumor at all (see Phantom Tumors, p. 478). The difficulty, and in some cases impos- sibility, of making a correct diagnosis, is one of the strongest arguments against the propriety of ovariotomy; and yet the operation should not on this account be considered unjustifiable, more than should the liga- tion of arteries for aneurism, on the ground that deligation has been occasionally performed when no aneurism existed. Treatment.—Solid tumors of the ovary do not, as a rule, call for ope- rative interference, and the same may be said of those tumors which con- tain both solid and fluid elements, with the exception of the fibro-cystic tumor, or cystic sarcoma, which may occasionally be properly removed by ovariotomy. Hence the remarks which follow are to be understood as applying to the treatment of cysts of the ovary, which are of much commoner occurrence than the other forms of tumor. The question whether or not a tumor of the ovary be cystic, can usually though not invariably be decided by noting the presence or absence of fluctuation, upon external, and especially upon vaginal palpation. In any case of doubt, an exploratory puncture with a small trocar should be resorted to. There may be a single cyst, or the tumor may be multilocular; in the latter case the secondary cysts may sometimes be recognized by pal- pation, and the contained fluid is usually darker and more viscid than that of a cyst which is unilocular; single cysts, moreover, rarely attain a very large size; the distinction is of importance as regards the prog- nosis of the case, single cysts being occasionally curable by milder mea- sures than ovariotomy, and offering a better prospect of recovery after that operation, than multilocular growths. Another point which is usu- ally considered of great importance as regards the prognosis of ovari- otomy, is the presence or absence of adhesions ; these may sometimes be detected by careful palpation and auscultation, but, on the other hand, may exist without giving any evidence of their presence; it is probable, however, that, as remarked by Spencer Wells, the prognosis after ope- ration is more influenced by the general condition of the patient than by the size and condition of the tumor. 820 DISEASES OF THE ABDOMINAL ORGANS. The surgical procedures resorted to in the treatment of ovarian cysts, are tapping, drainage, incision, partial excision, injection of iodine, and ovariotomy. 1. Tapping, the mode of performing which has already been described, is chiefly resorted to as an aid to diagnosis, or with a view to palliation rather than radical cure. It has been conclusively shown by Spencer Wells, whose experience in cases of ovarian disease is probably greater than that of any other living surgeon, that the prospect of recovery after ovariotomy is not lessened by the fact of the patient having been pre- viously tapped once or oftener; and hence there need be no hesitation in employing this simple operation, either to assist the diagnosis in a doubt- ful case, or as a means of affording temporary relief before resorting to graver measures. Special care must be taken to prevent the escape of the cystic contents into the peritoneal cavity (an occurrence which might be followed by peritonitis), by using Thomson's " siphon trocar," or some Fig. 449. Siphon trocar. similar instrument. Though in the large majority of instances tapping acts only as a palliative, it has occasionally been followed by permanent recovery ; an additional argument in favor of the practice which has been recommended. Tapping through the vagina or rectum is occasionally preferred to the ordinary operation through the abdominal parietes. 2. Drainage is effected by enlarging the puncture made in parietal or vaginal paracentesis, and introducing a tube which is fixed so as to allow the escape of fluid, and, if necessary, the washing out of the cyst with simple or medicated injections. This mode of treatment is chiefly adapted to cases of unilocular cyst, in which ovariotomy is contra-indi- cated by the extent of adhesions. 3. Incision consists in laying open the tumor through the abdominal wall; this plan, which maybe considered a modification of that last men- tioned, is only adapted for the treatment of firmly adherent multi- locular cysts, which do not admit of ovariotomy on the one hand, nor of simple drainage on the other. 4. Partial Excision consists in cutting away a small portion of the anterior wall of the cyst, and allowing the contents to escape into the peritoneal cavity; this mode of treatment is more applicable to cases of cystic disease of the broad ligament than to those in which the ovary is involved (see p. 819). 5. Injection of Iodine for the cure of ovarian cysts, appears to have been first successfully employed by Dr. Alison, of Indiana, in 1846, but was not brought prominently before the profession until some years afterwards, through the writings of Boinet and other European sur* OVARIOTOMY. 821 geons. The formula recommended by Boinet is 100 parts each of tinc- ture of iodine and water, with 4 parts of iodide of potassium. The ope- ration consists in introducing through the canula (after tapping) a flexible catheter, by means of which from four to ten ounces of the solu- tion are injected, the liquid being withdrawn again after ten or fifteen minutes; the catheter is retained as long as may be thought necessary, the injections, the strength of which is gradually increased, being occa- sionally repeated. This mode of treatment should, according to Peaslee, be reserved for cases of unilocular cyst, with clear, serous contents, in which simple tapping has been previously employed at least once; by so limiting its application, Dr. Peaslee believes that the mortality of the operation would be reduced to one in ten, and the proportion of cures increased to one in three. 6. Ovariotomy, or the formal extirpation of a diseased ovary, was suggested by Wm. Hunter and recommended by John Bell; but the first surgeon who actually resorted to the operation was McDowell, of Ken- tucky, who performed the first ovariotomy in the year 1809. This case was successful, the patient surviving thirty-two years. McDowell repeated the operation about a dozen times, with varying success, and his example was followed by a few surgeons both at home and abroad, but for many years the feeling of the profession at large was that ovari- otomy was an unjustifiable procedure, and it is within a comparatively short period only that this operation has been generally accepted as a legitimate resource of surgery. Among those who have acquired most distinction as ovariotomists may be particularly mentioned Bird, Clay, Baker Brown, Tyler Smith, Wells, Bryant, and Keith, among British surgeons; W. L. and J. L. Atlee, Kimball, Dunlap, Peaslee, and Thomas, in our own country, and Koeberle, in France. The operation is not usually a very difficult one, but is always one of great gravity, the mortality in the hands of the most skilful ovarioto- mists averaging from 28 to 30 per cent. This is in itself no valid objec- tion to the operation, for the death-rate is less than that of many other operations which ar% universally recognized as legitimate; but it is surely sufficient to render the surgeon very cautious in his prognosis, and to induce him to neglect no means of satisfying himself both as to the accuracy of his diagnosis, and as to the applicability of the operation to the particular case with which he has to deal. As Spencer Wells justly remarks, " it is seldom that a surgeon is called upon to perform ovariotomy in order to save a patient from imminent death. . . . There is generally as much time for discussion as in the parallel case of lithotomy in the male adult. And in both cases, the responsibility of operating, with the full knowledge that if the patient be not saved by the operation he or she is killed by it, must be fairly faced." This responsibility, moreover, is one which the surgeon has no right to throw upon the patient; every woman knows that, after an operation like ovariotomy, she may die or she may get well, and it is to the superior knowledge and wide experience of the surgeon that she looks for advice as to whether the operation is or is not desirable in her particular case. The ultimate decision in this, as in every other case, must of course rest with the patient, but the surgeon should honestly and plainly express his opinion, whether it be favorable or unfavorable; and if, after a full and careful consideration of all the circumstances of the case, he is brought to the conclusion that the operation is, upon the whole, not advisable, he should, in my judgment, simply decline to operate. 822 DISEASES OF THE ABDOMINAL ORGANS. The Operation of Ovariotomy may be performed as follows: The patient's bowels should have been emptied by the administration of a dose of castor oil a day or two previously, and by means of an enema on the morning appointed for the operation. The temperature of the room should be at least 70° Fahr., and the table well covered with blankets; the patient should be thoroughly anaesthetized, and at the last moment the contents of the bladder should be evacuated by means of the catheter. The first incision is made to correspond as nearly as possible to the position of the linea alba, and may reach from about an inch or an inch and a half below the umbilicus to within two inches of the pubes, though, in many instances, a smaller wound may be sufficient. Wells's statistics, however, go to show that provided the incision does not extend above the umbilicus, its exact length in inches does not affect the result of the operation. The dissection is cautiously continued until the peritoneum is reached, when, all hemorrhage having been checked, this membrane is opened by picking it up with forceps, making a small cut, and then intro- ducing the left forefinger, upon which as a director the wound is enlarged to the full extent of the external incision. A small quantity of serum now usually makes its, escape, when the cyst wall probably presents itself immediately below the wound ; should a fold of omentum or a loop of intestine intervene, these should be carefully lifted off and put to one side. The surgeon then proceeds to investigate the extent of adhesions, if there be any, by introducing first two or three fingers dipped in luke- warm " artificial serum," then a curved steel sound dipped in the same, so as to sweep around the base of the tumor, and finally, if necessary, the whole hand. The " artificial serum," the use of which was suggested by Dr. Peaslee, consists of half an ounce of table-salt, six drachms of white of egg, and two quarts of water. If the adhesions be extensive, or if the tumor be now ascertained to be chiefly or entirely solid, it may be necessary to carry the incision above the umbilicus—this being done by a curve to the left side, so as to avoid wounding the round ligament of the liver. Should the adhesions be found so firm and extensive as to forbid the hope of removing the tumor, the surgeon may attempt the treatment by drainage, incision, partial excision, or injection of iodine, according to the character of the cyst—whether single or multilocular— and the nature of its contents, which may be ascertained by making an exploratory puncture with a small trocar. (See pp. 819, 820.) If the adhe- sions be less firm and extensive, those which are accessible may be care- fully separated by the fingers, thus completing what may be called the second stage of the operation. The third stage consists in turning the patient on her side, and then lessening the size of the tumor by tapping the cyst, or the principal cysts, if there be more than one—a good instrument for the purpose being the winged trocar and canula of Spencer Wells (Fig. 450), or the ingenious hollow trocar, devised by Dr. Mears, of this city. The fluid may be conveyed away through a flexible tube, while the cyst-wall is held forwards with vulsellum forceps, and compression of the abdomen kept up by the hands of an assistant. The sac having been sufficiently reduced in size, is now gently drawn out through the external wound, any remaining adhesions being severed by the hand, by a small cautery iron (or the galvanic cautery), by an ecraseur, or by scissors, according to the peculiar circumstances of the case. If any hemorrhage occur, it may be controlled by torsion, by styptics, by the cautery, or by the ligature; in the latter case, silver wire should be used, or, which would OVARIOTOMY. 823 perhaps answer equally well, the antiseptic ligature of Prof. Lister. If the adhesions be inseparable, it may be necessary to leave a portion of the cyst-wall. Fig. 450. Spencer Wells's trocar and canula. The next step is to secure the pedicle of the tumor, so as to prevent hemorrhage. This may be done by means of the ligature or the clamp, by dividing the pedicle with the ecraseur, or the actual cautery; or by applying torsion to each individual vessel. The stump of the pedicle, if sufficiently long, should be fixed between the lips of the wound; but if too short for this, must be returned into the abdominal cavity ; or it may be " pocketed" in the deeper part of the incision (as suggested by Storer, of Boston), the external wound being accurately closed above it. When the stump is to be fixed in the external wound, the use of the clamp is probably the best method of securing the pedicle. Several varie- Fig. 451. Spencer Wells's clamp. ties of clamp have been employed, those devised by Wells, Koeberle, Atlee, and Dawson, being perhaps the best. When the stump is so short as to render its restoration to the abdominal cavity necessary, a different plan must be adopted; here the surgeon may choose between slow division of the pedicle and the application of torsion to each separate vessel, the use of the actual cautery, and the employment of the ligature. Torsion has not been resorted to sufficiently often to allow a positive opinion as to its merits. If the ligature be employed, the pedicle is transfixed and tied in two parts, when the ends may be brought out at the lower end of the wound (Clay's method), or may be cut short and dropped into the peri- toneal cavity, as advised by Tyler Smith and Peaslee; if the short cut ligature be used, it should be rendered antiseptic in the way recom- mended by Prof. Lister. If the cautery be used (as is done by Baker Brown), the surrounding parts may be protected by the use of the clamp-shield devised by Prof. Storer. 824 DISEASES OF THE ABDOMINAL ORGANS. The pedicle being secured, and the tumor removed, the surgeon ex- amines the other ovary (excising it also, if it be diseased), and then, having cleansed the peritoneum by careful sponging, closes the wound with large harelip pins, or with deep and superficial sutures, and applies water-dressing or oiled lint, supporting the whole abdomen with a broad flannel bandage. The sutures should be made of silver or flexible iron wire, and the deep set shoultl pass through the whole thickness of the abdominal wall, including the peritoneum. The after-treatment consists in adopting means to prevent the occur- rence of peritonitis, which is the cause of death in about one-fourth of the fatal cases. The patient should be kept perfectly quiet and tranquil, and fed upon liquid diet for ten days or a fortnight after the operation. A Sims's catheter should be retained in the bladder during the first four Sims's sigmoid catheter. or five days, and the bowels locked up by the moderate use of opium for about two weeks. If there be much tympanitic distension, a simple enema may be given on the eighth or ninth day. The chief sources of danger, beside shock and nervous prostration, are secondary hemor- rhage, peritonitis, and septic poisoning. Hemorrhage must be arrested by exposing or opening the wound, and securing the bleeding vessel in the pedicle, and peritonitis is to be treated in the way described in pre- vious chapters. Koeberle applies an ice-bag on either side of the inci- sion, as a prophylactic against both of these complications. Should symptoms of septic poisoning supervene, the lower part of the incision should be opened sufficiently to allow the introduction of an elastic catheter, through which disinfectant solutions may be injected, and the peritoneal cavity washed out, as recommended by Dr. Peaslee. This surgeon reports several successful cases, in one of which no less than 135 injections were made in the course of 78 days. The best disinfect- ants for the purpose are probably the Liq. sodae chlorinatis and carbolic acid, either being, of course, very much diluted. Quinia should, at the same time, be freely given internally. The sutures may be removed, a few at a time, from the fifth to the tenth day. Double Ovariotomy was first performed by Dr. J. L. Atlee, of Lancaster, Pa., in 1843, and has been since repeated by several surgeons, among whom may be particularly mentioned Dr. Peaslee, who reported his third case in 1864. The operation is attended with but little greater difficulty and risk than that of removing a single ovary, but has the necessary disadvantage of rendering the patient sterile. Extirpation of both Ovaries and of the Uterus has been per- formed in some 30 or 40 cases, usually, however, with a fatal result. In the light of past experience, the repetition of the operation cannot be recommended, though it is, of course, possible that wider observa- tion may, at some future time, compel the rendition of a more favorable verdict with regard to this operation, as it has already done with regard to the simpler procedure of ovariotomy. EXTIRPATION OF THE KIDNEY AND SPLEEN. 825 Cesarean Section. This operation may be performed with the hope of saving the child alone (in case of sudden death occurring to a woman far advanced in pregnancy), or with the hope of saving both mother and child, in cases of rupture of the womb, extreme deformity,of the pelvis, etc. The ope- ration consists in opening the abdominal cavity in the median line (as in ovariotomy), incising the womb, rupturing the membranes, and ex- tracting with the least possible delay both child and placenta. Bleeding is then to be arrested, the peritoneal cavity cleansed by sponging, and the wound of the abdominal parietes closed with sutures. The after- treatment is directed to the prevention of peritonitis. The Caesarean section has been occasionally repeated on the same patient, in successive pregnancies, from two to seven times. Nephrotomy for Renal Calculus. Calculous concretions have been occasionally extracted from the kidney or ureter, in cases in which the existence of an abscess or uri- nary fistula has served as an indication for the proceeding, but the first formal nephrotomy for the removal of renal calculus appears to have ) been performed by an Italian surgeon, named Marchetti, in the latter part of the seventeenth century. Several concretions were extracted, and the patient recovered with a renal fistula. The revival of this ope- Z ration has been recently advocated by T. Smith (in a paper in the Medico-Chirurgical Transactions, vol. Hi.), who recommends a longitu- dinal incision along the outer border of the erector spinae muscle, ex- tending downwards four inches from the lower margin of the last rib. The incision is cautiously deepened until the finger can be placed upon the hilus of the kidney, when, if thought proper, this organ can be laid open. This operation does not involve the peritoneal cavity, so that there is little risk of peritonitis, while urinary infiltration is prevented by the depending position of the wound. The great objection to the procedure is the difficulty of deciding (1) whether renal calculus exists at all, (2) which kidney is affected, and (3) whether the calculus be not so adherent as to render its extraction impossible. Since the publica- tion of Mr. Smith's paper the operation has been tried in two instances, but in neither case was any calculus found. Extirpation op the Kidney. In a case of urinary fistula which was caused by a wound of the ureter, unavoidably inflicted in the removal of the uterus and ovary, Simon, of Heidelberg, cut down in the left lumbar region and excised the kidney of that side, securing the renal vessels by ligature. The patient reco- vered. A similar operation has since been performed by Dr. Meadows, an English surgeon, in a case of cystic kidney, but the patient died on the sixth day. Extirpation op the Spleen. The spleen has been excised for traumatic causes, and in cases of cystic disease, and of chronic enlargement connected with leucocythemia—16 cases in all having been, according to Magdelain, recorded up to 1868. 826 DISEASES OF THE ABDOMINAL ORGANS. When performed for traumatic lesions, or for cystic disease, the opera- tion has occasionally been followed by recovery, but in the leucocy- themic cases has, I believe, invariably terminated fatally. Hemorrhage, either during or subsequent to the operation, appears to have been the usual cause of death, which in one of Bryant's cases occurred fifteen minutes after the patient left the operating table. The results of splenotomy, under any circumstances, are not, in my judgment, sufficiently encouraging to warrant a repetition of the ope- ration. Treatment of Abdominal Abscesses. The surgeon is occasionally called upon to evacuate collections of pus which have been formed in connection with the liver, gall-bladder, spleen, kidney, intestinal canal, or ovary, or in the deep layers of areolar tissue found in the neighborhood of the broad ligament. Hepatic Abscess is not unfrequently met with in tropical regions, The pus may occasionally find a vent into a neighboring portion of intestine, or may perforate the diaphragm and enter the lung, or finally may point externally. In the latter case surgical interference may be required, the treatment consisting in puncturing the abscess with a trocar and canula, the latter being provided with a stopcock as in the operation of paracentesis thoracis. The puncture should not be made until the signs of external pointing show that adhesions have been formed between the visceral and parietal layers of peritoneum, but if the other symptoms be urgent, an attempt may be made to hasten this occurrence, by the use of blisters or caustics, by making a superficial incision over the part, or by the introduction of acupuncture needles. The same means may be resorted to in dealing with other abdominal abscesses. Biliary Abscess.—The surgical treatment of abscess originating in the gall-bladder, is to be conducted on the same principles as that of hepatic abscess. Splenic Abscess is of rare occurrence. The treatment consists in evacuating the pus by means of a trocar and canula, as soon as adhesion has occurred between the adjacent layers of peritoneum. Perinephritic Abscess.—Collections of pus, originating in the areolar and adipose tissue around the. kidney, may find a vent by bursting into the kidney itself, or into the bladder (the pus then escaping in the urine), by perforating the diaphragm and entering the thoracic cavity, or by opening into the vagina or bowel, or on the ex- ternal surface, usually in the hypochondriac or lumbar region. This affection has been particularly studied by Trousseau, and more recently by Bowditch, of Boston, the last-named author having particularly insisted upon the importance of early surgical interference. The treatment consists in making a puncture or incision to evacuate the contents of the abscess, as soon as the existence of pus has been ascer- tained with reasonable certainty: the opening should as a rule be made in the lumbar region, because the kidney can be reached from behind without wounding the peritoneum; if, however, absolute pointing of the abscess should have occurred anteriorly, indicating the formation of ABDOMINAL ABSCESSES, HYDATIDS, AND CYSTS. 827 adhesion between the adjacent layers of peritoneum, the opening should rather be made at the point at which fluctuation is most distinct. With regard to the comparative advantages of incision, and of puncture with a trocar and canula, I should prefer the former; the objection usually urged, is, that the use of the bistoury is more apt to be followed by hemorrhage, but then if hemorrhage should occur, a free opening would afford greater facility for its control. Perhaps the best plan would be to make a superficial incision, and then thrust in a grooved director in the way recommended by Hilton for the opening of deep-seated abscesses in other situations (see page 381). Even if the flow of pus do not im- mediately follow the operation, Dr. Bowditch's experience has shown that the symptoms are quickly relieved, the swelling gradually melting away, as it were, under the influence of the suppuration which subse- quently occurs. Fecal or Stercoraceous Abscess may originate in connection with any part of the intestinal canal, but its most common seat is the neighborhood of the caecum or appendix vermiformis, where it consti- tutes Perityphlitic Abscess. Fecal abscess may result from injury, or from perforation of the bowel occurring in the course of typhoid fever, but its most common cause is the irritation produced by a foreign body. The treatment consists in making a free incision, as soon as the occur- rence of pointing renders it probable that adhesions have been formed between the parietal peritoneum and that covering the wall of the abscess. If the patient recover, it will probably be with a fecal fistula which must be treated as directed at page 371. Ilio-Pelvic Abscess originates usually in connection with the ovary, broad ligament, or retro-peritoneal areolar tissue, the affection being, in most instances, met with as a complication of the puerperal state. The pus may find its way into the rectum, uterus or vagina, bladder, or peritoneal cavity, or, if peritoneal adhesions have been formed, may point externally. When it is thought proper to open the abscess, this may be done by cautious incision, or by puncture with a trocar and canula, through the posterior wall of the vagina, the rectum, or the abdominal wall. If the latter situation be chosen, the operation should be delayed until after the establishment of adhesions between the adjacent layers of peritoneum. Suppuration occurring in an Ovarian Cyst (often though in- correctly called Chronic Ovarian Abscess) has been successfully treated by Bryant, by making an incision in the median line of the abdomen, laying open the cyst, stitching its walls to the edges of the external wound, and subsequently washing out the cavity daily by means of a syringe. Hydatids, Serous Cysts, etc. The surgeon is occasionally called upon to open hydatids, which occur in the liver, and more rarely in other organs. The opening may be made either with caustic or with the trocar and canula, with the same precau- tions against the escape of fluid into the peritoneal cavity as in the case of hepatic abscess. Dr. Southey, of St. Bartholomew's Hospital, London, has recorded a case of intra-thoracic hydatid, in which the cyst, after being tapped, was extracted through a free incision between the ribs: the patient recovered. 828 URINARY CALCULUS. The use of the trocar is also sometimes resorted to in cases of serous cyst of the liver,'kidney, or spleen, or in those of distension of the gall- bladder from accumulation of the biliary secretion. The same precautions should be adopted here as in the case of hydatids. CHAPTEE XLIY. URINARY CALCULUS. In the urine are found deposits of various solid substances, which when in the form of an impalpable powder are called sediments, when granular or crystalline are spoken of as gravel, and when concreted into masses constitute calculi or stones. The constitutional conditions which precede or accompany the formation of these deposits are often called diatheses, and surgeons thus speak of the uric acid, the oxalic, and the phosphatic diathesis. Varieties of Calculus. The most common and therefore the most important varieties of cal- culus are those composed respectively of uric acid, oxalate of lime, and phosphatic salts. Beside these, other varieties are occasionally met with, in which the concretion is composed of urates, cystine, xanthine, fatty matter, carbonate of lime, etc. Uric Acid Calculus.—This is very common, constituting, according to Roberts, five-sixths of all renal calculi, and of vesical calculi which Fig. 453. Fig. 454. Uric acid. Uric acid calculus. have recently descended from the kidney. When uric (or lithic) acid is deposited as gravel, it occurs in the form of little crystalline masses or flattened concretions of a yellowish or reddish-brown color. The uric acid calculus is ordinarily of moderate size, of a flattened oval form, and of a fawn color: on section, it is often found to be composed of con- centric laminae. Its weight rarely exceeds an ounce. The surface of VARIETIES OF CALCULUS. 829 the stone is usually smooth and somewhat mamillated, but occasionally rough and manifestly crystalline. The best test for uric acid is the development of a bright violet or purple hue (murexid), on applying the vapor of ammonia to the residue left by treating the suspected substance with nitric acid and heat. The urine of patients with uric acid calculus, is acid and frequently high-colored ; it often deposits uric acid crystals and amorphous urates. This form of stone is met with among free livers, especially those of a gouty habit, and among strumous, over-fed children. Urates.—The urates of potassa, soda, and ammonia are not unfre- quently deposited in the form of an amorphous sediment in urine after it has been voided, constituting the common lateritious deposit which is met with in febrile affections, or which may occur from mere concen- tration of the urinary secretion; but calculi composed of urates are very rare. They are almost exclusively observed in young children, and as renal concretions; though it is probable that urates occasionally form the nucleus of a vesical stone. The exact chemical composition of these calculi is a matter of some doubt, most authorities regarding them as concretions of urate of ammonia, though one of the latest writers, Roberts, of Manchester, appears to regard them as consisting of urate of soda. Urate calculi are soft, and never large; they may be recog- nized by their solubility in hot water. Urate of ammonia is often depo- sited in connection with phosphates from ammoniacal urine, and is thus met with in the outer layers of vesical calculi. Oxalate of Lime Calculus (Mulberry Calculus)—When evacuated in the form of gravel, oxalate of lime occurs as minute seed-like concre- Fig. 455. Fig. 456. Oxalate of lime. Mulberry calculus. tions, of a smooth and rounded form, and of a grayish-brown color. The oxalate of lime calculus is hard, of a somewhat spherical shape, dark- brown or black (more rarely bluish-gray) in color, and tuberculated on the surface, somewhat resembling a mulberry. It rarely attains a large size. Oxalate of lime and uric acid are often deposited in alternate layers, the calculus consisting of more or less perfect concentric laminae; the nucleus of such a calculus is usually composed of uric acid. Oxa- late of lime is soluble in nitric and hydrochloric acids, and when treated with the blowpipe leaves a residue of lime, which blues reddened litmus, and browns turmeric. The deposit of oxalate of lime appears to be due 830 URINARY CALCULUS. Fig. 457. to an imperfect metamorphosis of the azotized constituents of the blood originating sometimes in errors of diet, or in exposure to bad hygienic conditions of various kinds. Phosphatic Calculus.—Of this there are three varieties:— 1. Amorphous Phosphate of Lime (Bone Earth) is rarely met with as the sole constituent of a calculus. Stones of this variety are of a whitish chalky, or pale-brown color, are smooth and friable, and sometimes attain a considerable size. The phosphate of lime calculus may be recognized by its solubility in nitric and hydrochloric acids, and by its being totally infusible before the blowpipe. Phosphate of lime is also met with in the urine in a crystalline form (stellar phosphate), but does not under these circumstances occur as a calculus. The presence of amorphous phosphate of lime in the urine depends solely on the alkaline condition* of that secretion. 2. Phosphate of Ammonia and Mag- nesia ( Triple Phosphate).—This is more common than the phosphate of lime; the stones are of a whitish-gray color, and evidently composed of crystals. The triple phosphate is soluble in acetic, or in hydrochloric acid, and is precipi- tated by an excess of ammonia, in a crys- talline form. It is with difficulty fusi- ble before the blowpipe. 3. Mixed or Fusible Calculus.—This variety is formed of a mixture of the phosphate of lime and triple phosphate; it often occurs as a white mass, easily broken up, and resembling mortar; it is characterized by the great facility with which it may be fused before the blowpipe. The mixed phosphates rarely constitute the whole of a calculus, but, on the other hand, very frequently form some of the outer layers, deposited upon uric acid or other nuclei, or upon foreign bodies. The triple phosphate and mixed phosphates are met with in alkaline, and especially in ammoniacal urine. Fig. 458. Cystine Calculus.—This is a rare form of calculus. It is of a yellow color and has usually an oval shape, and a mamillated and slightly lustrous surface. On section, it presents a radi- ated appearance, and is at first of a yellow, wax- like color, turning to a pale green by long expo- sure to the light. Cystine is soluble in the mineral acids, and in ammonia; when precipi- tated from a solution in the latter (by evapora- tion of the solvent), it appears in the form of characteristic six-sided crystals. Xanthine or Xanthic Oxide is a very unusual constituent of cal- culous concretions; it is soluble in ammonia, but does not crystallize when precipitated. Fatty or Saponaceous Matters (Urostealith) have been occa- sionally found in calculi; the origin and precise nature of the substances in question are not positively known. Triple phosphate. Section of a cystine calculus, with a nucleus of uric acid, and an external coat of phosphates. RENAL CALCULUS. 831 Carbonate of Lime Calculi are very rarely met with. They are always small, are white, yellow, or ash-colored, and are smooth, hard, and sometimes lustrous. Fibrinous Calculi and Blood Calculi have been described by various writers, but can scarcely be considered as urinary deposits. They are called by Poland pseudo-calculi. Silica is occasionally met with as a constituent of calculi, but the masses which have been supposed to be entirely formed of this sub- stance, have been, according to Poland, pebbles or small stones intro- duced from without. For further information with regard to the various forms of urinary deposit and urinary calculus (of which the foregoing very brief sketch is all that the limits of this volume will allow), I would refer the student to special works on the diseases of the urinary organs, and particularly to the writings of Bird, Jones, Beale, and Roberts. Renal Calculus. Renal calculi are, in the large majority of instances, composed of uric acid. The symptoms produced by a renal calculus consist of pain of an aching character in the lumbar region, with occasional aggravations (nephritic colic) in which the pain shoots downwards towards the scro- tum and inner part of the thigh, and is attended by nausea or vomiting, and by dysuria and increased frequency of micturition. The urine at such times may contain blood, pus, or epithelial scales. When a calculus escapes from the kidney into the ureter, giving rise to a fit of the stone, the symptoms are greatly aggravated. The patient is suddenly seized with intense pain, radiating down the inside of the thigh and into the spermatic cord and testicle, the latter organ being retracted. There is constant vomiting, with a feeling of great prostration, constipation, partial suppression of urine, and, if the attack continue, decided febrile disturbance. The symptoms quickly subside when the calculus reaches the bladder, but if, as sometimes happens, the concretion becomes im- pacted in the ureter, dilatation of that tube will ensue, with consequent disease of the corresponding kidney. Should impaction occur on both sides, a fatal result will be inevitable. Treatment of Renal Calculus.—During the descent of a calculus, which may occupy several days, the patient should be kept fully under the influence of opium—warm baths, with hot fomentations or poultices to the loins and abdomen, being also of service. In some cases, cupping over the region of the kidney may be required. The bowels should be acted on by means of enemata, and diluents may be freely administered (if the stomach do not reject them) to encourage the flow of urine. During the intervals between the paroxysms of nephritic colic, an attempt should, in suitable cases, be made to effect the solution of the concretion by the administration of the citrate or acetate of potassa, which are easily taken, and which enter the urine in the form of carbon- ate. The cases which, according to Roberts, who has specially studied this subject, admit of solvent treatment, are those in which the urine has an acid reaction, and in which the concretion is probably composed of uric acid. In such cases, from two to three scruples of either of the 832 URINARY CALCULUS. salts named may be given in three or four fluidounces of water, regularly every three hours. The operation of nephrotomy for the relief of renal calculus has already been referred to (p. 825). Vesical Calculus. A vesical calculus may, as has been seen, originate from a concretion which has descended from the kidney; but in other cases stone is pri- marily formed in the bladder, by the aggregation of small granular par- ticles, around which, as a nucleus, fresh deposits subsequently take place, or by the deposit of calculous matter around some extraneous substance, Such as a bullet, pin, straw, or broken catheter, which has been introduced from without. Fig. 459. Section of an alternating calculus. Structure and Physical Characters of Vesical Calculi.— Structure.—Calculi may be composed throughout of the same sub- stance, but in many instances consist of several layers or laminae of dif- ferent chemical characters, deposited around a central portion or nucleus. These stones are called alternating calculi. The nucleus is usu- ally composed of uric acid, oxalate of lime nuclei coming next in frequency. When the nucleus is phosphatic, the stone is not alternating, the layers subsequently deposited being phosphatic likewise. Whatever be the primary nature of the calculus, it may become encrusted with phosphates in con- sequence of an ammoniacal state of the urine, due to vesical irritation. Calculous matter may be deposited around a mass composed of several small concretions aggregated together, the stone then appearing on section to contain several nuclei. Number.—In the majority of instances the bladder contains but a single calculus, but occasionally two or more are found in the same case,4 and in a few instances very large numbers of stones coexist; the most remarkable case on record is, perhaps, that of Chief-Justice Mar- shall, from whose bladder Dr. Physick is said, on the authority of Dr. Randolph, to have removed by lithotomy more than one thousand calculi. Sometimes several calculi become glued together by sabulous matter and inspissated mucus, forming one large stone somewhat resembling a grape-shot in miniature. Shape.—The most common shape of a vesical calculus is a flattened ovoid, though mulberry calculi are often somewhat rectangular, or irre- gularly rounded, while phosphatic stones are occasionally curiously branched or constricted. When several calculi are present, the opposing surfaces become worn by attrition, various facets being thus developed on the sides which are in contact. Size.—The size of calculi varies from that of a pin's head to that of a mass several inches in diameter. One of the largest stones known was extracted by a Belgian surgeon named Uytterhoeven, by the supra- pubic method, the concretion in this instance being six and a half inches long and four wide, and weighing over two pounds. Such large stones are, however, seldom seen at the present day, and one or two inches may be considered an average length of the calculi ordinarily met with in practice. CAUSES OF CALCULUS. 833 Weight.—The weight of vesical calculi varies as much as their size. The lightest stones mentioned in Crosse's tables weighed three and four grains respectively, and the heaviest, seven and eight ounces; but even this weight has been greatly exceeded by that of stones seen by Mayo, Harmer, Cooper, Mott, Cline, Morand,1 and other surgeons. The ave- rage weight is from one or two drachms to an ounce. Of 704 calculi referred to in Crosse's tables, there were 340 in which the weight was under and 364 in which it was over three drachms. Hardness.—The hardness varies according to the chemical nature of the calculus—stones of the mulberry variety being the least, and those'of the phosphatic the most easily broken. Some of the latter variety are extremely friable, and of a mortar-like consistency. Situation.—The situation of calculi in the bladder varies with the amount of urine contained in the organ, the size of the stone, and the position of the patient. The locality in which a stone is usually found upon sounding, is, at least in the case of small calculi, at the bas-fond of the bladder; but a stone may at other times rest directly upon the neck of the viscus, or may be lodged above the pubes, or behind the prostate—the latter being, indeed, the usual locality in cases of chronic prostatic enlargement. A calculus usually floats loosely in the bladder, but may be fixed in one of the pouches of the organ (if this be sacculated), when the stone is said to be encysted; it may also be ad- herent to the side of the bladder, or may be caught in the orifice of a ureter, or may be partially surrounded by a fungous growth. In other cases calculous matter, instead of being concreted into the form of a stone, is deposited in ridges or layers upon the vesical mucous membrane. Causes of Calculus.—The causes of calculus are in most cases very obscure, for though it is often possible to trace the occurrence of urinary deposits to certain definite states of the constitution, there is no apparent reason why these deposits should form calculous concretions in some cases and not in others. Occasionally, however, the development of calculus is evidently due to the presence of a foreign body, as a broken catheter, slate-pencil, or hair-pin. Age—Age appears to exercise a decided influence upon the occurrence of calculus, the statistics collected by Civiale, Gross, Coulson, and Thompson showing that, in round numbers, about two-thirds of the whole number of cases are in persons under twenty, and about two- fifths in those under ten years of age. These figures furnish, however, but an approximation to the true statement, for while, on the one hand, a stone may persist for many years before it is detected, the total number of persons between (e.g.) the ages of five and ten is, on the other hand, much larger than at any quinquennial period of adult life, so that the relative proportion of patients at any particular age may be very different from that above given': Sex.—Persons of the male sex are undoubtedly more apt to be af- flicted with vesical calculus than women ; but the difference is probably not greater than can be accounted for by the respective anatomical peculiarities of the male and female urethra, the escape of small calculi through the latter being much easier than through the former. Residence.—The frequency of calculous disorders varies in different localities; thus in our own country stone is, according to Gross, more common in the States of Kentucky, Virginia, Tennessee, and Ohio than in 1 Morand is said to have seen a vesical calculus weighing six pounds. 53 834 URINARY CALCULUS. any other regions. In the neighborhood of Philadelphia it is certainly very rare; the records of the Pennsylvania Hospital showing that of about eighty thousand patients treated in its wards, in one hundred and sixteen years, there were but one hundred and twenty-five cases of stone a proportion of less than one-sixth of one per cent. Other Causes—Among other circumstances which have been supposed to influence the frequency of the occurrence of calculus, may be men- tioned race, climate, diet, the use of limestone water, social condition, hereditary predisposition, etc. Finally, any circumstance which, by interfering with the excretion of urine, leads to vesical irritation, and, in consequence, to an ammoniacal state of the contents of the bladder, maybe considered as predisposing to the production of stone ; thus stricture of the urethra, enlargement of the prostate, and paralysis of the bladder from injuries of the spine, may all act as causes of vesical calculus. Symptoms of Vesical Calculus.—These vary according to the shape and size of the stone, the age and general condition of the patient, etc. A smooth and rounded calculus produces less irritation than one which is sharp and angular, and a small stone usually causes less dis- turbance than a large one. In children, though there be a good deal of local distress, there is seldom much constitutional suffering, the patients often appearing particularly rosy and hearty. This is not, however, invariably the case, and children are occasionally seen who are much emaciated and worn down by the constant irritation produced by the stone. In adults, the general health suffers at a comparatively early period, and inflammation of the bladder and kidney are common com- plications of stone at this period of life. Phosphatic calculi are usually said to produce more irritation than those of other varieties; but this is, I believe, erroneous, the fact being that cystitis (with an ammoniacal condition of the urine) almost invariably precedes and accompanies the deposit of phosphatic matter. Pain is usually a prominent symptom of stone, and often the first which attracts attention; beside a dull pain and feeling of weight in the region of the bladder and in the perineum, there is pain referred to the groins, testes, thighs, or, even the arms or soles of the feet, with a peculiar, sharp, cutting pain in the glans penis, which is most marked in children—leading to a habit of squeezing and dragging at the part, and giving rise to*elongation and hypertrophy of the prepuce. The pain is usually worst immediately after urinating, from the stone then falling forward on the neck of the bladder, which is the most sensitive part of that organ. In order to prevent this, caleulous patients get the habit of making water in the recumbent position. The pain is always increased by riding or walking, or by any movement which causes the stone to jolt about in the bladder; these variations in the amount of pain felt, are less marked in those cases in which the stone is habitually lodged behind an enlarged prostate, and are almost absent in cases of encysted calculus. Frequent and Painful Micturition is a very constant symptom of vesical calculus; in some instances there is absolute incontinence of urine, and in others retention; the flow sometimes stops suddenly from the stone falling over the orifice of the urethra, beginning again when the patient changes his position. The urine often contains blood, and, if there be cystitis, may be heavily loaded with mucus or pus; when the kidneys become implicated, the urine is commonly albuminous. The SOUNDING FOR STONE. 835 Sound for examining bladder. and smooth, and the shaft narrower than the beak, which is of a somewhat bulbous shape. The sound may be plated with nickel, which renders it less liable to rust. Sir H. Thompson recommends, as preferable to the ordinary sound, one which is hollow, so as to allow, if necessary, the gradual escape of urine, and with a grooved cylindrical handle^ which permits more delicacy of manipulation than the broad and flat handle of the instrument commonly employed; the shaft is graduated and provided with a slide, so as to measure the size of the stone. The operation of sounding is occasionally followed by some pain and constitutional disturbance, and should therefore not be performed during the existence of great vesical irritation, but should, under such circumstances, be postponed for a few days, until the irritation has been allayed by the administration of demulcents and other suitable remedies. The operation is thus performed: The patient is laid on his back on a hard mattress, with the hips slightly elevated, and may be etherized if this be thought desirable ; there should be a mode- r te quantity of liquid in the bladder, and therefore if the patient have passed his urine shortly before the few ounces of tepid water may be injected through an Fig. 461. detection of crystals of uric acid or oxalate of lime in the urine, would serve to throw some light upon the nature of the calculus. Prolapse of the Rectum is a not unfrequent accom- paniment of stone in children, and is occasionally seen in adults; it evidently results from the straining efforts made in the endeavor to empty the bladder. Priapism and Involuntary Seminal Discharges are among the rarer symptoms of vesical calculus. Diagnosis.—From observation of some or all of the symptoms mentioned, the surgeon may suspect the existence of a calculus in the bladder, but cannot be certain of it until he has elicited physical evidences of the presence of the stone. In children the calculus may sometimes be felt by the finger introduced into the rectum, and in women by a similar exploration, per vaginam, but the common means of determining the presence of a stone is by the introduction of a sound into the bladder. Sounding for Stone.—A sound is a solid steel instrument of the general shape of a catheter, but with a shorter beak (not much exceeding an inch in length), and more abruptly curved; the handle is made broad Fig. 460. A sound with slide and scale, for ascer- taining the magnitude of a stone. The handle, which resembles that of a modern lithotrite, but smaller, affords great facility in sound- ing. examination, a elastic catheter. 836 URINARY CALCULUS. The surgeon, standing between the thighs of the patient, or on either side,1 and holding the sound previously warmed and oiled in his right hand, and in a horizontal direction, introduces the beak into the urethra, and drawing the penis forwards with the left hand, gradually elevates the shaft of the instrument, which passes in by its own weight, until from being horizontal it has assumed a vertical position ; it is held thus for a few seconds while it traverses the membranous portion of the urethra, when by gently depressing the handle between the thighs, the beak rises through the prostatic portion into the bladder. In many cases the stone will be immediately touched by the sound, which then communicates a peculiar sensation to the hand of the surgeon, accom- panied by a distinct noise or " click," which is commonly audible to the by-standers, and which may be intensified, for purposes of class demon- stration, by attaching a small sounding-board to the handle of the instrument. In other instances, the stone will not be so easily dis- covered, and the surgeon must then cautiously search for it, turning the sound first on one side and then on the other, and varying the position of the handle so as to explore with the beak every portion of the bladder in succession ; this is done with a kind of tapping motion, imparted by lightly rotating the instrument between the thumb and forefinger. Fig. 462. Sounding for stone behind prostate. The stone will usually be found on one or other side of the neck of the bladder, or at the fundus of the organ near the orifices of the ureters; it may, however, in an adult, be lodged behind the prostate, or may rest above the pubes. To explore the former region, the position of the sound is reversed, the beak being turned downwards and the handle elevated, while the stone may be pushed upwards by means of the finger in the rectum ; to find a stone above the pubes, the beak of the sound is tilted forwards while the handle is well depressed between the thighs, the bladder being at the same time pressed downwards by placing the hand over the lower. part of the abdomen. Occasionally the position of the patient may be advantageously varied, by placing a 1 The beginner may stand on the left side, as in catheterization, and cross over to the right side when the sound has reached the bladder, but, with a little practice, it will, I think, be found more convenient to stand on the right side, when no change of position will be required to enable the exploration of the bladder to be conducted with the right hand. Fergusson prefers to stand on the right side and introduce the instrument with the left hand. When it is desired to aid the diagnosis by means of the finger in the rectum, the surgeon should stand between the patient's thighs. SOUNDING FOR STONE. 837 Sounding for stone above pubes. high pillow beneath the buttocks, or by causing him to lie on either side, to sit, or even to stand; or the bladder may be distended with water which is then allowed to escape slowly through the Fig. 463. hollow sound, when, as the organ contracts, the stone will probably fall against the instrument. If the presence of the calculus is not deter- mined in the course of five or ten minutes, the instrument should be withdrawn, and further exploration post- poned for three or four days —prolonged sounding being attended with some risk of producing cystitis. After the use of the sound, it is better that the patient should keep pretty quiet, and if there be any pain, an opium suppository may be introduced into the rectum. Beside determining merely the existence of a stone in the bladder, the surgeon may by sounding acquire valuable information as to the number, size, and hardness of the calculi, whether they be adherent or encysted, and as to the general condition of the bladder and prostate— all points of importance in regard to treatment. If the sound strike a stone on either side of the bladder, the surgeon knows that there is more than one calculus; but this can be better determined by the use of a light lithotrite, seizing one stone and then using the instrument as a sound in searching for others. The lithotrite affords also the best means of ascer- taining the size of a stone, though this may be done with approximate accuracy by moving the sound from side to side, or by touching the cal- culus first with the convex and then with the concave surface of the instrument. The hardness of the stone may be estimated by the cha- racter of the "click" produced by the contact of the instrument, a phos- phatic concretion giving a dull thud, while a uric acid, and more espe- cially an oxalate of lime, calculus gives a sound of a clear, ringing cha- Fig. 464. Sounding for encysted calculus. racter. If the stone were invariably found in the same locality, no matter what the amount of liquid in the bladder nor what the position of the patient, the surgeon would suspect that the calculus was adhe- 838 URINARY CALCULUS. rent; and if, in addition, the sound, while touching the stone but at one point, passed over a prominent swelling projecting into the bladder, the inference would naturally be that the calculus was encysted. The con- dition of the bladder, whether sacculated, ribbed, or incrusted with phosphatic deposits, and the size and relations of the prostate, can also be pretty accurately determined by exploration with the sound. A stone, though present, may escape detection, from its being encysted or lodged in one of the sacculi of the bladder, from being coated with blood or mucus, or even from its small size enabling it to slip away and elude the sound. Hence in any case in which the rational symptoms indicate the presence of a calculus, though none can be found, the sur- geon should repeat the exploration from time to time, varying the con- ditions under which the examination is conducted, until the diagnosis is rendered certain. The surgeon may, on the other hand, think that he has detected a stone when none is present, being misled by striking the sound against a cal- culous incrustation, against a tumor in the bladder, or in the neighbor- hood of, and compressing that organ, or even against the walls of the bony pelvis. That the possibility of these errors being made is not merely imaginary, is shown by the fact that such eminent lithotomists as Cheselden, Crosse, and Roux, each cut for stone (the former in three in- stances) in cases in which no stone could be found after the operation. Sounding for Stone in Women is effected with a short and very slightly curved instrument, resembling in shape the ordinary female catheter. Great assistance may be derived from tilting forward the stone by means of two fingers introduced into the vagina. Prognosis.—Stone in the bladder, unless removed by treatment, leads to serious morbid changes in the urinary organs, a fatal result being, sooner or later, almost inevitable. The prostate commonly be- comes enlarged, and cystitis occurs, the bladder usually being contracted and ribbed, but sometimes dilated; congestion and ultimately granular degeneration of the kidneys follow, and the patient dies worn out by suffering, or from the progress of the renal affection. If, on the other hand, the presence of the stone be recognized at an early period, and proper treatment adopted before the viscera, and especially the kidney, have become seriously involved, the prognosis is quite favorable, litho- tomy being an exceedingly successful operation in the case of children, and lithotrity (when not too long delayed) equally so in the case of adults. Treatment of Vesical Calculus.—There are several modes of treatment employed in cases of vesical calculus, and each may be pro- perly resorted to in suitable cases. That surgeon will do more to pro- mote both the welfare of his patients and his own reputation, who, in the treatment of stone, varies his remedies in accordance with the par- ticular circumstances of each individual case, than he who uniformly follows one exclusive mode of practice. Litholysis. Litholysis, or the Solvent Treatment of Stone, is unfortunately appli- cable to but a very limited number of cases. In the management of renal calculus, as already mentioned, a trial of this plan is often proper, for there is nothing else to be done; but, in dealing with stone in the LITHOTRITY. 839 bladder, the surgeon has no right to waste time and deprive his patients of the great advantages to be derived from an early operation, by resort- ing to a mode of treatment which is at best slow and uncertain. There are cases, however, in which the solvent treatment may be proper. Thus, as an adjuvant to lithotrity, in the case of a uric acid (or cystine) cal- culus, advantage may be sometimes gained from the administration of the citrate or acetate of potassa in the way already mentioned, so as to keep the urine moderately alkaline, provided there be no tendency to am- moniacal decomposition. If the urine be ammoniacal, the alkaline treat- ment is positively contra-indicated. In dealing with phosphatic calculi, injections of dilute nitric acid (Ac nitric, dibit. (U.S.P.) f«,ij, Aquas Oj) may be employed, as an adjuvant to lithotrity (as has been done by Southam), or alone, when the general condition of the patient forbids operative interference, as in the well-known case recorded by Sir Benja- min C. Brodie. Oxalate of lime calculi do not appear to be amenable to any form of solvent treatment. Lithotrity. Lithotrity, or the operation of Crushing a Stone in the Bladder, is now generally, and in my opinion justly, considered the best mode of treat- ment for any case of vesical calculus to which it is applicable. The first formal proposition to treat calculus in this manner is usually attributed to Gruithuisen, a Bavarian surgeon, who wrote in the year 1813 ; but a claim of priority has been advanced, and upon apparently good grounds, for two Italian surgeons named Santonio and Ciucci, who flourished in the seventeenth century.1 However this may be, it is to Civiale that is unquestionably due the credit of giving the operation a place among the recognized procedures of practical surgery, his first operation upon the living subject having been done in the year 1824. Since then lithotrity has been very frequently practised in France and England, and to a certain ex- tent in our own country; and the instruments employed have been brought to a high degree of perfection, chiefly through the labors of Civiale, Fergusson, and Thompson, aided by the well-known manufacturers Char- riere, Matthews, Coxeter, and Weiss. Two instruments are required, one with the female blade fenestrated, for crushing stones or large fragments, and one with both blades plain for reducing the smaller fragments to powder; the plain-bladed lithotrite is often though incorrectly called the scoop. The blades of the instrument are rather wider than the shafts2 (which should be as light and slender as may be compatible with Fig. 465. Weiss and Thompson's improved lithotrite. sufficient strength), and the male blade should be narrower than the female. The shaft and blades, which are united at an angle of 110°- 120°, should be cut out of solid pieces of steel, as they will thus fit more accurately and be much stronger than when bent into shape from flat 1 Brit, and For. Med. Review, vol. xi., Jan. 1841, p. 270. 2 The shaft attached to the male blade is technically called the sliding rod. 840 URINARY CALCULUS. plates of metal. The'handle of Weiss and Thompson's improved litho- trite (Fig. 465), which is probably the best now before the profession, is in the form of a grooved cylinder, the force being applied by means of a screw, and the handle being furnished with a button,, which by an in- Fig. 466. jflmiK3tt Forgusson's lithotrite ; the male blade is moved by the key. genious mechanism enables the screwing to be instantly converted into a sliding motion, and vice versa. In Fergusson's instrument the force is applied by means of a rack and pinion. Preparatory Treatment.—For a few days, at least, before sub- mitting a patient to lithotrity, the surgeon should enjoin rest in a recumbent position, and should adopt suitable means to bring the digestive system into a good condition, and to combat any vesical irri- tation that may exist, by the use of hip baths, anodynes, demulcents, etc. Sir H. Thompson speaks yery highly of a decoction of the triticum repens, or couch-grass, of which he directs a pint to be taken in divided doses in the course of the day. The urethra may also be accustomed to the use of instruments by the introduction first of an elastic, and subsequently of metallic bougies of gradually increasing sizes, and, finally, of an ordinary sound with which the stone may be touched and some notion gained of its size and composition. If the introduction of instruments produces great constitutional disturbance, the operation should be postponed for a short time until the irritable condition of the urethra has been overcome: and if this cannot be done, the surgeon may be induced by this circumstance alone to abandon crushing and resort to lithotomy. The urine should be examined, and if it contain much mucus or pus, the bladder may be washed out (through a flexible catheter) with simple injections of tepid water, which may be replaced by a very weak solution of nitric acid, if there be a copious deposit of phosphates. The conditions wished for and sought to be obtained by preparatory treatment are, according to Thompson, (1) a fairly ca- pacious and not very tender urethra; (2) a bladder capable of retaining three or four ounces of urine, not very irritable, and yet with sufficient tone to be able to expel its contents; and (3) fair general health. With these conditions and a stone of but moderate size and hardness, the operation of lithotrity offers an exceedingly favorable prognosis. Operation.—Some difference of opinion exists as to the propriety of employing anaesthetics in lithotrity. If performed with skill and deli- cacy, the operation is attended with little or no pain, and anaesthesia is therefore not required unless in exceptional cases. There is, moreover, a certain advantage in operating without ether, in that the surgeon can thus judge of the irritability of the bladder, and extend or abridge the duration of the " sitting" accordingly. The operation itself may be OPERATION OF LITHOTRITY. 841 described as occupying three stages, viz., (1) the introduction of the lithotrite; (2) the seizing, and (3) the crushing of the stone. The patient should lie on his back on a firm mattress, with his right side close to the edge of the bed, and the hips slightly elevated; the thighs should be slightly flexed and supported upon pillows, and should be sufficiently separated to allow the free play of the lithotrite between them, the knees being for this purpose kept at least twelve inches apart. If the prostate be much enlarged, a firm cushion should be placed beneath the pelvis, so as to raise this part from four to six inches above the level of the shoulders; the stone thus rolls backwards from its position behind the prostate, and comes more readily within the grasp of the in- strument. If the patient has passed his urine within half an hour of the time fixed for operating, three or four ounces of tepid water may be slowly injected through a flexible catheter; but this is not usually necessary, and the preliminary catheterization is in itself undesirable, as prolonging the sitting. Introduction of the Lithotrite—The surgeon, standing on the right side of the patient, holds the lithotrite, previously warmed and well oiled, lightly in his right hand, in a horizontal line, and in a direction nearly parallel to the long axis of the patient's body. The left hand raises the penis, and slowly draws the urethra upwards over the blades of the instrument, which is allowed to enter by its own weight as it is Fig. 467. gradually raised into a vertical line. The lithotrite thus reaches the bulbous portion of the urethra, and must then be held vertically for a few seconds, until the membranous portion has been traversed, when, by gently depressing the handle between the patient's thighs, the ; blades of the instrument slowly / rise through the prostatic portion j of the canal into the bladder. Sir > H. Thompson advises that at this :.! time a slight lateral rotatory move- ment should be given to the litho- trite, and that the surgeon should press _ over the pubes so as to relax introduction of the lithotrite. the triangular ligament of the penis. As the instrument enters the bladder, its shaft forms an angle of 20° or 30° with a horizontal plane, and when the introduction is completed the urethra loses its curve and is brought into a straight line. Finding and Seizing the Stone.—There are two ways in which this may be done. Heurteloup's plan, which was followed by Brodie, and which has been usually adopted in England, was to depress the base of the bladder with the angle or convexity of the lithotrite, and then, drawing back the male blade, give the instrument a tap or jerk so as to cause the calculus to fall within its grasp. The other method, which originated with Civiale, is adopted by Thompson, and seems to me the best. In this method the blades of the lithotrite are passed to about the centre of the bladder, the handle (which is attached to the female blade) being lightly held in the left hand, while the sliding-rod is worked with the right. If, as often happens, the stone is touched by the instru- ment as it enters the bladder, the blades are slightly inclined in the 842 URINARY CALCULUS. opposite direction, the male blade gently withdrawn, and the opened blades then inclined towards the stone, which is readily caught between them when the lithotrite is closed. Under other circumstances, the in- strument is made to go in search of the calculus, by opening the blades in the centre of the bladder, turning them to the right, and closing; opening them again in the centre, turning to the left, and closing; then repeating the same movements with the handle of the lithotrite de- pressed, and so on until, if necessary, the whole cavity of the bladder has been explored. During the rotation of the blades the handle of the lithotrite is held steadily with the left hand, so that the shaft, which is in contact with the urethra and neck of the bladder, shall have no motion except upon its own axis, while the blades are inclined in various direc- tions by the rotatory movement imparted by the right hand, and greatly facilitated in Thompson's instrument by the cylindrical shape of the handle. The following formula is given by Thompson as expressing the different directions in which the blades of the instrument are to be made to seek for the calculus: Yertical, right and left incline, right and left horizontal, and (if the prostate be enlarged) right and left reversed incline, and reversed vertical. For the reversed exploration a short- bladed lithotrite is preferred. In the description given above, the female blade is supposed to be fixed, and the jaws of the lithotrite to be opened by drawing the male blade backwards, but it is often found convenient in practice to fix the male blade and open the instrument by projecting the female blade. Crushing the Stone.—When the calculus has been seized, the surgeon rotates the lithotrite a little, to make sure that none of the vesical mucous membrane is included in its grasp, and then fixes it by drawing up the button attached to the handle of the instrument, which changes the sliding into the screwing action; the stone, being now held firmly in the centre of the bladder, the screw is to be turned slowly until the resistance yields, which it will do gradually or suddenly, according to Fig. 468. Position of lithotrite in crushing the stone. the consistence of the calculus. The male blade is then to be drawn out (the screwing being, for this purpose reconverted into the sliding mo- tion), when, without altering in any respect the direction of the instru- ment, one of the fragments may be picked up and crushed as before; and this process may, under favorable circumstances, be repeated two or three times. The instrument is then accurately closed and slowly drawn out by reversing the steps by which it was introduced. It is better not to attempt too much at the first sitting, and Thompson's rule is, that the lithotrite should not remain in the bladder more than one or two minutes. In the first sitting it is sufficient to crush the stone (which, un- AFTER-TREATMENT IN LITHOTRITY. 843 less the calculus be small, is best done with the fenestrated lithotrite), the pulverization of fragments being left for subsequent occasions. The sit- tings, if all go well, may be repeated at intervals of from three to six days. After-treatment.—For at least twenty-four or thirty-six hours, after each of the earlier sittings, the patient should lie in bed, and particularly avoid passing water except in the recumbent posture, so as to prevent angular fragments from falling upon the neck of the bladder or becom- ing impacted in the urethra. He should be warmly wrapt up, and a hot napkin may. be applied over the pubes and perineum, an opium and bel- ladonna suppository being at the same time introduced into the rectum. The sharp corners of the fragments are soon worn off by the contact of the urine, and' after two or three sittings a considerable quantity of debris will be passed whenever the patient makes water, or may be with- drawn in the grasp of the plain-bladed lithotrite. The final exploration, by which it is designed to detect and pulverize the last fragment, is best made with a small, short-bladed lithotrite, which is successively directed Fig. 469. Clover's lithotritic injection apparatus. 1. Elastic stylet for lithotrity catheter. 2,3,4,5. Lithotrity catheters with large eyes at end or in different sides, to be used with or without the injection apparatus. to all parts of the bladder, and particularly to the pouch behind the prostate. As a test of the complete removal of the calculus, W. J. Coulson advises that the patient should take a drive over a rough road, 844 URINARY CALCULUS. when, if any fragment remain, its presence will be revealed by the irri- tation produced by the jolting. Washing Out the Bladder.—In ordinary cases, it is probably wiser, as advised by Thompson, for the surgeon to content himself with breaking up the stone, leaving the extrusion of detritus to the unaided efforts of nature; but in some cases, as, for instance, if there be enlargement of the prostate,' with retention of urine, it is necessary to adopt artificial means to accomplish this object. In some cases it will be sufficient to use an "evacuating catheter," provided with a large eye near its extre- mity, through which the debris of the stone may escape,1 but in other cases it will be better to wash out the bladder through a double catheter, or to employ one of the ingenious instruments devised for the purpose by Mr. Clover and Prof. Dittel. Clover's apparatus (Fig. 469), consists of an elastic bottle, with a glass reservoir, and evacuating tubes of different sizes and shapes; the bottle is filled with tepid water which is slowly injected into the bladder, bring- ing with it as it returns the detritus, which is detained in the reservoir. The process may be repeated 10 or 12 times at each sitting, with great gentleness, however, lest the mucous membrane of the bladder be in- jured by the eye of the catheter. Prof. Dittel, of Vienna, has recently suggested an ingenious applica- tion of the siphon principle to the evacuation of detritus after litho- trity, and his instrument appears to me even better than that of Clover; the evacuating catheter is connected with a long, flexible siphon tube which reaches to a vessel placed on the floor, while an arrangement of valves permits water to be thrown into the bladder, the outward current depending upon the force of atmospheric pressure; the advantages of this method are that the bladder can be more completely emptied than by any other plan, while there is comparatively little risk of inflicting injuYy upon the vesical mucous membrane. Accidents and Complications of Lithotrity.—If the lithotrite be properly employed, there can be no danger of lacerating the urethra or injuring the mucous lining of the bladder; it has happened that the instrument has broken in attempting to crush a hard calculus, and should such an unfortunate event occur, there would be no alternative to cutting into the neck of the bladder and extracting the foreign body. To prevent the possibility of such an accident, every lithotrite should be tested before it is used, by crushing with it a lump of sandstone about the size of an English walnut. One of the most annoying complications which can be met with after the operation of lithotrity, is the impactibn of a fragment of calculus in the urethra—an accident which is usually traceable to the restlessness of the patient, and particularly to the neglect to keep the recumbent posture when urinating. Apart from the pain and local irritation produced by the impacted fragment (which may cause cystitis, or abscess in the neighborhood of the urethra, leading perhaps to urinary extravasation), there is often great constitutional disturbance, with repeated rigors and possibly the development of a pyaemic condition. The course to be pursued in the event of impaction occurring, varies according to the point at which the fragment has been arrested: should this be in front of the membranous portion of the urethra, the offending body should be 1 After the earlier sittings these means of artificial evacuation should not be em- ployed, for there is then no fine debris to be washed out. If retention exist, the urine may be drawn off with an ordinary catheter. STATISTICS OF LITHOTRITY. 845 extracted through the external meatus with delicate urethral forceps (Fig. 470), with a curette, or with Civiale's scoop; while if lodged in the prostatic or membranous portion, it should be pushed back into the Fig. 470. Urethral forceps. bladder with a full-sized bougie or a stream of water directed through a catheter with an open end, or if these means fail, should be removed through an incision in the median line of the perineum; under these cir- cumstances, it might be well to convert the operation into what has been named by Dolbeau, perineal lithotrity, reducing the remaining fragments to a sufficient size to enable them to be extracted through the wound. Other complications of lithotrity (which, however, are not peculiar to this operation, but may follow the use of a simple bougie or catheter) are urethral fever, haematuria, and inflammation of the bladder, prostate, or testis : these will be considered hereafter. Retention of urine is another complication which not unfrequently occurs, particularly in old persons, and which, on account of the insidious manner in which it is developed, should be carefully watched for ; here, as in other cases, the true condition is masked by apparent incontinence ; the treatment consists in using the catheter at regular intervals, until the natural tone of the bladder is restored. Statistics of Lithotrity.—The statistical results of lithotrity, in the hands of any operator, will necessarily vary very much according to the good or bad judgment which he exercises in the selection of his cases, and, as justly remarked by Sir Henry Thompson, unless the surgeon can arrive at an accurate diagnosis of the nature and size of the stone (and, I may add, of the condition of the urinary organs of his patient), it is probably safer to avoid lithotrity entirely, and uniformly resort to lithotomy. But if an accurate diagnosis can be made, the risk to life, in suitable cases, is, I think, certainly less (in the case of an adult) if the stone be crushed than if it be removed by cutting: to establish this, it will be sufficient to refer to the experience of those surgeons who have practised the operation most frequently, and who may therefore be sup- posed to have brought it to its highest state of perfection. Omitting Civiale's cases (the record of which is considered inaccurate by many of those best qualified to form an opinion on the subject), the experience in lithotrity upon male adults of Brodie, Fergusson, Keith, and Thomp- son, as given by the last-named gentleman in the second edition of his work on " Practical Lithotomy and Lithotrity," is summed up in the following table:— Brodie......115 cases, 9 deaths, or 7.83 per cent. Fergnsson.....109 " 12 " H " Keith (of Aberdeen) . . . 116 " 7 " 6.03 Thompson.....204 " 13 " 6.37 " Aggregate .... 544 41 7.54 846 URINARY CALCULUS. These results, it will be seen, are very satisfactory: they cannot, of course, be in any way compared with the results of lithotomy—and still less with those of lithotomy since the introduction of the crushing method; for lithotrity is now confessedly chosen for the most favorable, and lithotomy for the least favorable cases. An approximate judgment as to the actual benefits derived from the introduction of lithotrity, may, however, be arrived at by comparing the mortality in all cases of stone submitted to operation by those who practise both methods, with that of cases in the hands of surgeons who employ lithotomy only: from such a comparison it appears that the death-rate, in cases of adult males, is reduced about two per cent, by the adoption of the former course:— 495 cases operated on by both methods, by Fergusson and Keith, gave 90 deaths, or 18.18 per cent. 799 cases operated on by lithotomy exclusively, collected by Thompson, gave 161 deaths, or 20.15 per cent. It is thus seen that a slight but positive gain is derived by resorting to lithotrity in suitable cases; and it is surely, therefore, the surgeon's duty to employ the crushing rather than the cutting method, whenever the former is not positively contra-indicated. Circumstances which forbid a Resort to Lithotrity.—These have regard to the age of the patient, the nature and size of the stone, the condition of the urinary organs, and the state of the patient's general health. 1. Age.—In the first place, lithotrity is contra-indicated in the treat- ment of children below the age of puberty; the grounds for this assertion are, that (1) the urethra is too small at this age to permit the free play of an instrument of sufficient strength; (2) the bladder is placed so high—in the abdomen rather than in the pelvis—as to render the use of the lithotrite difficult and not very safe; (3) children do not bear with impunity the frequent repetition of operations required in the various sittings of lithotrity; (4) the operation can scarcely be performed in children without the aid of anaesthesia (which is in itself undesirable); and (5) lithotomy is such a successful procedure in early life, as to render it difficult for any other mode of treatment to compete with it. I know of no extended statistics of lithotrity in children, but Guersant reports 40 cases (5 of them, however, in girls), with 7 deaths, or a mortality of 17£ per cent. Several cases, moreover, required subsequent lithotomy. ' His lithotomies number 100, with 14 deaths, and his total number of cases, treated by both methods, 140, with 21 deaths, or a mortality of 15 per cent. Thus, even in his own hands, lithotrity (in children) has been less successful than lithotomy, while the results of the latter operation when indiscriminately applied to all cases under puberty, have been still more favorable, 1028 cases collected by Thomp- son, giving but 68 deaths, or a mortality of less than 7 per cent. Com- paring these figures with those given in the preceding pages, we find that indiscriminate lithotomy, in children, is safer even than lithotrity, in selected cases in adults; and that, on the other hand, lithotrity, in selected cases in children, is not much less dangerous than indiscriminate lithotomy in adults. Hence, the inference seems to me inevitable, that an age below puberty is a positive contra-indication to lithotrity. 2. Nature and Size of the Stone.—No absolute rule can be laid down CONTRA-INDICATIONS TO LITHOTRITY. 847 upon these points, but it may be said, in general terms, that in the case of hard calculi (as of oxalate of lime), one inch is the maximum diameter which admits of crushing, and for lithotrity to be properly applied to a mulberry calculus of this size, all the other circumstances of the case should be favorable; in the case of uric acid, and particularly of phos- phatic calculi, this limit may be somewhat exceeded, but even in dealing with such stones, if more than an inch and a half in diameter, lithotomy will usually be a safer operation than lithotrity. Two inches would be the maximum, even if the calculus were phosphatic and the bladder healthy—a combination of circumstances which is not very likely to occur. The existence of multiple calculi is in itself no contra-indication to lithotrity; on the contrary, if, as then usually happens, the calculi be small, the operation of crushing may be considered as having been par- tially accomplished by nature ; if, however, the stones be numerous and large, lithotomy would undoubtedly be a safer procedure. If the calculus be adherent or encysted, lithotrity is of course out of the question. 3. Condition of the Urinary Organs.—Several circumstances require consideration under this head. (1.) Stricture of the Urethra is almost always a contra-indication to lithotrity, though Sir Henry Thompson has shown that the crushing operation may occasionally be successfully resorted to in these cases, the stricture being of course submitted to dilatation as a preliminary measure; in the large majority of instances, however, and certainly in the hands of the majority of operators, lithotomy either by the lateral or median method, according to the size of the stone, would be a prefer- able procedure in cases of this kind. (2.) Enlargement of the Prostate is not in itself a contra-indication to lithotrity, though it renders the operation more difficult, and requires the use of Clover's apparatus or some similar contrivance to aid in the evacuation of detritus; if, however, the enlargement be complicated with an irritable condition of the bladder, lithotomy should be preferred, par- ticularly if the calculus be of considerable size. (3.) Atony, or Paralysis of the Bladder, is usually thought to contra- indicate lithotrity, but does not, in the judgment of Sir H. Thompson, whose opinion upon this point is entitled to great respect. If, however, the stone be large, in a case of atony of the bladder, the crushing opera- tion should probably not be performed. (4.) A Sacculated, Condition of the Bladder, if it could be detected beforehand, would ordinarily contra-indicate lithotrity, on account of the probability of fragments becoming lodged in the sacculi, where they would produce irritation, and might elude the efforts of the surgeon to find and dispose of them. It is possible, however, that by using Dittel's siphon arrangement, much of this difficulty might be avoided. (5.) Cystitis, if present in an aggravated degree, may be a bar to the performance of lithotrity. If the urine be loaded with mucus, or still worse with pus, and the introduction of the sound be productive of great pain and irritation, lithotomy will usually be the better operation. If, however, the stone be small and friable, an attempt may be made to lessen the irritability of the bladder, by keeping the patient in bed and daily injecting tepid water, as advised by Brodie, when, if this plan succeeds, lithotrity may perhaps be safely resorted to. (6.) Malignant Disease of the Bladder would certainly diminish the 848 URINARY CALCULUS. chances of successful lithotrity, but would still more positively contra- indicate lithotomy; if the stone in such a case be friable and of moderate size, it would, I think, be justifiable to crush it, merely as a palliative measure. (7.) Organic Disease of the Kidney, as evidenced by the presence of albumen and tube-casts in the urine, is usually considered to contra- indicate the performance of lithotrity. It undoubtedly renders the prog- nosis of the case very gloomy, and it is even a question whether any operation should be performed under these circumstances. If in any case of this kind it be determined to attempt the removal of the stone, and the surgeon has to, choose between lithotrity and lithotomy, his decision should, I think, be chiefly guided by the character of the cal- culus ; if this be such that the bladder can probably be cleared in one or two sittings, the crushing operation should be preferred; but under opposite circumstances, lithotomy would be the safer procedure. (8.) A Tendency to the Development of Urethral Fever is, I think, a positive contra-indication to lithotrity; if the surgeon finds that a rigor, with subsequent febrile disturbance, follows every introduction of an instrument into the bladder (and this can be tested by the preliminary use of bougies), all idea of crushing the calculus had better be aban- doned, and lithotomy resorted to instead. If lithotrity be persisted in under these circumstances, the operation will not improbably be followed by deep-seated suppuration, pysemia, and perhaps death. 4. General Condition of the Patient___If the health of the patient be feeble, and his strength failing, without there being any special disease of the urinary organs, lithotrity is unquestionably preferable to lith- otomy, and should be performed if the size of the stone permit. This condition is not unfrequently met with in old people, whose constitu- tional powers seem to have deteriorated, without any particular lesion being present to account for the change. If, on the other hand, the patient be of a nervous, anxious, and irritable disposition, the length of time which the successive sittings of lithotrity necessarily occupy, con- stitutes in itself an objection to the operation, and in a doubtful case may serve to turn the scale in favor of lithotomy, which rids the patient at once of the source of his discomfort. Lithotomy. Lithotomy, or the operation of Cutting into the Bladder to Extract a Stone, is the remaining resource in all cases (among patients of the male sex) not admitting of lithotrity; it is, therefore, the mode of treatment to be adopted in all cases below the age of puberty, and in a certain proportion, variously estimated by authors at from one-half to one-sixth, of the remainder; hence every surgeon who sees a fair proportion of both youthful and adult patients, will have to cut at least twice for each time that he crushes once. It is not my intention to give any account of the history of lithotomy, for which I would refer the student to the works of John Bell; but to describe the principal operative procedures which are in use at the present day, beginning with the ordinary lateral method, which is essen- tially that introduced by Cheselden, and considering subsequently the median, bi-lateral, and other forms of operation, and the circumstances by which, in my judgment, each is specially indicated. LATERAL LITHOTOMY. 849 Preparatory Treatment.—It is seldom, if ever, that there is any necessity for an immediate resort to lithotomy; but, on the contrary, there is usually ample time for the surgeon to satisfy himself, by careful and repeated sounding, and by chemical and microscopical examination of the urine, as to the nature, size, and relations of the calculus, the condition of the urinary organs, and any other points which it may be necessary to investigate, in order to form a correct judgment as to the state of his patient. An important question, which occasionally arises in practice, is whether the surgeon should operate in every case, pro- vided the patient desire it—giving him the " ghost of a chance," as it is sometimes called—or whether the operation should be declined whenever the surgeon's experience and judgment lead him to believe that operative interference can be productive of no benefit. The latter course is, I think, the one to be pursued; the case is very different from that of amputa- tion for injury, or herniotomy, or colotomy for imperforate rectum, or even tracheotomy for croup. In those cases the patient is in imminent danger, and the operation, even if it do not avert, will at least not hasten death; but in lithotomy, as in ovariotomy, in the excision of tumors from the parotid region, and in other operations for diseases not attended with immediate risk, if the surgeon's interference do not cure, it will certainly kill; hence, in any case of vesical calculus, if, after care- ful examination and deliberate reflection, the surgeon comes to the con- clusion that the patient will, in all human probability, not survive the operation, that operation should, in my judgment, be positively declined. Fortunately this contingency is of rare occurrence, and it is almost always possible (unless the case be complicated by far advanced renal disease) to bring the patient into a fit state for operation, by enforcing rest for a week or ten days previously, and by adopting means to bring the digestive functions into a good state, and to lessen or relieve any existing irritation of the urinary organs (see page 840). A full dose of castor oil should be given on the previous day, and a simple enema a short time before the operation, so that the awkward accident of the patient's defecating over the. surgeon's hand may be avoided, and that the rectum, being empty, may be less exposed to the risk of being wounded. It is well also, in the case of an adult, to have the perineum shaved before the patient is brought under the influence of the anaes- thetic. Lateral Lithotomy. For the performance of lateral lithotomy a firm operating table is re- quired, of rather less than the ordinary height, so that when the surgeon kneels or sits before it his breast shall be about on a level with the patient's buttocks. Four assistants are required, one to hold the staff, one to give the anaesthetic, and two to fix the patient's limbs, one on either side. Many operators prefer to have a fifth assistant to hand the instruments, but if the surgeon adopt the kneeling posture (which I think the best), the instruments may be conveniently placed within his own reach, on a tray upon the floor. Instruments. — The instruments required are a staff, a simple straight bistoury or scalpel, of a size proportioned to the age of the patient, a probe-pointed knife, two or three pairs of forceps, a scoop, and a large long-nozzled syringe. It is well, in addition, to have 54 850 URINARY calculus. Fig. 471. within reach a blunt gorget, a searcher, and a litho- tomy tube. The staff should be boldly curved, and of as large a size as the urethra will admit. It should have a deep and smoothly-finished groove on the left side, or (which I prefer) in the middle line of its convexity, beginning two or three inches above the commence- ment of the curve and terminating abruptly in a right angle about a quarter of an inch from the extremity of the instrument. In using the common staff, the groove of which becomes gradually shallower, till it ends on the surface, there is great risk of the knife slipping off and wounding the posterior wall of the bladder. The handle of the staff should be broad and roughened, so as to give the assistant who holds it a firm grasp of the instrument. The particular form of the knives used in lithotomy, may vary with the fancy of the operator. Almost every distinguished lithotomist has devised some special form of instrument, which bears his name, but, for my own part, I do not know of any which is better than the common straight bistoury, which is found in every " minor operating-case." The probe-pointed knife is useful in case it is found necessary to enlarge the incision after the withdrawal of the staff. The forceps should be of various sizes and shapes, some straight and some curved. It is better, I think, to have the blades fenestrated, which Lithotomy staff. Fie. 472. Open-bladed lithotomy forceps. gives more room and diminishes the weight of the instrument, and the blades should be lined with linen (as advised by Liston), thus allowing extraction to be effected without the application of so much force as to endanger the crushing of the calculus. The scoop, well curved and of moderate size, should be firmly fixed in a roughened handle, to prevent its slipping. Fvi. 473. Lithotomy scoop. The syringe should have a capacity of at least half a pint, and may be made of gutta-percha or of metal. The blunt gorget, which is often combined with the scoop, should be probe-pointed, and is used to guide the introduction of the forceps when the perineum is too deep for the finger to reach the bladder. The searcher is merely a sound of slight curve, while the tube, which is introduceci through the wound in case of hemorrhage, may be made either of silvei, LATERAL LITHOTOMY. Fig. 474. 851 Tube for plugging the wound in lithotomy. or of gum-elastic, and should be rounded at the end, with large late- rally-placed eyes, and rings at the outer extremity to admit the tapes by which it is held in place. Operation.—The operation is thus performed: The patient being thoroughly etherized (with his rectum empty, and his perineum shaved), the surgeon usually injects a few ounces of tepid water into the bladder (though this is not absolutely necessary), and then introduces the staff, with which, used as a sound, he should recognize the presence of the stone. If this cannot be done, the staff is withdrawn and an ordinary sound introduced, when, if the stone still cannot be found, the operation must be postponed. This is a well-established rule of surgery, and should be inflexibly adhered to ; for (1) the stone, if small, may have been sponta- neously evacuated upon some occasion of the patient's passing water; (2) it may have become caught in some pouch or sac of the bladder, from which it cannot be dislodged; or (3) the instruments may not have entered the bladder at all, but may have gone through some false pas- sage into the recto-vesical space ; under any of which circumstances the operation, if persisted in, could but result in injury to the patient and in the utter discomfiture of the operator. It is safer, indeed, unless the surgeon's skill should enable him to be sure that the staff is actually in the bladder, not to proceed with the operation unless the stone can be touched with this instrument, as well as with the sound. The staff having been introduced, the patient is brought to the foot of the table, with his buttocks projecting over the end, and is secured in the "lithotomy position" by fastening together his Fig. 475. hands and feet with band- ages, or with leather straps provided for the purpose. Assistants then take charge of the limbs on either side, and expose the perineum by drawing the thighs outwards and backwards. The surgeon now fixes the staff in the way in which he wishes it to be held, and intrusts it to an as- sistant, who, standing on the patient's left side, holds it firmly in his right hand, while with the left he draws aside the patient's scrotum. It is this assistant's duty to keep the staff exactly as the ope- rator has fixed it, until he is directed to withdraw it from the bladder. There are two ways in which the staff may be fixed. Liston's plan, which I think much the best, was Position of patient and line of incision in lateral litho- tomy. 852 URINARY CALCULUS. to hook the staff firmly under the pubic arch, and draw it almost verti- cally upwards and exactly in the median line, thus obtaining a point d'appui which insures the steadiness of the instrument, and widening the space between the urethra and the rectum. Many surgeons, however, believe that the operation is rendered easier by turning the staff a little to the left, and by making its convexity bulge into the perineum. The surgeon now, casting a glance to see that all his instruments are in readiness, sits, or, which I much prefer, kneels on his right knee before the patient, and introduces the forefinger of his left hand into the rectum, so as to insure the contraction of this tube, and, at the same time, fix in his mind the relative positions of the staff, prostate, rectum, and tuber ischii. Holding the knife lightly but firmly as a pen between the fore and middle fingers and thumb of the right hand, he now begins his inci- sion a little to the left of the raphe and (according to the size of the perineum) from an inch to an inch and a half in front of the anus, and cuts obliquely downwards and outwards to a point below and between the anus and tuberosity of the ischium, but rather nearer the latter than the former. This incision should divide the skin and superficial fascia and fat, and should be rather deeper below than above; the left fore- finger is next placed in the wound so as to press down the rectum and Fig. 476. Deep incision in lithotomy. feel for the staff, which is soon reached by making a few light touches with the edge of the knife, dividing the transverse perinei, and opening the triangular space between the accelerator urinse and erector penis muscles. The finger-nail is pressed into the groove of the staff at as low LATERAL LITHOTOMY. 853 a point as can be felt, and upon the nail the point of the knife is intro- duced, so as to open the membranous part of the urethra; the surgeon then drops the handle of his knife a little, so as to fix it firmly beneath the knuckle of the index finger, and turning the blade half sideways (lateralizing the knife) and slightly depressing its handle, pushes it steadily onwards along the groove of the staff (which it must never leave), following it constantly with the left forefinger to protect the rectum, until the cessation of resistance and the escape of urine show- that the bladder has been reached; the knife is then cautiously with- drawn, still lateralized, and kept closely to the staff, so as not to enlarge the incision. The surgeon now lays down his knife, and placing his left forefinger above the staff, insinuates it by a twisting movement into the bladder, between the concavity of the staff and the roof of the urethra ; by observ- ing this precaution, there is no danger of the surgeon pushing the neck of the bladder before him, and thrusting his finger into the recto-vesical space. The stone is usually felt lying at the end of the staff. If the perineum be very deep and the prostate much enlarged, the surgeon's finger may not be long enough to reach the bladder, and then the blunt gorget must be substituted, being introduced by cautiously pushing it along the groove of the staff. The finger having entered the bladder, the surgeon directs his assistant to withdraw the staff, and then, while selecting the forceps which he is going to use, dilates the incision of the prostate by pressing his finger in different directions; the forceps are next introduced closed, along and above the palmar surface of the finger, which is slightly withdrawn as the forceps enter; the forceps having touched the stone, are opened, one blade being depressed against the wall of the bladder, when the calculus will commonly fall into the orasp of the instrument; the left forefinger is now placed upon the stone, rectifying its position, if necessary, so as to make its long axis Fig. 477. Direction of forceps in extraction of stone. correspond to the line of the wound, and extraction is then effected, in the direction of the axis of the pelvis, with a slow, swaying, to-and-fro movement, such as obstetricians employ in applying the forceps to the fcetal head. 854 URINARY CALCULUS. Fig. 478. In some cases it is more convenient to lay aside the forceps, and effect extraction with the scoop employed as a vectis; should, unfortunately, the stone be broken in extraction, the scoop must likewise be used to remove the fragments. After the calculus has been extracted, the surgeon again in- troduces his finger (or the searcher, if the perineum be deep and the bladder sacculated), and makes a careful ex- ploration to ascertain if there is another stone remaining, such being cautiously dealt with in the same manner as the first. When all calculous matter has been removed, the surgeon, as a matter of precaution, washes out the bladder through the wound with a syringeful of tepid water, and then, having seen that there is no hem- orrhage, has the patient untied and placed in bed. Position of finger and scoop in extracting stone. Fig. 479. Fig. 480. Physick's cutting gorget. Frere Come's Who- ome cachi. After-treatment.—This is suffi- ciently simple. The bed must be pro- tected with India-rubber cloth covered with a folded sheet or blanket, to ab- sorb the urine (which of course flows through the wound), the sheet being frequently changed, so as to keep the patient dry and comfortable. For a day or two the urine escapes entirely by the wound, then probably for a few hours by the urethra (owing to the swelling of the deep part of the inci- sion), and then again partly by the wound in gradually decreasing quanti- ties as the healing process continues. No dressing should be applied as long as any water escapes through the perineum, but after this, the incision may be treated as a superficial wound in any other situation. Opium may be administered in the form of a sup- pository, to relieve pain and insure sleep, the diet and general treatment of the patient being adapted to his constitutional condition. Variations.—The operation of lat- eral lithotomy, as above described, is varied in different ways by many surgeons; thus as regards the staff, many, as already mentioned, have the groove on the left side, and project the instrument into the perineum; Aston Key employed a straight staff, and Buchanan, of Glasgow, uses one which is not curved but rectangular; the latter instrument has been further modified by Hutchinson, by making DIFFICULTIES IN LATERAL LITHOTOMY. 855 the staff hollow and adding a stopcock, so that it can be used as a catheter. Still more complicated forms of apparatus have been devised by Earle, N. R. Smith, Corbett, Wood, and Avery, designed to render it impossible for the surgeon to miss the groove of the staff in making his incision. Instead of using the same knife for the deep as for the superficial part of the wound, some surgeons employ a probe-pointed or beaked knife after opening the urethra, while others prefer the cutting gorget (Fig. 479), and still others the lithotome cache (Fig. 480); excellent operations have been done with each of these instruments, and I have no wish to decry their usefulness in the hands of those who feel that the procedure is thereby rendered easier or safer; but for my own part I am quite satisfied with the simple bistoury, and think it an advantage not to have to change the instrument during the operation. In common with most surgical writers of the present day, I have advised a very limited incision of the prostate and neck of the bladder, the wound to be subsequently dilated with the finger—and I certainly believe this to be the best mode of practice; other surgeons, however, as Teevan, recommend a free division of the prostate, and believe that by this course they increase the probability of a successful result. I have not advised the introduction of the lithotomy tube in cases uncomplicated by hemorrhage, but many surgeons employ it in every instance, partly to prevent the accumulation of clots in the wound, and partly with the idea that its use diminishes the risk of urinary infiltration; I do not think it necessary in ordinary cases, but there is no particular objection to its employment, and if the surgeon cannot see his patient at short intervals after the operation, its use would be proper as a measure of precaution. Difficulties in the Operation.—The most difficult part of the operation, in the case of children, is to reach the bladder, the extraction of the stone being then usually effected without any trouble. If the rule which has been given, to pass the finger between the upper surface of the staff and the roof of the urethra, be followed, there will be little risk of missing the bladder; if, however, the finger be thrust in from below, it may readily tear across the membranous portion of the urethra, and, pushing the neck of the bladder before it, enter the recto-vesical space. If such an accident should happen, and should be noticed before the staff is withdrawn, the surgeon may retrace his steps, and, fixing the knife firmly in the groove of the instrument, notch the neck of the bladder, and cautiously introduce his finger into the organ; if the staff has been already withdrawn, it should be reintroduced, if possible, when the surgeon may proceed as before; but if this cannot be done, the ope- ration should be abandoned and the wound allowed to heal. This course, though mortifying to the surgeon's pride, is infinitely preferable to en- dangering the life of the patient by attempting to reach the bladder without a guide. In the adult, the bladder is usually reached without trouble, but there may be considerable difficulty in seizing and extracting the stone. This is commonly due either to the position or to the size of the calculus. (1.) Difficulty in Extraction from the Position of the Stone.—The stone may be lodged at the inferior fundus of the bladder, behind an enlarged prostate ° extraction is to be effected by using forceps with a de- cided curve, and by pushing up the bladder with the finger in the rectum. If the stone' on the other hand, is at the superior fundus, above the pubes, it may be brought into reach, as advised by Aston Key, by compressing 856 URINARY CALCULUS. the wall of the abdomen. If the stone be caught between folds of the vesical mucous membraneiov between the enlarged fasciculi of the blad- der, an attempt may be made to dislodge it by patient manipulation with the finger and scoop, or perhaps by directing upon the calculus a stream of tepid water; it is sometimes recommended to expand the walls of the bladder by opening very large forceps within it, in the hope that the stone may then drop out from its hiding-place, but the plan is not free from danger, and there is reason to believe that rupture of the bladder has been thus produced. Spasm of the bladder—a kind of hour-glass contraction of the organ—is said to occur sometimes, preventing the seizure of the stone; all that could be done in such a case would be to wait patiently until the spasm should disappear, postponing, if neces- sary, the completion of the operation until another day. If the calculus be adherent or encysted, its removal will be attended with great diffi- culty ; if merely adherent, the stone may perhaps be coaxed away from its bed with the scoop—with all gentleness, however, lest the bladder itself be torn. If the calculus be encysted, it will probably be necessary to abandon the operation, though an attempt might in some instances be made to enlarge the orifice of the cyst (as was done by Brodie), with a probe-pointed knife, and then enucleate the stone, as it were, with the scoop. Deformity of the pelvis from rickets may prove an obstacle to extraction, as in cases observed by Erichsen, Thompson, and others. (2.) Difficulty arising from the Size of the Stone.—If the short dia- meter of the calculus exceed an inch and a half in length, extraction will always be difficult, and if it exceed two inches, almost impossi- ble without dangerous bruising of the prostate. Under these circum- stances the surgeon must either (1) gain more room by incising the right side of the prostate, (2) reduce the size of the stone by crushing it within the bladder, or (3) resort to the recto-vesical, or to the supra- pubic operation. Incision of the right side of the prostate was the plan recommended by Liston, and is readily accomplished with the probe- pointed knife, guided by the finger. Crushing the stone within the blad- der is attended with some risk, on account of the contracted state of the organ, unless the calculus be soft, when it may be readily broken up with strong forceps. This plan was adopted by Prof. Nathan Smith, of New Haven, who, according to his son Prof. N. R. Smith, of Baltimore, "was always desirous of accomplishing that which many operators have deprecated, the fracture of the stone by the forceps." After crushing, the fragments must be carefully removed, and the bladder repeatedly washed out with a stream, of tepid water. If the incision of the right side of the prostate does not give sufficient room, and the stone cannot be crushed without endangering the integrity of the bladder, the only remaining course is to perform either the recto-vesical, or the high ope- ration—the former being probably the preferable procedure. Dangers, Complications, and Accidents of the Operation.— These may arise during or after the operation. Thus, in making the incision, if the knife be entered too far forwards, or penetrate too deeply at the upper part of the wound, the artery of the bulb, or the vessels of the corpus cavernosum, may be cut, giving rise to troublesome hemorrhage; if, on the other hand, the incision be placed too low, there is some risk of wounding the rectum, of cutting through the entire breadth of the prostate and neck of the bladder, thus allowing infiltration of urine behind the pelvic fascia, or even of opening the bladder entirely behind the prostate, an accident which would in all probability be fatal. Again, COMPLICATIONS OF LATERAL LITHOTOMY. 857 if the knife be too much lateralized, in making the deep incision, the pudic artery may be wounded; while, if not sufficiently lateralized, the rectum will be endangered. Finally, if the knife be not kept closely to the staff, in the deep incision, the posterior wall of the bladder may be injured, and it has, according to Miller, even happened (with the cut- ting gorget) " that by a more heroic thrust the bladder has been com- pletely perforated, the intestines have protruded, and after death the liver has been found wounded." Dangers may arise during the extraction of the stone from a portion of mucous membrane being caught in the grasp of the forceps, from the surgeon pulling too much upwards—not in the direction of the axis of the pelvis—and thus attempting to force the stone through the narrowest part of the pelvic outlet, or from the extraction being effected with such rapidity as to bruise and tear instead of dilating the prostate. It occa- sionally happens that the extraction of a stone is impeded by a portion of an enlarged prostate—a lobule, as it were, resembling an adenoid tumor—becoming entangled in the triangular space between the blades of the instrument and the calculus. The usual practice, under these circumstances, is gently to push back the protruding body, but Sir Wil- liam Fergusson has given the high sanction of his name in commenda- tion of a bolder course, no less than the enucleation of these semi- detached prostatic masses—a plan which he declares is perfectly safe, while it has the manifest advantage of enabling the surgeon to relieve the prostatic affection at the same time that he removes the stone. Among the rarer accidents occasionally met with after lithotomy are (1) the discovery, after a few days, that a second stone or calculous fragments, which at first escaped detection, remain in the bladder—to be remedied by dilating the wound and extracting, or by lithotrity; (2) the persistence of a perineal fistula—the treatment of which condition will be described hereafter; (3) sexual impotence, usually attributed to wound of the seminal duct, but, according to Thompson, really due to sloughing or inflammatory action—probably incurable ; (4) incontinence of urine—to be treated as when arising from other causes ; and (5) no stone being discoverable when the forceps are introduced—a most morti- fying occurrence, which may result from an error of diagnosis, no cal- culus having existed, from the stone being encysted or lodged in a pouch of the bladder, where it cannot be found, from its having escaped from the wound with the first gush of urine, or, finally, from the surgeon hav- ing missed the bladder and cut mto the recto-vesical space. If the stone cannot be found, all that can be done is to abandon the operation for the time, and this should be done before the patient is exhausted by the repeated but fruitless introduction of instruments into the bladder. If the symptoms of calculus persist after the wound has healed, a careful examination with the sound should be again instituted, when, if the stone be unmistakably present, the operation may be repeated. It has occasionally happened that a second lithotomy has enabled the surgeon to extract a calculus which completely eluded discovery at the time of the first operation. Treatment of Complications.—1. Hemorrhage—The superficial and transverse perineal arteries, one or both, are always divided in late- ral lithotomy, but rarely give trouble, though, if large, they may require ligatures. The artery of the bulb or the internal pudic may be wounded, even in the hands of the most skilful operator, on account of an abnor- mal distribution of these vessels, and, from a similar cause, the dorsal 858 URINARY CALCULUS. artery of the penis or the inferior hemorrhoidal may be likewise exposed to injury. The application of ligatures to the deep arteries of the peri- neum is sometimes attended with great difficulty, or may even be impos- sible. Under such circumstances the surgeon may rely upon pressure, kept up by the fingers of assistants for several hours, or may pass a tenaculum beneath the bleeding vessel and tie the instrument in the wound, as was successfully done by Physick, in 1794, and as has since been recommended by Thompson, and by Keith, of Aberdeen, the latter surgeon having devised for the purpose a tenaculum, from which the handle can be detached at will. Another plan, also suggested by Physick, is to pass, with suitable forceps, a curved needle armed with a ligature beneath the vessel, and then, disengaging the forceps, draw out the needle and secure the vessel with a knot. When the bleeding artery is far back, at the side of the prostate or by the neck of the bladder, " I know," says John Bell, " of no way of securing it but by laying hold of it with the old artery-forceps and letting them remain for the night." The same purpose may be accomplished by using the "artery-compres- sor" with movable handle, devised by Prof. Gross, or by catching the vessel with an ordinary serre-fine, provided with a ligature hanging out of the wound, to facilitate its withdrawal. Venous hemorrhage sometimes occurs very insidiously, the blood flowing backwards into the bladder, where it may become coagulated, instead of escaping externally. When the bleeding is from a superficial vein, this should be unhesitatingly tied; but if the hemorrhage proceed from the prostatic plexus, it will be better to introduce the lithotomy- tube, surrounded with a piece of muslin arranged as a " petticoat" or " shirt" (canule a chemise), into which strips of lint can be stuffed so as to firmly plug the entire wound. Cold irrigations and the applica- tion -of ice-bags to the perineum and hypogastrium may also be of service. Hemorrhage, though seldom the immediate cause of death after litho- tomy, is always to be dreaded, as it certainly predisposes the patient to the occurrence of diffuse inflammation of the areolar tissue around the wound. Secondary hemorrhage is a comparatively rare complication of litho- tomy. It is to be treated by the application of ligatures, if the source of hemorrhage can be discovered, but if not, by the use of styptics and pressure, or by the actual cautery. 2. Wound of the Rectum is an annoying, but usually not a very serious, accident. If the wound be of small extent and low down, it will pro- bably heal spontaneously, but, under other circumstances, may lead to the formation of a recto-vesical fistula, which must be remedied in the way described at page 802. 3. Diffuse Inflammation of the Areolar Tissue surrounding the Neck of the Bladder and the Rectum may arise from infiltration of urine, or from bruising of the part in the attempt to extract a large stone. Uri- nary infiltration, which is probably not so often met with as was formerly supposed, arises from too free division of the prostate in the deep inci- sion. It has been suggested that the occurrence of this accident might be prevented by the use of the lithotomy-tube, but as the urine always flows out alongside of the tube as well as through it, it is evident that nothing can be gained in this way. The second condition which gives rise to diffuse areolar inflamnfation, bruising of the parts around the neck of the bladder, is due to rough manipulation and the endeavor to bring a large stone through an opening which is too small for the pur- BILATERAL LITHOTOMY. 859 pose. The remedy is not to hastily enlarge the incision, for this exposes to the risk of urinary infiltration, but to effect gradual dilatation by means of the finger and by the lever-like action of the forceps, notching, if necessary, the opposite side of the prostate, crushing the stone, or even resorting to the recto-vesical section (see p. 856). The occur- rence of diffuse inflammation of the areolar tissue is certainly predis- posed to by the existence of renal disease, and by excessive loss of blood at the time of the operation. The treatment consists in the administra- tion of nutritious food, with stimulants and tonics, and in making free incisions to allow the escape of pent-up fluids. Brodie in one case saved his patient by freely dividing all the tissues between the perineal wound and the rectum. 4. Other Complications may arise, such as sloughing of the wound, inflammation of the bladder or kidneys, peritonitis, erysipelas, pyaemia, or tetanus, the treatment of which affections is to be conducted on the principles which guide the surgeon in their management when they occur under other circumstances. Results of Lateral Lithotomy.—The results of lithotomy are unquestionably more influenced by the age and general condition of the patient, the size of the stone, etc., than by the greater or less degree of skill with which the operation is executed; manual dexterity is, how- ever, by no means to be despised, and lithotomy is justly declared by Sir Henry Thompson to be a "grand operation," and "one of the best practical tests of a good surgeon." The statistics of lithotomy have been investigated by numerous authors, and the general mortality—for all ages and conditions—appears to be about one in. seven or eight. The effect of age in influencing the result of the operation is very marked; 377 operations on patients between 6 and 11 years old, gave, according to Thompson, but 16 deaths, a mor- tality of but little over 4 per cent., while, on the other hand, 233 opera- tions on patients between 59 and 70, gave 63 deaths, a mortality of over 27 per cent. In neither category were the cases in any way selected. That the size and weight of the stone, influence the result of the opera- tion^ seen from Crosse's tables, which show that the mortality of cases in which the stone weighed less than half an ounce was 8^ per cent., and of those in which it weighed more than half an ounce, 19^ percent. But nothing influences so decidedly the results of lithotomy as the condition of the urinary'organs; "it is," says Brodie, "organic disease of the urinary organs, the kidneys, or bladder, or parts connected with them, that is to be especially apprehended, as increasing, tenfold, the hazard of the operation. Of persons in whom the calculus is not of a large size, on whom the operation is performed, I will not say very well, but not very unskilfully, and who are free from all organic disease, there are very few who do not recover; while of those in whom organic disease exists, there are few who do not die." For the statistical results of lateral lithotomy as compared with litho- trity, see page 846. Bilateral Lithotomy. This operation was introduced in its present form by Dupuytren, in 1824, and has been, in this country, particularly illustrated by Prof. Eve, of Nashville, who has performed it with very good results in about eighty cases. The instruments required are a staff, grooved in the median 860 URINARY CALCULUS. line, a scalpel, a double lithotome cache (Fig. 481), modified by Dupuy- tren from the single lithotome of Frere Come (Fig. 480), which is still used by French surgeons in the lateral operation, forceps, scoops, etc. The first incision is made in a curve around the rectum, the extremity Fis. 481. Dupuytren's lithotome cachi, opened. on each side reaching to a point midway between the anus and tuber ischii, or a little nearer the latter, and the middle of the incision passing from a half to three-quarters of an inch in front of the anus; the wound is then deepened until the membranous portion of the urethra is ex- posed, when this is opened sufficiently to admit the beak of the lithotome, which is introduced, closed, along the groove of the staff into the blad- der. The instrument having touched the stone, is turned with its con- cavity downwards, when the staff is withdrawn; the surgeon now ex- pands the blades of the lithotome to an extent previously determined, and regulated by means of a screw, and Fig. 482. divides both lobes of the prostate from within outwards by drawing the instru- ment out with the handle well depressed and exactly in the median line of the pa- tient's body. The finger is then passed into the bladder, and upon this the for- ceps are introduced, extraction being completed as in the lateral operation. The theoretical advantages of this ope- ration are, that the wound. being placed low, there is little or no risk of hemor- rhage, the arteries of the bulb and the transverse and superficial* perineal arte- ries being all above the line of incision, and that the prostate is equally'divided upon both sides, thus giving a free opening into the bladder; in practice, however, the bilateral is not found to be any more successful than the lateral method, which is, I think, an easier operation. Gross has collected 207 cases of bilateral lithotomy, with 32 fatal results, a mortality of about 1 in 6£. Instead of pushing in the lithotome along the groove of the staff, some operators take the latter instrument in their own hands, as soon as the beak of the lithotome is lodged in its groove, and by depressing the handle with a quick rocking motion, bring both instruments together into the bladder; this manoeuvre I have seen skilfully executed by Prof. Pan- coast, of this city. Line of incision in the prostate in bilate- ral lithotomy, showing its relation to the bulb and the internal pudic artery. Pre-Rectal Lithotomy. This, which is a modification of the ordinary bilateral method, was introduced by Nelaton, and consists in making a careful dissection in 1345 MEDIAN LITHOTOMY. 861 front of the rectum, so as to open the urethra at the apex of the pros- tate, without coming in contact with the bulb; the remaining steps of the operation are the same as in Dupuytren's method. Medio-Bilateral Lithotomy. This operation was introduced by Civiale, in 1829, and was adopted in several instances by Sir Henry Thompson, who has, however, since abandoned it in favor of the lateral method. The staff being firmly held by an assistant, an incision about an inch and a half long is made in the median line of the perineum, terminating a little in front of the anus, and cautiously deepened so as to open the membranous portion of the urethra, without wounding the bulb; a straight double lithotome is then lodged in the groove of the staff and pushed on into the bladder, dividing both lobes of the prostate as it is withdrawn, just as in Dupuytren's method. Sir Wm. Fergusson has imitated this plan, as regards the external wound at least, by making a perineal incision in the form of an in- verted \. Civiale's seems to me on the whole better than Dupuytren's operation, but neither presents any particular advantage over the lateral method; either may, however, be properly resorted to in cases in which the stone is large, and in which hemorrhage is to be for any reason specially dreaded. Median Lithotomy. This is an old operation formerly known as the " Marian" (from Ma- rianus Sanctus Barolitanus, a surgeon of the sixteenth century), but revived with improvements by Manzoni, De Borsa, and Rizziolf, and perfected by Allarton, whose name it now generally bears. A staff grooved in the median line is firmly held against the pubes by an assist- ant, when the surgeon introduces his left forefinger with the palmar surface upwards into the rectum, placing its tip upon the apex of the prostate; a straight bistoury, double-edged at the point, is then entered with its principal cutting edge upwards, in the median line of the peri- neum, half an inch in front of the anus, and pushed steadily onwards until it penetrates the membranous portion of the urethra and lodges in the groove of the staff; the apex of the prostate is now notched by pushing the knife a few lines towards the bladder, and the urethra then slightly divided and the external wound enlarged to about an inch and a half, by cutting upwards as the knife is withdrawn. A ball-pointed probe is next passed into the bladder, along the groove of the staff, which is then removed—the surgeon's finger following the probe and dilating the prostatic incision in its course; the forceps are then intro- duced, and the stone extracted as in other operations. In order to assist the dilatation of the prostate, Allarton has suggested the use of fluid pressure applied by means of an Arnott's dilator, and Teale has devised a branched metallic instrument for the same purpose; as pointed out, however, by both Erichsen and Thompson, instrumental is much less safe than digital dilatation. Allarton's operation has been variously modified by other surgeons, as by Thompson, who exposes the staff by cutting from before back- wards, and by Erichsen, who employs a rectangular staff, passes a beaked director along the groove after making the incision (to open the way for 862 URINARY CALCULUS. the finger), and effects digital dilatation before withdrawing the staff, as in the lateral operation. The advantage of the median over the lateral operation is the dimin- ished risk of hemorrhage (though, according to Thompson, the gain in this respect has been greatly exaggerated), and of urinary infiltration. Its disadvantage is the limited amount of space which it affords for the extraction of the stone. Hence its application should, it seems to me, be practically limited to those cases among adults in which, though the stone is small, lithotrity is inadmissible, and hemorrhage particularly to be feared. It is decidedly contra-indicated by the presence of a laro-e stone, and by hypertrophy of the prostate, which interferes with the manipulation of the forceps through the small opening afforded by the median incision. There is, however, another class of cases, in which the median opera- tion often answers a very good purpose, and that is when it becomes necessary to cut into the bladder to remove a foreign body (see p. 374). Allarton has collected 139 cases of the median operation, with 13 deaths, or a little over 9 per cent.; his tables are, however, according to Poland, not very accurate, many known cases of death after the median operation being unrecorded, and section of the prostate having been re- quired in two of the author's own cases which are reported as successful. The statistics of the Norfolk and Norwich Hospital, as collected by Mr. Williams, give a much less favorable picture, 64 cases, at all ages, having given 13 deaths, a mortality of almost 20 per cent. Medio-Lateral Lithotomy. This operation, which was introduced by Buchanan, of Glasgow, in 1847, has been already referred to as a modification of the ordinary late- ral method. It is performed with a rectangular staff, grooved upon the left side, which is fixed so that the angle corresponds to the apex of the prostate, and well pressed down so as to be readily felt from the peri- neum. The operator, keeping his left forefinger in the rectum, "enters a long straight bistoury opposite the angle of the staff, and therefore im- mediately in front of the anus: he holds it in his right hand, with the palm upwards; the blade horizontal and its edge directed to the left; and he pushes it straight into and along the groove as far as to the stop at its extremity. He thus enters the bladder at once, taking care to keep the blade parallel with the horizontal or grooved portion of the staff throughout the whole of the thrust. Next he withdraws the bistoury slowly, but, as he does so, cuts outwards and downwards a distance rather more than equal to another breadth of his blade [a quarter of an inch], and then directly downwards to the same extent, describing, in this manner, a curved line equal to about one-fourth of a circle round the upper and left side of the rectum." This operation makes an external wound of about an inch and a quarter in length, and has, according to Thompson (from whose pages the preceding description is taken), been performed over 60 times, with results corresponding very closely to those obtained by Allarton's method. The name medio-lateral is also given by H. Lee to a somewhat similar operation devised by himself. These are the principal operations by which it is sought to remove a stone from the bladder by incisions through the perineum, and from which the surgeon has to choose in ordinary cases. Each method has certain merits and demerits, and each may be properly adopted in par- ticular circumstances. As, however, the success of lithotomy depends to SUPRA-PUBIC LITHOTOMY. 863 a considerable extent upon the readiness and skill with which the ope- ration is performed, and, as to acquire equal facility in each of these methods would require a wider experience in stone cases than falls to the lot of most surgeons, I would strongly advise the general practi- tioner to familiarize himself with one procedure (and the ordinary late- ral method I consider decidedly the easiest and safest in the large majo- rity of instances), and having acquired sufficient skill in its performance, to be content. It is doubtless desirable for the professed lithotomist, who counts his cases by scores or even by hundreds, to try every new plan that is suggested, and to publish his experience with it for the benefit of the whole profession; but there is no reason why the general practitioner, who, perhaps, sees but half a dozen cases in the whole of his career, should feel obliged to operate by three or four different me- thods. It will, on the contrary, I believe, be much better for his patients for him to be able to do one operation well, than a larger number with doubt and hesitation. Recto-Yesical Lithotomy. This operation, which was devised by Sanson, aims to extract the stone by an incision through the rectum. A staff is held in the ordinary manner, and into its groove the surgeon thrusts the point of his knife (guarded by the left forefinger) through the prostate, from the rectal surface, cutting then upwards and outwards through the sphincter ani and perineum. The finger-nail is then placed in the groove at the mem- branous portion of the urethra, and the bladder opened by an incision from before backwards, joining the original wound. Extraction is effected as in other operations. Maisonneuve has modified this proce- dure by making an incision through the rectum above the sphincter, which is not divided, the section of the prostate being completed with a double lithotome. Chassaignac has performed recto-vesical lithotomy with the ecraseur. This operation, in addition to the risk of diffuse cellulitis and perito- nitis by which it is attended, exposes the patient to the possibility of the formation of a recto-vesical fistula ; to meet this contingency, Prof. Bauer, who is the most prominent advocate of the method in this country, adjusts the edges of the wound with metallic sutures, with the view of securing primary union, and a similar plan has been followed by Dr. Noyes. Konig has collected 83 cases of this operation, which gave 56 cures, 11 recoveries with fistula, and 16 deaths. The operation is, in my judgment, only to be recommended in cases of very large stone, in which extraction by the lateral incision has been found impracticable (see page 856). Supra-Pubic Lithotomy. (The High Operation.) This operation, which appears to have originated with Pierre Franco, in the latter part of the sixteenth century, and which was first performed in this country by the late Prof. Wm. Gibson, is designed, as its name implies, to effect the extraction of a vesical calculus through an incision above the pubes, where the bladder is not covered by peritoneum. It may be performed as follows: The parts having been shaved, and the 864. URINARY CALCULUS. rectum emptied by means of an enema, the patient is etherized, lying on his back with the pelvis elevated, so that the abdominal viscera may not press upon the bladder; this organ is then fully injected (but not over-distended) with tepid water, and a well-curved sound or solid catheter introduced, so that by depressing its handle between the patient's thighs, the beak of the instrument may become prominent in the supra-pubic region. An incision, about three inches long, is now made, exactly in the median line, and reaching at its lowest point to the upper margin of the pubic symphysis : the wound is cautiously deepened until the linea alba is reached, when this is opened at the lowest part of the incision, and divided upwards with a probe-pointed knife for a distance of an inch and a half or two inches, taking great care not to wound the peritoneum, by gently pushing it out of the way of the knife. The surgeon now carefully cuts down upon the extremity of the sound, which is made to project in the wound, and thus opens the bladder—the incision into this organ, which should be held forward with tenacula, being then enlarged by cutting downwards towards its neck (and therefore below the symphysis) with a probe-pointed knife. One or two fingers are next introduced so as to ascertain the position of the stone, which is extracted with forceps in a line corresponding to the oblique direction of the wound. Civiale devised several special instruments for use in this operation, the most important being the sonde a dart, a catheter with a stylet which could be protruded from the concave surface of the instrument, designed to make the opening into the bladder from without inwards. The after-treatment is very simple; the patient should be kept in bed with the limbs drawn up so as to relax the abdominal muscles, the wound being allowed to heal by granulation1 under simple dressing. A flexible catheter may be introduced through the urethra and allowed to remain so as to prevent urinary accumulation, but should be removed if it produce any vesical irritation. Diffuse areolar inflammation may follow the operation, and is usually attributed to the occurrence of urinary infiltration: it is probable, how- ever, that, as in the case of the lateral method, bruising of the edges of the wound in extracting a large calculus is at least equally efficient in giving rise to this complication. The high operation has been recommended by some of its advocates as a method of universal application, but is now generally and, in my opinion, properly reserved for cases in which the calculus is of unusual size—more, for instance, than two or two and a half inches in its lesser diameter—or in which the lateral or other perineal methods are contra- indicated by the existence of pelvic deformity. The mortality after this operation is variously estimated by Belmas, Humphry, anel Gross, at from 22 to 30 per cent. It is to be remembered, however, that the supra- pubic, unlike the median operation, is habitually reserved for unfavorable cases. Recurrent Calculus. The recurrence of vesical calculus after an operation for its removal, may be due to the persistence of the causes which gave rise to the existence of the first stone, or to the imperfect removal of the stone, a 1 Bruns, of Tubingen, recommends the introduction of sutures, in hope of obtain- ing primary union. URETHRAL CALCULUS. 865 fragment having been allowed to remain in the bladder. The descent of a renal calculus is comparatively seldom a cause of recurrent stone, which is more frequently due to the continued deposit of phosphatic matter in the bladder, as the result of cystitis with an ammoniacal state of the urine. Fragments may be left in the bladder after either lithotomy or lithotrity, but are more likely to form the nuclei of fresh calculous formations after the latter, than after the former operation, because in this the wound affords a free means of exit, by which any portions of stone that may be chipped off, are readily washed out by the flow of urine. In the early days of lithotrity, recurrence was, indeed, a frequent event, and was not unreasonably considered a grave objection to that operation ; it is satisfactory, therefore, to know that with larger experience, and with the aid of the improved forms of instrument now in use, the probability of a relapse has been considerably diminished ;! moreover, as pointed out by Brodie, patients are willing to submit to a repetition of lithotrity, when they would refuse a second cutting ope- ration. The treatment of recurrent calculus consists in removing the stone by either lithotrity or lithotomy, the choice of operation being made in accordance with the principles already laid down. If it be decided to cut a patient a second time, the incision may be made in the line of the cicatrix left by the first operation. Urethral Calculus. Urethral calculi usually consist of renal or small vesical concretions, which, being too large for spontaneous evacuation, have become im- pacted in the urethral canal; but calculous matter may occasionally be primarily deposited in the urethra, in cases of urinary obstruction from organic stricture, etc. The symptoms of urethral calculus are difficult or painful micturition, and in some instances complete retention of urine, followed, perhaps, by ulceration and urinary extravasation; the stone can usually be felt through the structures of the penis, perineum, or rectum, and can generally be touched with a sound introduced into the urethra. The treatment consists in effecting removal, either by gentle manipulation with the finger and thumb, pushing the stone towards the meatus, by the use of narrow forceps, etc., as in the case of foreign bodies, or of fragments impacted after lithotrity, or by cutting into the urethra and extracting the stone through the incision. Before resorting to the last mode of treatment, the calculus should if possible be pushed back into the perineal portion of the canal, as urethrotomy in the scrotal portion is attended with risk of urinary infiltration, and in the penile portion with danger of the formation of a fistula. The operation may be facilitated by introducing a full-sized staff as far as the position of the calculus, the incision being made directly upon the point of the instrument. In some instances it may, perhaps, be thought better to push the calculus back into the bladder, and then dispose of it by . lithotrity. In all cases of urethral calculus, a careful exploration of the bladder should be made, to ascertain if vesical concretions be likewise present; if any be found, they may, if of suitable size, be crushed; or, if the urethra has already been opened in the perineum, the incision may 1 Of 36 cases submitted to litbotrity by Civiale, in the year 1860, no less than 10 were cases of recurrent calculus, while of 204 cases operated on by Thompson, during six years ending in 1870, only 19 were cases of recurrence. 55 866 URINARY CALCULUS. be readily extended so as to convert the operation into a median, or into a lateral lithotomy. Prostatic Calculus. Calculous concretions are sometimes found in the prostate gland, resulting from the deposit of phosphatic matter upon the inspissated secretion of the part; they may be conveniently referred to in this place, though not strictly belonging to the category of urinary calculi. Prostatic calculi usually consist of about eighty-five parts of phosphate of lime, with fifteen parts of animal matter, and a trace of carbonate of lime; hence they may be readily distinguished from the vesical calculi which occasionally lodge near and become imbedded in the prostate. Prostatic calculi rarely attain a large size, have a rather smooth surface__ often presenting numerous facets—and are usually of a light-brown or gray color; they may exist in considerable numbers, occupying the various cells and ducts of the gland, or several may become aggregated into a single mass, through the gradual disappearance by absorption of the intervening intercellular substance. The symptoms are a sensation of weight and distension in the perineum, often attended by a flow of mucus, and sometimes by retention of urine; the calculus can usually be detected by exploration with a sound, aided by digital examination through the rectum. The treatment consists in extraction by the urethra, with long and delicate forceps—this is rarely practicable—or through a perineal incision as in the opera- Y\s 433 tion of median lithotomy. If the concretions are small and very numerous, it may, per- haps, be better not to resort to operative interference, but to employ palliative measures only, to relieve the irritation of the part. Treatment of Vesical Cal- culus in Women. The operations for the re- moval of stones from the female bladder are lithectasy, litho- trity, and lithotomy. Lithectasy,1 or Dilatation of the Urethra and Neck of the Bladder, is much the best mode of treatment for all stones of a moderate size. The dilatation may be effected slowly, by the introduction of sponge tents of gradually increasing sizes; or, which is much preferable, rapid- Urethral dilator. ' This name was applied by Dr. Willis to an operation which he proposed for stone in the male, and which consistedin opening the perineal urethra and dilating the neck of the bladder; a procedure which has been supplanted by the median operation as modified by Allarton. CALCULUS IN WOMEN. 867 ly, by means of a two-bladed dilator, or simple dressing forceps, intro- duced closed, and then opened, so as to dilate the part upon withdrawal. The stone is extracted with ordinary lithotomy forceps or with the scoop, as may be found most convenient. The operation should be performed with the aid of anaesthesia. Bryant, who has ably investigated the literature of the subject, finds that, in children, calculi one inch in dia- meter, and, in adults, calculi two inches in diameter, can be safely removed by rapid urethral dilatation, without any resulting incontinence of urine. Lithotrity is adapted for cases in which the stone is too large to be removed by lithectasy, and yet in which the urinary organs are in a healthy condition. The operation may be performed with a short-bladed lithotrite, or with strong forceps; it is not necessary (as it is in the male) to reduce the calculus to powder, but it is sufficient to break it into fragments—these being then immediately extracted with lithotomy forceps through the urethra, which is rapidly dilated for the purpose. The patient should be in a state of anaesthesia, so that the whole opera- tion maybe completed at one sitting; injections of tepid water are required to insure the removal of detritus. Lithotomy.—This may be performed in several ways. 1. Urethral Lithotomy is often combined with lithectasy; the opera- tion consists in introducing a probe-pointed bistoury into the urethra, and incising the mucous membrane with or without the submucous tissue, directly upwards as practised by Brodie, directly downwards as suggested by Chelius, downwards and outwards on both sides as done by Liston, or, in fact, in any direction that suits the surgeon's fancy. The operation is very apt to be followed by incontinence of urine, and appears to me in every way inferior to the method by simple rapid dila- tation. 2. Vaginal Lithotomy has been particularly commended by Marion Sims, Aveling, and Emmet, and is probably the best mode of treatment for cases in which the calculus is large, and in which crushing is inad- missible, but seems to me, under ordinary circumstances, decidedly infe- rior to lithectasy and lithotrity. The operation may be thus performed: A straight staff is introduced into the bladder and held by an assistant Fig. 484. Female staff. so as to depress the vesico-vaginal septum, the point of the instrument being fixed by the surgeon's left forefinger introduced into the vagina. A sharp bistoury is then thrust through the septum into the groove of the staff, just behind the urethra, and the incision carried backwards for the space of about an inch and a half, taking care not to infringe upon the peritoneum; the stone is extracted with forceps, and the edges of the wound immediately brought together with sutures, the case being, in fact, treated as one of vesico-vaginal fistula. 3. The High Operation maybe required incases in which the calculus is too lar^e to admit of vaginal lithotomy. The operative procedure 868 DISEASES OF THE BLADDER AND PROSTATE. is the same as in the male sex, but requires even more care not to wound the peritoneum. Prof. Parker has, according to Gross, practised supra- pubic lithotomy in the female on three occasions, and in each instance with a successful result. Extra-pelvic Vesical Calculus. Calculus is occasionally developed in the protruded bladder, in cases of hernia of that organ, or cystocele. Prof. Gross has collected eight cases of this description. The treatment consists in cutting down upon the hernia (which has no peritoneal investment), and extracting the calculus—a catheter being kept in the bladder during the healing of the wound, to prevent urinary infiltration. CHAPTEK XLV. DISEASES OF THE BLADDER AND PROSTATE. ■ In no department of surgery is it more necessary for the practitioner to be a good physician, than in that which relates to diseases of the urinary organs. So intimately connected with each other are these organs, both anatomically and physiologically, that it is impossible to treat satisfactorily even those affections which are usually considered purely surgical, as, for instance, stone in the bladder, hypertrophy of the prostate, or stricture of the urethra, without an accurate knowledge of the whole subject of urinary pathology, and more particularly a practical acquaintance with the methods of examining the urine, both chemically and by the aid of the microscope. It is the more necessary to make this statement, because the limits of this volume will only admit a description of those diseases of the urinary organs which the surgeon is habitually called upon to treat; and I must therefore refer the student for information on the other topics mentioned, to works on the Practice of Medicine, and to treatises spe- cially devoted to the subject of Urinary Disorders. Malformations and Malpositions of the Bladder. In some cases the bladder has been totally absent, the ureters open- ing directly into the urethra, or into the rectum or vagina, while in other instances two or more bladders are said to have coexisted in the same subject, though, as justly remarked by Thompson, it is probable that in most of these cases the condition has not been congenital, but rather one of extreme sacculation, the result of disease. Extroversion or Exstrophy of the Bladder is by far the most common congenital defect of this viscus, and is met with sufficiently often to make its treatment a subject of considerable importance. This deformity, which is much commoner in the male than in the female sex, and which appears to be due to an arrest of development during foetal life, consists in an absence of the anterior wall of the bladder, with a EXTROVERSION OF THE BLADDER. 869 corresponding deficiency of the lower part of the abdominal parietes, and usually of the pubic symphysis. The penis, in the male, is epispa- diac and shortened, and the clitoris, in the female, is split into two por- tions corresponding to the nymphae, the anterior commissure of the vulva being wanting, and the bladder and urethra thus opening between the labia and directly into or immediately above the vagina; the uterus is commonly well formed, and in a case which was under my care the vaginal orifice was normally closed with a hymen. The anus is placed in front of its usual position, and, in the male, the scrotum not unfre- quently contains a hernia on one or both sides. The recti abdominis muscles are separated at their lower part, passing obliquely outwards to their insertions into the pubic bones, and in many, but by no means in all cases, the separation is continued upwards almost to their costal attachments, in which case there is no umbilicus, the interval between the recti being filled with a fibrous tissue analogous to the linea alba. The appearances in a case of exstrophy of the bladder are quite characteristic. The posterior wall of the bladder (covered, of course, with mucous membrane) is pushed forward by the abdominal viscera which are behind it, and forms a prominent but reducible tumor in the situation of the pubes. The mucous surface, which is red, papillated, and vascular, is continuous at its periphery with the abdominal walls, the line of junction having a thin cicatricial appearance. At the lower part of the projecting vesical surface, the ureters can be seen, giving exit to the urine by drops, or sometimes in a stream. The exposed mucous membrane, which is constantly irritated by the contact of the patient's garments, becomes inflamed, and bleeds when touched, while the groins, thighs, and buttocks are excoriated from urine flowing over them. In addition to the physical distress thus occasioned, the patient has the annoyance of knowing that he is deformed in a part which few are so philosophical as to consider of no importance in their own persons, and is besides rendered, by the continual dribbling of urine, an object of disgust to himself as well as to others. Otherwise the deformity does not particularly interfere with the general health, and is by no means incompatible with a long life. In the female the reproductive function is not impaired, and instances are on record in which women with extroverted bladders have borne children; but in the male sex the accompanying deformity of the genital organs is so great as to render procreation impossible. Treatment.—Until within a few years, this malformation was thought to be beyond the reach of surgical aid, and the utmost that was at- tempted for patients thus affected, was to supply a mechanical apparatus to shield and protect the exposed bladder from injury, and to convey the urine into a suitable receptacle; but the apparatus was necessarily cum- brous and irksome, and fulfilled its design in, at best, a very unsatisfac- tory manner. Within a few years, endeavors have been made to remedy, or at least to alleviate, by operative interference, the condition of pa- tients afflicted with exstrophy of the bladder, and in several instances with very gratifying success. The operations which have been devised for the purpose may be divided into two categories, viz., 1, those which aim to divert the course of the renal secretion into another channel, and, 2, those the object of which is merely to cover in the exposed bladder by a plastic operation, and thus render possible the adaptation of a con- venient receptacle for the urine. To the first category belong the opera- 870 DISEASES OF THE BLADDER AND PROSTATE. tions of Simon and Holmes, and to the second the plastic procedures of Richard, Pancoast, Ayres, Holmes, Wood, Maury, and others. 1. Mr. Simon, of St. Thomas's Hospital, in the case of a boy of 13, established, by an ingenious procedure, fistulous communications be- tween the ureters and rectum, with the hope that, the flow of urine being diverted, the exposed mucous surface of the bladder would assume the character of skin. The operation was, from the first, only partially suc- cessful, and the patient died about a year afterwards from disease of the ureters and kidneys, which apparently was set up by the irritation caused by the operation itself. In two other cases in which similar pro- cedures were undertaken, by Lloyd and Athol Johnstone, the patients died within a few days from acute peritonitis, so that, as justly remarked by Holmes, as far as present experience goes, the danger and difficulty of the operation appear to outweigh its probable advantages. This ex- cellent surgeon has himself suggested a plan of effecting the desired object, by applying in the bladder and rectum the two branches of a pair of screw-forceps (with a plate broad enough to extend from one ureter to the other), which, acting like Dupuytren's enterotome, should establish the necessary communication between the organs without risk of perforating the peritoneal cavity. This suggestion, which seems to me worthy of* future attention, has not, as yet, however, been satisfac- torily tested in practice. 2. Plastic Operations, varying more or less in their details, have been employed by several surgeons for the relief of extroverted bladder, and in most instances with very gratifying results. (1.) Richard, modifying ]Selaton's operation for epispadias, operated, in 1853, by dissecting a broad flap from below the umbilicus, turning it with its skin surface towards the bladder, and covering it in with a bridge of skin taken from the front of the scrotum. This operation, though most ingeniously planned, unfortunately induced peritonitis, which proved fatal. (2.) To Prof. Pancoast,. of this city, belongs the honor of having (in 1858) performed the first successful plastic operation for exstrophy of the bladder. His method consisted in taking flaps from the groins, in- verting them over the protruded organ, and attaching them together in the median line, thus leaving a broad granulating surface which slowly cicatrized. The patient recovered from the operation, but died some months later from another affection. (3.) In the same year Dr. Ayres, of Brooklyn, N. Y., operated on a woman (who had previously given birth to a child) by turning down an umbilical flap—as had been done by Richard—covering it in by simply dissecting up the skin of the abdominal walls on either side, and bring- ing together the tissues thus loosened in the median line. The operation was perfectly successful. (4.) Mr. Holmes, who has operated in five cases, employs two flaps, one from the groin, which is inverted, with its cutaneous surface towards the bladder, and the other taken from the opposite side of the scrotum and slid over to cover in the first. This plan was also followed by J. Wood, in some of his earlier cases. (5.) Dr. F. F. Maury, of this city, has obtained a most gratifying result in two cases, by taking a saddle-shaped flap, attached at both ends, from the scrotum, and inverting it bridge-like over the bladder— leaving the raw surface of the flap to heal by granulation and cicatriza- tion. He succeeded in each case (as did Pancoast) in effecting the cure of a hernia by the contraction which accompanied the healing process. EXTROVERSION OF THE BLADDER. 871 (6.) Mr. Barker, of Melbourne, has successfully operated in a youno- girl, by simply dissecting up the integument on either side of the bladder, uniting the flaps thus formed with deep and superficial sutures and relieving tension by means of lateral incisions. Fig. 485. Fig. 486. Fig. 487. Plastic operation for extroversion of the bladder. (From a patient in the Children's Hospital.) (T.) Prof. Wood, of King's College, London, has operated in eight cases, and has latterly employed a method which is now usually known by his name, and to which I resorted with gratifying success in the case from which the annexed illustrations are taken. Three flaps are used, one taken from the umbilical region and inverted over the bladder, as in Richard's and Ayres's methods, and the others, one from each groin, united in the median line over the first, which they cover in. The great advantage of the inverted umbilical flap, is that it effectually prevents the escape of urine in an upward direction, while the groin flaps cover in the raw surface of the other without undue tension, and, having broad bases, are in no danger of sloughing. In the case of a male subject, Mr. Wood forms a roof for the urethra, at a subsequent operation, by inverting flaps from the newly-formed covering of the bladder, and from 872 DISEASES OF THE BLADDER AND PROSTATE. the sides of the penis, adjusting over them a bridge-like flap from the scrotum, as in Nedaton's and Richard's procedures. By this operation the patient is placed in a very comfortable condition; incontinence of urine, to a certain extent, necessarily continues, re- quiring the patient to wear a " railway urinal," or some similar contri- vance, but the bladder is effectually protected from irritation, and exco- riation is readily prevented. The principal points requiring attention in the after-treatment, are to prevent tension on the flaps and encourage the contraction of the granulating surfaces by the position of the patient, who should be placed in an almost sitting posture, with the knees flexed over pillows. In an adult, trouble may be caused by the growth of the pudendal hairs, if the reversed flaps embrace any portion of skin natu- rally thus covered, and it will then be necessary, from time to time, to practise avulsion with suitable forceps, until the inverted surface shall have lost its cutaneous character and become assimilated in nature to mucous membrane. Injections of dilute acetic or nitric acid may also be required, to relieve vesical catarrh and prevent the deposit of phosphates. Malpositions.—Under this head may be included two affections, one of which, Hernia of the bladder, or Cystocele, has already been referred to, the other being Inversion of the bladder, which is extremely rare, and exclusively met with in female children. Inversion of the Bladder consists in a protrusion or invagination of the bladder through the urethra, where it appears in the form of a red vascular tumor; this, in one of the few cases of the affection on record, was mistaken for a new growth, and preparations had been actually made to remove it by ligation, when the discovery of the orifice of a ureter fortunately prevented the consummation of the operation. The protru- ding organ is readily reduced by manual pressure, but re-descends when the pressure is removed, and incontinence of urine necessarily remains. To remedy this, Dr. John Lowe, of Lynn, made repeated applications of the actual cautery to the urethra, keeping the bladder in place by means of a catheter with a.bulbous extremity; he thus induced sufficient con- traction to prevent any protrusion whatever, and to diminish, though not entirely to remove, the incontinence. Cystitis. Cystitis, or Inflammation of the Bladder, may be acute or chronic, and in the latter case may or may not be accompanied with vesical catarrh. Acute Cystitis.—The seat of inflammation is the mucous lining of the bladder, especially the part around the neck of the organ. In some cases, however, the submucous and muscular coats are also involved, and the inflammation may even spread to the adjacent layer of perito- neum. The vesical mucous membrane is found after death to be injected or deeply congested, and sometimes, if the inflammation has been long continued, of a slate-colored or chocolate hue. Occasionally, shreds or patches of lymph are formed, and in rare instances a complete cast of the interior of the organ has been thus produced. Ulceration and gan- grene may be met with in the worst cases. Causes.—Acute cystitis may result from various forms of injury, from the irritation produced by a calculus or foreign body, from the action of certain medicines, as cantharides or some of the mineral poisons, chronic cystitis. 873 from the use of irritating injections, from acridity of the urinary secre- tion, from the extension of inflammation from neighboring parts (espe- cially from the urethra, as in cases of gonorrhcea), from an exacerbation of chronic cystitis, from exposure to cold, from gout, etc. Symptoms__There is pain over and behind the pubes, and in the sacral region, perineum, and thighs, attended in bad cases with tender- ness on pressure, and increased by rectal exploration and by the use of the catheter. The desire to urinate is almost constant and irresistible, the act of micturition itself being intensely painful and often accom- panied with great tenesmus. In mild cases, such as ordinarily follow gonorrhoea, and in which the inflammation is usually limited to the neck of the bladder, the urine is cloudy and contains a certain quantity of mucus and pus, but in severe cases it is tinged with blood, and soon becomes decidedly purulent, containing also shreds of partially organ- ized lymph or false membrane. In these cases there is also a great deal of constitutional disturbance (which is almost absent in the milder forms of the affection), the patient soon falling into a typhoid condition, often attended with delirium ; death may ensue, usually in the course of the second week. In the milder cases resolution occurs—when recovery may be complete—though, in many instances, the inflammation subsides into a chronic state. Treatment.—The patient must be kept in bed. A few leeches may be applied to the hypogastrium or perineum, and followed by hot poultices or fomentations. The bowels must be kept in a soluble condition, and pain and vesical irritation relieved by the use of hyoscyamus and opium, given by the mouth, or in the form of suppository. Hot hip-baths may be administered during the acute stage, and the patient should drink moder- ately of flaxseed tea, or other" demulcent, medicated with a small quantity of citrate of potassa. When the inflammation begins to subside, buchu or copaiba may be cautiously administered. The diet should in ordinary cases be mild and unirritating; but if typhoid symptoms appear, free stimulation must be resorted to. If retention of urine occur, catheter- ization with a flexible instrument must be cautiously practised, and if symptoms of nephritis are manifested, wet or dry cups should be applied over the kidneys, and followed by mustard poultices or turpentine stupes. Chronic Cystitis may result from the same causes as those which produce the acute form of the affection (which indeed it often succeeds), from atony or paralysis of the bladder, or from any obstruction to the free evacuation of its contents—both of these conditions causing ac- cumulation and partial decomposition of the urine, which then becomes very irritating to the vesical mucous membrane—or from tumors or other structural diseases of the bladder itself or of neighboring organs, as the rectum, uterus, or vagina. 1. Simple Chronic Cystitis, the form of the affection which is unattended with vesical catarrh, is the pathological condition which is present in most of the cases commonly called " irritability of the blad- der"__a term which is not very well chosen, as it refers to a mere symptom. Microscopic examination of the urine, in cases of simple chronic cysti- tis, will always detect the presence of pus, and this, with increased frequency of micturition, and slight augmentation of the amount of vesical mucus, are the evidences by which the surgeon may recognize the existence of the disease. The treatment is the same as for the mildest 874 diseases of the bladder and prostate. cases of acute cystitis, the inflammation in many instances subsiding under the influence of rest alone. 2.. Chronic Cystitis with Vesical Catarrh is characterized by the deposition from the urine of a ropy, tenacious, muco-purulent sub- stance, usually of a grayish-white color, and of alkaline reaction. This is often mixed with phosphates, the urine itself being ammoniacal and extremely offensive. The bladder becomes thickened, roughened, and sometimes sacculated ; ulceration sometimes occurs; and the case may terminate fatally by the patient falling into a typhoid or uraemic con- dition. This form of cystitis is particularly apt to supervene in cases of vesical paralysis from injury of the spine (see p. 326). In the treat- ment of this condition, topical remedies are of the highest importance; urinary accumulation should be prevented by the cautious use of the catheter, and great benefit may often be derived from washing out the bladder, by injecting at first warm water merely, and subsequently, if this is well borne, mild astringent or sedative lotions ; the best, accord- ing to Thompson, are those containing acetate of lead (gr. ss to fjiv), nitrate of silver (gr. ss to f^iv), dilute nitric acid (n^x to f^iv), car- bolic acid (n^ij to f^iv), or borax (Soda? boratis 5ss, glycerinae f"5ij, aquae f^iv). The injections are most conveniently made by means of an India-rubber bottle with a nozzle, and an ordinary elastic catheter; not more than three or four fluidounces should be used on each occasion, the injected liquid being kept in the bladder for a few minutes, and then allowed to flow off. Counter-irritation to the supra-pubic region is often of service, and pain may be relieved by the use of anodyne suppositories. A belladonna plaster over the pubes may be used for the same purpose. A large number of internal remedies have been employed in this affection, and it must be confessed often in rather an empirical manner, those which seem to succeed best in some cases, failing utterly in others. Those which are probably most deserving of mention are buchu, uva ursi, pareira, matico, chimaphila, triticum repens, senega, copaiba, and cubebs.' Alkalies, especially the liquor potassae, in combination with the tincture of hyoscyamus, may be tried if there be much vesical irri- tation, but must be watched, lest they increase the tendency to phos- phatic deposit. The mineral acids may be useful on account of their tonic properties. It is scarcely necessary to add that if the condition of the bladder depends upon any removable cause, such as vesical cal- culus or urethral stricture, this must be attended to before the cystitis can be cured. Structural Diseases of the Bladder. Sacculated Bladder.—Obstruction to the flow of urine, as from enlarged prostate or stricture, leads to hypertrophy of the muscular walls of the bladder, and gives its inner surface a roughened and fascicu- lated appearance. As a result of the violent contractions of the organ in the effort to expel its contents, the vesical mucous membrane and submucous tissue protrude between the interlacing bundles of muscular fibre, and form sacs or pouches, sometimes of very large size, in which the urine accumulates and undergoes decomposition, giving rise to cys- titis, and often leading to the formation of phosphatic calculi. The treatment should be directed to preventing accumulation, which may tumors of the bladder. 875 most conveniently be done by the use of an elastic catheter, aided by the siphon arrangement of Prof. Dittel (see p. 844). Tumors of the Bladder.—Various forms of morbid growth are met with in the bladder—as the fibrous or fibro-cellular, constitutino- the polypoid tumors met with in this organ, the papillary or villous, closely resembling in structure the chorion, very vascular, and sometimes, though by no means always, of a cancerous nature (see pp. 475 and 487), the enceph- aloid, the scirrhous (usually secondary to scirrhus of the rectum), and the epithelio- matous. Any of these tu- mors may become incrusted with phosphatic matter, and thus simulate calculus; but the diagnosis can usually be made by careful sounding. Hemorrhage attends both the villous and the malig- nant growths—in cases of the former kind being of the character of capillary oozing, and in those Of the latter OC- Polypoid vesical tumors. curring less constantly, but in considerable quantities at a time. The treatment, in the large ma- jority of instances, must be merely palliative, consisting chiefly in the free administration of anodynes, with stimulants, if necessary. Astrin- gent injections may be tried in the cases of villous tumor, but should not be repeated if they produce vesical irritation. Polypoid growths may be removed from the female bladder by ligature, the urethra being dilated for the purpose ; and it may occasionally be possible to remove a vesical polypus in the male by avulsion with a lithotrite, as was done in one instance by Civiale. Tubercle of the Bladder is a rare affection, and is probably never met with except in connection with tuberculosis of other organs. The treatment, as far as the bladder is concerned, must be merely palliative. Bar at the Neck of the Bladder.—This name was given by Guthrie to a rare form of obstruction situated at the neck of the blad- der, and entirely distinct from the common hypertrophy of the middle lobe of the prostate. There are two forms of bar—one consisting in a ridge-like elevation of the mucous and submucous tissues, due to en- largement of the lateral lobes of the prostate, the median lobe being unaffected—and the other a similar fold or ridge, which Guthrie attri- buted to disease of an "elastic structure" (which he described as exist- ing at the neck of the bladder), and which occurs without there being any apparent cause for its formation. The treatment in most cases must be palliative merely, though, if the condition could be accurately 876 DISEASES OF THE BLADDER AND PROSTATE. diagnosticated during life, it might be occasionally proper to divide the bar with a catheter carrying a concealed blade, as recommended by Guthrie and Mercier, HEMATURIA. The existence of blood in the urine may be a symptom of various affections of the urinary organs, and it often becomes important to determine the source of the hemorrhage. 1. Bleeding from the Kidney may be due to blows on the loin, to the existence of acute Bright's disease, to the irritation produced by a renal calculus, etc. The blood is usually intimately mixed with the urine, but may form a clot, in which case, by floating out the coagulum in water (as suggested by Hilton), its shape may betray its origin. 2. Vesical Hematuria may result from congestion of the bladder, from the irritation caused by a calculus, or from the presence of a villous or malignant growth. The blood often coagulates within the bladder, but, when passed in a liquid form, the urine which first flows is less tinged than that which follows. If the hemorrhage be caused by a mor- bid growth, the appearance in the urine of shreds of the abnormal tissue, recognizable with the microscope, may aid the diagnosis. 3. Bleeding from the Prostate may depend upon congestion, in- flammation, or malignant disease of that organ. The diagnosis from vesical hemorrhage may be aided by exploration with the finger in the rectum. 4. Hemorrhage from the Urethra may depend upon congestion or inflammation of the part; upon laceration from blows on the perineum, injuries inflicted by instruments, impacted calculi, etc.; upon rupture from straining in the effort to urinate, or from violent coitus j1 upon ulceration from malignant disease, etc. The diagnosis of urethral hemorrhage may always be made by observing that, in urinating, blood precedes the flow of urine, and that this, if drawn off by the catheter, is clear. Treatment of Haematuria.—This must vary with the source of the hemorrhage. If due to renal injury, calculus, etc., the patient must be kept in bed, and astringents, such as gallic acid or acetate of lead, with opium, administered. When of vesical or prostatic origin, cold applications are of service. It is better, as a rule, not to interfere with clots in the bladder, but to leave their disintegration to the efforts of nature. If, however, it becomes necessary to adopt artificial means of evacuation, a portion of the clot may be gently drawn out through a large-eyed catheter, by means of Clover's lithotrity apparatus or an ordi- nary stomach-pump. Hemorrhage from the urethra may be controlled by cold applications, or, if these fail, by introducing a full-sized catheter, and compressing the penis upon it with strips of adhesive plaster or a bandage. 1 The bleeding which occasionally follows immoderate sexual intercourse without rupture, is, according to Hilton, usually prostatic. RETENTION OF URINE. 877 Intermittent or Paroxysmal Haematuria has been observed in several cases, by Greenhow and other writers, the paroxysm usually following exposure to cold. The treatment consists in the administra- tion of tonics, particularly iron and quinia. Paralysis and Atony of the Bladder ; Retention and Incontinence of Urine, etc. True Paralysis of the Bladder is not very often met with; it is most commonly seen in cases of injury or organic disease of the brain or spinal cord, though it occasionally occurs as a result of functional exhaustion of the spinal system from sexual excesses, as a reflex pheno- menon dependent upon injuries or diseases of other parts of the body, or as a temporary consequence of the use of belladonna or similar drugs. When the paralysis affects the neck of the bladder only, the urine con- stantly flows away, giving rise to incontinence; when the body of the organ alone is involved, the bladder cannot expel its contents, and the result is retention; while, if the whole organ be affected, though most of the urine may escape, the bladder remains partially distended—and incontinence and retention may thus coexist. The treatment consists in keeping the bladder empty (when this is necessary) by the cautious and gentle use of a flexible catheter, and in relieving by suitable remedies any cystitis that may occur. In some cases, galvanism and the adminis- tration of various tonics, especially strychnia, may be of service. Atony of the Bladder, from over-distension of this organ, is, on the other hand, frequently met with. This condition may arise in the course of low fevers, if the catheter be not used—or even from voluntarily neglecting the calls of nature—but is most commonly due to some source of obstruction, either prostatic or urethral, which, while not giving rise to absolute retention, yet renders the bladder unable to expel its whole contents. A certain quantity of "residual urine" thus remains, and gradually increases in amount until the organ is completely distended, when the neck of the bladder becomes partially dilated, and, as pointed out by Thompson, an overflow takes place, masking the real condition, and leading the patient—and sometimes his medical adviser—to consider the case one of incontinence rather than retention of urine. Retention of Urine, though merely a symptom, is one of such importance as to demand special consideration. When it occurs gradu- ally (as is the case when it arises from paralysis or atony of the blad- der), the vesical cavity becomes slowly distended, until it may contain several quarts of urine, and forms a prominent tumor in the hypo- gastrium, reaching nearly to the umbilicus. The patient is usually not conscious of passing a smaller quantity of urine than in the normal con- dition, though a certain amount of difficulty may be experienced incom- pleting the act of micturition—the water being expelled with less force than in health, and dribbling of urine continuing after the bladder has been apparently emptied, or occurring during sleep or upon making any muscular exertion; when the bladder has become fully distended, over- flow occurs in the way already described, and simulates incontinence. The diagnosis of retention is usually made with facility; even if there be no hypogastric tumor, there will be dulness on percussion over the pubes, and the distended bladder can be felt by placing a finger in the rectum, when by tapping over the supra-pubic region fluctuation can be 878 DISEASES of THE BLADDER AND PROSTATE. distinctly recognized. If, however, the walls of the bladder be thick- ened and contracted, the diagnosis may be more difficult. Retention of urine, if unrelieved, leads to cystitis, with an ammoniacal state of the con- tents of the bladder; it may even prove fatal through the supervention of a typhoid or uraemic condition. Treatment.—The treatment of retention with overflow, which is the condition met with in cases of atony of the bladder, requires in the first place the systematic use of the catheter, two or three times a day, so as to evacuate the "residual urine." A long and large flexible catheter is the best, but, whatever form of instrument may be used, care must be taken that it actually enters the bladder, and not merely the prostatic portion of the urethra, which in these cases is often dilated, and may contain a couple of ounces of urine. When the retention has lasted for a long period, it may be better not to evacuate the entire contents of the bladder at once—which would probably give rise to cystitis—but to draw off a portion at a time, and thus enable the organ gradually to return to its normal state. In cases of short duration the bladder may perfectly regain its tone, but in many instances all that can be done is to palliate the patient's condition. Thompson recommends the applica- tion of the cold douche to the lumbar spine and abdomen, and the injec- tion of cold water into the bladder. Hysterical Retention of Urine is occasionally observed in women, in connection with various other phenomena which are conventionally denominated hysterical. The treatment consists in regulating the state of the bowels, and administering tonics and nerve stimulants, with the local use of the cold douche; the catheter may be used once, to make sure that there is no actual obstruction, but should afterwards be with- held ; rupture of the bladder never occurs in these cases, and the patient usually passes her water without difficulty, as soon as the distension becomes painful, and she is convinced that instrumental relief will not be afforded. Incontinence of Urine.—This may occur either in children or in adults. 1. Nocturnal Incontinence in Children__The patient may wet his bed during sleep only occasionally, or may do so once or oftener every night. This infirmity may result from habit (through neglect of the nurse to take the child up at proper intervals), from excessive secretion of urine or some irritating quality of this fluid, from irritation transmitted from neighboring organs, as the rectum, from the existence of slight chronic cystitis, of phimosis, etc. The treatment consists (1) in removing the cause, if this can be ascertained; (2) in improving the general health; (3) in obtunding the excessive sensibility of the bladder; (4) in endeavoring to induce a habit of attending to the calls of nature at suitable inter- vals; and (5) above all, in developing a hearty wish for relief on the part of the patient, for without his co-operation, as justly observed by Brodie, little can be accomplished. The first indication is to be met by regulating the diet, attending to the digestive functions, forbidding ex- cessive use of liquids, etc.; the second, by the administration of tonics, and the employment of sea-bathing or the cold douche; and the third, by the use of belladonna given by the mouth, in the form of tincture or extract, or by the hypodermic administration of atropia, aided in obsti- nate cases by the application of a solution of nitrate of silver to the prostatic urethra. The patient should be aroused and made to urinate INFLAMMATORY DISEASES OF THE PROSTATE. 879 once or twice during the night, and should be induced to strive himself to get relief from his infirmity—not by threatening punishment, but by encouraging the formation of cleanly habits. A'arious remedies beside those mentioned above have been employed with more or less success, such as blisters to the sacrum, the use of an apparatus to prevent the patient lying on his back (the urine, when this position is assumed, resting on the trigone of the bladder, which is its most sensitive part), the application of collodion to the meatus, as re- commended by Corrigan, circumcision, the administration of hydrate of chloral, etc. These may be, each or all, properly tried in obstinate cases. 2. True Incontinence of Urine in the Male Adult is very rare, the real condition in most cases so described being, as already mentioned, retention with overflow. In women, owing to the shortness of the ure- thra, incontinence of urine is more common, resulting usually from injury received during parturition. True incontinence in the male may, however, result from paralysis of the neck of the bladder—in which case the treatment appropriate to that condition must be adopted—or from a peculiar form of hypertrophy of the prostate, in which the enlarged third lobe projects wedge-like between the lateral lobes, keeping the neck of the bladder constantly patulous. Under these circumstances little can be done beyond the adaptation of a well-fitting urinal to keep the patient dry. Irritability, Spasm, and Neuralgia of the Bladder are often spoken of as distinct diseases, but are almost invariably merely symp- tomatic of other conditions, such as cystitis, tumor of the bladder, or vesical calculus. The treatment must be addressed to the relief of the particular pathological condition to which the symptoms may be due. Anodynes and antispasmodics are often useful as palliatives. Inflammatory Diseases of the Prostate. Acute Prostatitis.—Acute inflammation of the prostate usually follows urethritis, especially when due to gonorrhoea, but may also result from various forms of injury, as from the introduction of instruments or the use of strong injections, from exposure to cold and moisture, as from sitting in wet grass, from previously existing cystitis, or from vesical calculus. As a complication of urethritis, it is apt to be excited by the use of alcoholic stimulants or by excessive venery. The symptoms of acute prostatitis are pain and weight in the perineum, with great fre- quency of micturition, dysuria, and vesical tenesmus, the pain also being increased by the act of defecation. There is a good deal of constitu- tional disturbance, and the swelling is sometimes so great as to induce complete retention of urine. The diagnosis can be readily made by rectal exploration. The inflammation may terminate in resolution, or may run on to the formation of an abscess, which usually bursts into the urethra; even if resolution occurs, however, the urine will proba- bly contain pus, from the coexistence of cystitis. The treatment con- sists in the enforcement of rest and the administration of laxatives, with the application of leeches or cups to the perineum, followed by hot hip- baths and poultices. Pain may be relieved by the use of anodyne ene- mata. Should complete retention occur, it may be necessary to use the catheter. 880 DISEASES OF THE BLADDER AND PROSTATE. Abscess of the Prostate usually occurs as a sequel of acute pros- tatitis, but may be developed in an insidious manner from bruising of the part in the use of instruments, etc. In the latter cases it is often the areolar tissue around the prostate which is affected, rather than the organ itself, and the affection is then called peri-prostatic abscess. Pointing usually occurs, as already mentioned, in the direction of the urethra, but occasionally towards the rectum, or even externally in the perineum. The symptoms are those of deep-seated suppuration in gene- ral, and the diagnosis can be made by rectal exploration. Retention is apt to occur when the swelling is principally on the side of the urethra, and the introduction of the catheter may then serve the double purpose of opening the abscess and evacuating the contents of the bladder. When the swelling makes its appearance in the perineum, an early and free incision is required, to relieve tension and prevent the formation of a rectal or urethral fistula. If fluctuation is distinctly felt in the rectum, it may be proper to make a puncture in that locality. Prostatic abscesses usually heal without difficulty, but occasionally fall into a chronic state, persisting as suppurating cavities which form receptacles for urine. This condition is often not recognized during life, the symptoms closely resembling those of chronic cystitis. Benefit may sometimes be derived from the application of a weak solution of nitrate of silver. Chronic Prostatitis or Prostatorrhcea.—This may be a sequel of acute prostatic inflammation, or may occur as a primary affection, resulting from the urethritis which accompanies organic stricture of long standing, from bruising of the perineum in equestrian exercise, from inordinate indulgence in sexual intercourse, from onanism, or from piles, habitual constipation, etc. The symptoms are pain and weight in the region of the prostate, increased during micturition or coitus; dimi- nution in the force with which the urine is evacuated; a slight, thin, gleety discharge, sometimes in sufficient quantity to discolor the clothing; and usually the presence of a little pus in the urine, with occasionally a few drops of blood. Nocturnal seminal emissions occur in some cases. The affection is chiefly important on account of the mental distress it often occasions to patients, who believe the gleety discharge to consist of the seminal fluid. This is, perhaps, the most prominent symptom of the disease, and has suggested the name prostatorrhoza, which is employed by Prof. Gross, who has given an excellent account of the affection. The diagnosis between the prostatic fluid and semen can always be made by microscopic examination; the former contains very few, if any, spermatozoa, while these are, on the other hand, abundant in the latter. The treatment consists in removing any cause that can be detected, in the administration of tonics (with laxatives, if required), and in the ap- plication of blisters or other counter-irritants to the perineum. In cases accompanied by nocturnal emissions, a solution of nitrate of silver (gr. x-xxx to fgj) may be occasionally applied to the prostatic urethra, by means of a syringe with a catheter-like nozzle. Chronic Hypertrophy of the Prostate. This is an affection of advanced life, being seldom if ever met with in men less than fifty years old, though inflammatory enlargement (a totally distinct condition) may of course exist at any age at which pros- ENLARGED PROSTATE. 881 Fiff. 489. tatitis itself is possible. So often is prostatic hypertrophy seen among those past the middle period of life, that Sir Benjamin Brodie considered it almost a normal condition under such circumstances; but the statis- tical investigations of Thompson, Messer, and Lodge, have shown that its actual frequency is less than has been supposed, appreciable enlarge- ment existing in but about one-third of the cases examined in persons more than sixty years of age. The hypertrophy may affect only the unstriated muscular fibres and connective tissue of the prostate, or may involve-its glandular structure as well; there may be enlargement of the whole organ, or the increase of size may be confined to its lateral lobes, or to its central portion, constituting what is com- monly called the enlarged "third lobe of the prostate." In many cases indepen- dent or semi-isolated tumors are found— principally in the lateral lobes—almost identical in structure with the prostate itself, though containing less glandular tissue, and that imperfectly developed ; these prostatic tumors, which have been specially studied by Thompson, are some- times surrounded by a fibrous capsule, and may often be readily enucleated with the finger, as has been done in the operation of lithotomy (see p. 857); they are in many respects analogous to the fibrous or fibro- muscular growths (myomata) met With in Enlargement of mediau lobe of pros- the uterus. tate- Physical Characters.—The weight of an hypertrophied prostate may vary from one to twelve ounces, and its size from two to four inches transversely, and from one to three inches in an antero-posterior direction. The consistence may be firmer or softer than in the normal condition, the increased firmness being usually attributable to the presence of the prostatic tumors which have been referred to. Hypertrophy of the prostate produces various changes in the form and direction of the prostatic portion of the urethra; this is increased in length and often rendered tortuous; it is usually contracted laterallv, and widened from before backwards, so that on making a transverse section it appears as a narrow chink instead of a round tube; but in other cases this portion of the urethra is dilated into a pouch which may hold an ounce or two of urine. When the central portion or " third lobe" of the prostate is enlarged, the urethra is commonly bent for svarcls at an angle—its course being thrown also to the right or left if either lateral lobe is increased in size, and the deviation being to the side opposite to that of the principal enlargement. . The internal orifice of the urethra uusally assumes a crescentic shape, the concavity of the crescent corre- sponding to that lobe of the prostate which is principally affected; but if the whole organ be irregularly enlarged, the urethral opening is much and curiously distorted. A projecting portion from the median lobe not unfrequently hangs over the orifice in a valve-like manner, closing it more or less completely when the patient attempts to urinate. Another mode in which the urethral orifice may be occluded, is by the forma- 56 882 DISEASES of the BLADDER and PROSTATE. Section of bladder and prostate, the former hy- pertiophied, the latter forming prominent tumors within the bladder. Fig. 490. tion of a bar at the neck of the bladder from the elevation of the mucous and submucous tissues by enlargement of the lateral lobes (see p. 875). In the large majority of cases, hypertrophy of the prostate inter- feres with the complete evacuation of the contents of the bladder in one of the ways mentioned, lead- ing to a thickened, roughened, and sacculated condition of that organ, which becomes slowly dis- tended and falls into a state of atony attended with habitual over- flow of urine ; under these circum- stances, a very slight cause, such as exposure to cold, or local conges- tion produced by alcoholic indul- gence or sexual emotion, may be sufficient to produce an attack of complete retention. On the other hand, it occasionally happens that the median, projecting between the lateral lobes, keeps the urethral orifice constantly patulous, thus giving rise to true urinary incontinence (p. 879). In cases of long standing the ureters and pelves of the kid- neys often become dilated, and chronic renal disease supervenes. Symptoms.—The early symptoms of enlarged prostate are diminution of the force with which the contents of the bladder are expelled, the stream, though perhaps not smaller than in health, being feeble and slow, and tending to drop vertically from the meatus. The patient has to strain at the beginning of micturition, and the process requires a longer time than usual, because the bladder is in a state of partial atony; as the organ, moreover, is never completely emptied, the desire to make water recurs with undue frequency, and the normal sense of relief is not experienced from the act of urination; the water continues to dribble after the dis- charge of all that can be voluntarily evacuated, and particularly at night when the control of the will is withdrawn. There is a feeling of weight and distension about the perineum, with irritation of the rectum, tenesmus, piles, or prolapsus; and ultimately the symptoms of chronic cystitis are developed, with an ammoniacal state of the urine, and per- haps the formation of phosphatic calculi. Diagnosis.—Hypertrophy of the prostate may always be recognized by careful exploration with the catheter, aided by the finger in the rec- tum ; in this way the surgeon can ascertain not merely that the prostate is enlarged, but can determine approximative^ the degree of hypertro- phy, which lobe or lobes are particularly affected, and the direction in which the urethra deviates from its normal course. The ordinary cathe- ter frequently will not reach the bladder, on account of the elongation and altered direction of the prostatic urethra which have been referred to: hence the surgeon should have at hand some prostatic catheters, which are from two to four inches longer than the ordinary instruments, TREATMENT OF ENLARGED PROSTATE. 883 and have a larger curve (Fig. 491). Rectal exploration will also enable the surgeon to ascertain if the distended bladder can be felt beyond the prostate—an important point in case the question of puncturing the organ for relief of retention should arise. By conjoined urethral and rectal exploration, the surgeon can distin- guish prostatic hypertrophy from paralysis, or from simple atony of the bladder, from the bar at the neck of the organ unconnected with pros- tatic disease, and from chronic cystitis; the diagnosis from stricture of the urethra may be made by observing the locality of the obstruction (which in stricture is rarely more than six, and in prostatic hypertrophy, at least seven inches from the meatus), and the different character of the stream, which in stricture is small and often forked, but is not always reduced in force, and sometimes keeps its normal parabolic curve, while in prostatic obstruction, though perhaps not diminished in size, it is always weak, and tends to drop vertically from the meatus. The diagno- sis from calculus may be made by careful exploration with a sound ; but it must not be forgotten that calculus and prostatic disease often coexist. Acute prostatitis can be recognized by rectal exploration alone, through the pain which is thus excited ; while the catheter alone will show whether or not there is atony of the bladder, the flow when the obstruc- tion is overcome being forcible and partially under the control of the will, when this organ is healthy, but weak and totally uninfluenced by voli- tion, if it be in a condition of atony. This circumstance will of itseli" suffice to distinguish simple atony from prostatic obstruction. Tumor of the bladder is to be diagnosticated by observing the presence of blood and of fragments of the morbid growth in the urine, and by careful in- strumental exploration (see pages 875 and 876). Treatment.—The most important point is to obviate the effects of obstruction, by emptying the bladder at suitable intervals by catheter- ization. Twice a day—morning and evening—is usually often enough, but the frequency with which the instrument is used, must depend upon the degree in which obstruction is present. The patient should be taught to pass the instrument for himself, the best form for ordinary use being the "English" gum-elastic catheter, which should be kept, as advised by Brodie and Thompson, on an over-curved stylet (Fig. 491, a), so that, when this is removed, it may pass readily into the bladder. For special cases it may be necessary to use silver instruments, some of which should have a large curve—a third of the circumference of a circle, the radius of which is 2| inches—and others a short beak like a litho- trite; or it may be necessary to use the gum instrument with the stylet, so that the curve can be altered at will, or so that the curve may be increased when the catheter reaches the point of obstruction, by par- tially withdrawing the stylet, in the way recommended by Hey, of Leeds. An ingenious instrument for use in cases of retention of urine from prostatic enlargement, has been recently described by Dr. Squire, of Elmira, under the name of vertebrated catheter; its construction can be seen from Fio\ 492. If it should be necessary to leave a catheter in the bladder__which should, as a rule, only be done in cases of retention in which the introduction of the instrument has been attended with great difficultv__the vulcanized India-rubber catheter should be chosen, and may be introduced with or without the stylet, as may be found most convenient; if the stylet is used, it is, of course, to be withdrawn as soon as the instrument is in place. The catheter may be most con- veniently secured by means of adhesive strips, reaching from the instru- 884 DISEASES OF THE BLADDER AND PROSTATE. ment to the penis, and fastened to the latter by other strips applied circularly around the organ. Care must be taken not to produce so much constriction as to lead to ulceration or sloughing. Fig. 491. a, Gum catheter mounted on a stylet of the proper curve for use in cases of prostatic obstruction; b, e, d, silver prostatic catheters of different curves. Beside periodically emptying the bladder by the use of the catheter, the surgeon must pay great attention to the general condition of the Fig. 492. Squire's vertebrated prostatic catheter. patient, who should live temperately, dress warmly, and take moderate walking exercise in the open air. The treatment of cystitis with vesical RETENTION FROM PROSTATIC OBSTRUCTION. 885 catarrh, a frequent complication of enlarged prostate, has already been referred to. Yarious drugs, particularly conium, mercury, muriate of ammonia, and iodine, have been employed in the hope of causing absorp- tion of prostatic enlargement, and systematic compression (first pro- posed by Physick) has been used for the same purpose: none of these remedies have, however, sustained the reputation which was claimed for them, and they are now generally abandoned. Yarious operations, such as incision, excision, cauterization, avulsion, strangulation with the ligature, crushing with a lithotrite, etc., have also been suggested, but do not appear to offer any hope of benefit commensurate with the risk which they entail. Prof. Gross speaks highly of the occasional appli- cation of leeches, and of the formation of a seton in the perineum. Fig. 493. Treatment of Retention from Prostatic Obstruction. If complete retention occur, the surgeon may try the effect of a hot bath with a full dose of opium; but if this fail (as it usually will), perse- vering attempts must be made to pass a catheter. The patient should be in a recumbent position, for if erect, fatal syncope may occur from the rapid withdrawal of a large quantity of fluid (as in the operation of tapping the abdomen), and the surgeon should then try in succession, with all gen- tleness however, prostatic catheters of vari- ous kinds and shapes, until, if possible, relief is afforded, when, if thought proper, the in- strument may be fastened in the bladder. Jf the distension has been very great, it may be prudent to remove only a portion of the urine at a time (see page 878). The chief points to be attended to in catheterization, in these cases, are (1) to firmly depress the ex- tremity of the instrument between the patient's thighs, so that its beak may ride over the enlarged third lobe into the bladder, and (2) to make sure that the bladder is actually reached, and that the catheter does not merely enter the elongated and dilated urethral pouch which often exists in cases of prostatic enlargement. If catheterization cannot be accomplished, the bladder must be punctured in one of four ways, viz., (1) through the prostate; (2) through the rectum; (3) above the pubes ; or (4) through the pubic symphysis. Puncture through the Prostate (Tunnelling the Prostate)—This operation was recommended by Home, Brodie, and Liston, the two former surgeons simply perforating the obstruction by pushing through it a silver catheter, while the latter employed a large and slightly curved canula carrying a concealed blade. The surgeon first satisfies himself that the instrument is exactly in the median line, and has not deviated from the urethra, and then pushes it steadily onwards while he depresses its handle, until the cessation of resistance and the flow of urine show that the bladder has been reached. A false passage is thus made through the projecting third lobe of the prostate, and in this false pas- sage the instrument should be left for about forty-eight hours, when the Catheterization in enlarged prostate. 886 DISEASES OF THE BLADDER AND PROSTATE. parts will usually be sufficiently consolidated to allow the catheter to be withdrawn and re-introduced as often as necessary. This mode of treat- ment is not entirely free from risk, but constitutes probably the .best course that can be pursued, provided that the surgeon can satisfy him- self that his instrument has not left the channel of the urethra, and that it impinges directly upon the obstructing portion of the prostate. Under other circumstances the bladder might not be reached at all, and the operation would probably be followed by serious consequences. Puncture through the Rectum is the next best mode of treat- ment, but is not applicable to cases of very great prostatic enlargement. If, however, the fluctuation of the distended bladder can be distinctly recognized above the prostate, by digital exploration through the rectum, this operation may be safely resorted to, as the puncture can then be made below the recto-vesical fold of peritoneum. The patient being in the lithotomy position, the bladder is steadied and pressed downwards by an assistant placing one hand on either side of the abdomen ; the surgeon, then, having satisfied himself as to the extent and relations of the pros- Fig. 494. Puncture of the bladder through the rectum, and above the pubes. tate, introduces upon the left forefinger, which serves as a guide, a curved trocar and canula, seven or eight inches in length, and by depress- ing the handle of the instrument carries its point through the contiguous walls of the rectum and bladder, the cessation of resistance showing when the latter organ has been entered. The trocar is then carefully withdrawn, and the canula secured in place by means of tapes fastened to a bandage around the waist. After a few days, probably, the catheter CANCER OF THE PROSTATE. 887 can be introduced without difficulty, when the rectal canula may be taken out, the wound usually closing without any trouble. The risks of rectal puncture, apart from wound of the peritoneum (which can scarcely occur if the operation be reserved for cases in which vesical fluctuation is distinctly recognized by the finger in the rectum), are injury of the seminal vesicle, abscess of the recto-vesical septum, leading perhaps to urinary infiltration, and the formation of a recto-vesical fistula. Em- physema has occasionally followed the operation. Puncture above the Pubes.—If perforation of the prostate be deemed inadvisable, and the size of that organ be such as to forbid punc- ture through the rectum, the bladder may be tapped above the pubes (in which position it is uncovered by peritoneum), by making a small incision in the median line just above the symphysis, and then intro- ducing a straight or slightly curved trocar and canula (with the con- vexity upwards) in a direction downwards and backwards, so as to penetrate the bladder: the canula may be left in for two or three days, after which a gum-elastic tube may be substituted—the latter instrument being subsequently renewed as often as may be found necessary. Dr. Dieulafoy, of Paris, has suggested a modification of this opera- tion, by which the bladder is emptied through an exploring canula by means of a suction apparatus. Puncture through the Symphysis Pubis was first suggested by Brander, of Jersey, in 1825, and has since been successfully resorted to by Leasure, of Pennsylvania, and several other surgeons. It is accom- plished with a strong hydrocele trocar and canula, by pushing the in- strument through the symphysis in a direction " obliquely downwards and backwards towards the sacrum." This mode of treatment is only applicable to cases in which the cartilage of the symphysis is unossified, and has not been employed often enough to allow the expression of a positive opinion as to its merits or disadvantages. Other Diseases of the Prostate. Atrophy of the Prostate is occasionally observed either as a con- genital or as an acquired affection. The prostate may be considered as atrophied whenever its weight (in an adult of medium size) is less than half an ounce. The affection presents no special symptoms and requires no special treatment. Cancer of the Prostate is usually of the encephaloid variety, though, according to Jolly, true scirrhus is occasionally found in this organ. The affection, which is one of great rarity, may occur either in early childhood or in late adult life; the symptoms are those of pros- tatic obstruction, with pain, hsematuria, glandular implication, and, ulti- mately, general cachexia. The diagnosis is almost impossible during the early stages of the disease; and, indeed, according to Jolly, has rarely been made during the life of the patient. The treatment must be purely palliative, and instrumental interference should be, if possible, avoided. If absolute retention, occur, puncture of the bladder may be required as a means of prolonging the life of the patient, though, of course, ultimate recovery is impossible. For further information on the subject of prostatic cancer the reader is referred to the writings of Gross and Thompson, and especially to an elaborate and exhaustive 888 DISEASES OF URETHRA AND URINARY FISTULA. memoir recently published by Jacques Jolly, in the numbers of the Ar- chives Generales de Medecine for May, June, July, and August, 1869. Tubercle of the Prostate occurs in connection with tubercle of other organs, but presents no special indications for treatment. Cysts of the Prostate are of the kind called by German patholo- gists, retention cysts, resulting from obstruction of the glandular tubes of the organ by calculous concretions; they are seldom recognized during life. Prostatic Calculi have already been referred to at page 866. CHAPTER XLYI. DISEASES OF THE URETHRA AND URINARY FISTULA. Exploration of the Urethra. This is accomplished by the aid of catheters, bougies, or sounds, and may be aided in sOme cases by the use of the endoscope. Catheterization of the urethra is an operation which is very frequently required, and in the performance of which every surgeon should strive to acquire such skill as to inflict the least possible amount of pain upon his patient. Catheters.—These are hollow tubes, made either of metal—when they must have a curve corresponding to that of the normal urethra—or of India-rubber, or other flexible substance. There are two principal varieties of flexible catheter in the market—the English and the French. The former is of a yellowish-brown color, and is provided with a stylet; it can be made of any curve the surgeon chooses, by moulding it in hot water and then quickly plunging it into cold water, when it becomes stiff, and will retain its, curve long enough to allow its introduction in Fig. 495. ~~~ ~~~^r=r----o French flexible bougie and catheter. all ordinary cases. The French instrument, of a black color, is, on the contrary, perfectly flexible, bending with the utmost facility in every direction ; it is conical- towards its extremity, and terminates in an olive-shaped point, to prevent its catching in the lacunae of the urethra. A catheter should be ten or eleven inches long, and provided with one or two large, smoothly finished eyes near its vesical extremity; the metallic instrument should be heavily silver or nickel plated, and should have rings at its outer end to enable the surgeon to judge, by their position, of the exact situation of the beak of the instrument, when it BOUGIES AND SOUNDS. 889 is in use. The curve of a catheter should correspond to that of the normal urethra; the instrument employed by Thompson has a curve which forms a quarter of the circumference of a circle with a radius of one and five-eighths'inches (three and a quarter inches in diameter). Benique's instrument, which is preferred by Bumstead, has the same curve, but occupies a greater arc of the circle. The curve of the catheter should be continued quite up to its point. The sizes of catheters are arranged by either the English or French scale—the latter being the best, as having more numbers, and therefore allowing more nicety of gradua- tion. The English scale runs from one to twelve, and the French from one to thirty, the numbers in the latter representing the exact circum- ference in millimetres. For purposes of exploration, or for ordinary use, a medium-sized catheter should be chosen, as it is less likely to inflict injury than a smaller one, and will not be caught in the laciinse of the urethra. A double-curved or S catheter is a convenient form of the in- strument for office use. Bougies and Sounds.1—These may be regarded as solid catheters. The bougie (originally made of wax, whence the name) is a flexible in- strument, and there are two varieties corresponding to the English and French catheters. Beside the ordinary conical, olive-pointed French bougie, the surgeon should have some of the kind which go under the name of bougies a boule, or, as Bumstead more accurately terms them, Fig. 496. Bougies a boule. acorn-pointed bougies. These are particularly valuable for purposes of exploration, enabling the surgeon to judge of the extent of a stricture by noting the point at which resistance is felt, both upon the introduc- tion and upon the withdrawal of the instrument. Filiform bougies are simply bougies of very small size; they may be made of whalebone, or of the same material as the ordinary French bougie or catheter, the latter being upon the whole the best. These instruments are indispens- able for the treatment of tight strictures. Sounds are made of steel, pewter, or other metallic substance, and should be perfectly smooth and highly polished, or, which is better, plated with silver or nickel. Their curve should be that of a well-made metallic catheter, and they should have a broad handle to prevent them from slipping when in use. Their, sizes are graduated by the same scale as catheters. Introduction of the Catheter.—The patient may be in a standing, sitting, or lying posture, the last being much the best under ordinary cir- cumstances. He should lie perfectly flat on his back, with the shoulders slightly elevated and the thighs somewhat flexed and separated; the drawers should be slipped down, and the shirt tucked up so as to fully expose the genital organs. The surgeon, sitting or standing on the left 1 Or urethral sounds, in contradistinction to the vesical sounds used for exploring the bladder. 890 DISEASES OF URETHRA AND URINARY FISTULA. side of the patient, raises the penis with his left hand, and, holding the catheter or sound (previously warmed and oiled) lightly between the thumb and two fingers of the right hand, introduces its beak between the lips of the meatus, its shaft being nearly horizontal and lying in the direction of the fold of the patient's left groin. The penis being steadied and slightly drawn upwards so as to efface the folds of the urethra, the instrument is very gently pushed onwards, entering almost by its own weight, and being "swallowed," as it were, by the canal, until the beak has passed beneath the symphysis pubis. During the first two inches of its course the catheter should be kept to the floor of the urethra, so as to avoid the lacuna magna, but should afterwards be made to cling to the roof of the canal, to avoid the sinus of the bulb and the openings of any false passages that may be present. When the point of the catheter has passed beneath the pubes, the shaft is to be brought into the median line and slowly elevated to a vertical position, Fig. 497. Introduction of the catheter. when, by gently depressing the handle between the patient's thighs, supporting at the same time the convexity of the instrument by press- ing on the perineum or with the finger in the rectum, the beak will glide into the bladder. If any difficulty be experienced, the instrument should INTRODUCTION OF THE CATHETER. . 891 be slightly withdrawn, and re-advanced with its point held more closely to the roof of the canal. The points requiring special attention are, to avoid the lacuna magna, to keep the handle of the instrument down until its point is well beneath the pubes, and to combine the progressive and curving motions in a slow and gentle sweep, so that the beak of the instrument may follow the normal course of the urethra, which the surgeon must constantly bear in mind. Above all, the surgeon must avoid the use of force. If the resistance be from spasm, this will yield to very gentle pressure; if from congestion and engorgement of the prostate, from excessive de- velopment of the uvula vesicse, or from the presence of a bar at the neck of the bladder, it may be necessary to employ a prostatic catheter; while if from organic stricture, a smaller instrument must be used. Under no circumstances should the surgeon attempt to overcome the obstruction by violence, for the walls of the urethra are readily lace- rated, and a false passage is very easily made; whereas, in the words of Sir Henry Thompson, "temper, patience, and a light hand will overcome almost all cases of difficulty." Instead of oiling the catheter, it is some- times better to distend the urethra with oil, thrown in with an ordinary penis-syringe. If the patient be very fat, difficulty may be experienced in bringing the catheter to the median line of the body without prematurely elevat- ing its handle, and under these circumstances a manoeuvre known as the "tour de maitre" should be adopted. This is, indeed, a very convenient mode of catheterization, and I often employ it instead of the ordinary method. The surgeon stands on the right side of the patient, and intro- duces the catheter with its convexity upwards and its shaft lying ob- liquely across the patient's left thigh; as the point of the instrument reaches the bulb, the handle is swept around towards the abdomen—when the beak enters the membranous portion of the urethra, and is carried into the bladder by depressing the shaft between the patient's thighs in the way already described. One or other of these plans is to be adopted in using metallic cathe- ters or sounds, and English flexible catheters and bougies. To employ either of the latter with satisfaction, the surgeon must have at hand two basins, one of hot water and the other of cold. The instrument is moulded to the proper curve in the firsthand then instantly plunged into the other, by which method its curve is fixed and will remain unchanged long enough for ordinary purposes. If, however, there be much delay in the introduction, the warmth of the urethra will again soften the instrument, and it will lose its curve. The English catheter should, as a rule, be used without the stylet. The object of the latter is not to aid in the introduction of the instrument, but to enable the surgeon to give it a permanent curve by keeping it on the stylet when not in use. When the catheter without the stylet is not sufficiently firm, a metallic instrument will commonly be safer and more efficient. If, however— in a case of enlarged prostate, for instance—it be necessary to leave the catheter in the bladder, the metallic instrument is undesirable, and it may then be necessary to introduce the flexible catheter with the stylet, the latter being, of course, withdrawn as soon as the catheter is in place. , . , . _ . The French instrument is introduced by simply pushing it gently in the line of the urethra. It is impossible to guide its point, which will, however unless in cases of great obstruction, readily find its own way into the' bladder. The French catheter is, unfortunately, a perishable 892 DISEASES OF URETHRA AND URINARY FISTULA. form of instrument, and is with difficulty kept in order in warm climates. A great difference of opinion prevails among surgeons as to which is the best, the flexible or the metallic instrument; it is commonly said that though a gum catheter may be the safest in the patient's own hands, yet that, for the surgeon, an undeviating instrument is preferable; such was formerly my own opinion, but increasing experience has convinced me that Sir Henry Thompson is right in declaring that for all ordinary cases the flexible catheter is quite as easy of introduction, and much less dan- gerous and painful to the patient than the metallic. In dealing, how- ever, with some very tight strictures, a silver catheter may undoubtedly be preferable to any other, and in this as in most other departments of surgery, the practitioner will do wisely not blindly to follow one exclu- sive method, but to vary his remedies according to the exigencies of each particular case. Before using any catheter, whether flexible or metallic, the surgeon should carefully examine into the condition of the instru- ment ; from neglect of this precaution the end may be broken off in the bladder, and form the nucleus of a calculous concretion. The Endoscope.—This consists of a somewhat conical metallic tube, straight for the urethra, and beaked like a vesical sound for the bladder, Fig. 498. Desormeaux's endoscope. with an eye-piece, an illuminating apparatus, and an arrangement of mirrors, by which a strong light can be thrown upon whatever touches the end of the tube. This mode of exploring the urinary passages appears to have been suggested by Avery, but was first practically introduced to the notice of the profession by Desormeaux; modifications of the instrument have since been proposed by Cruise, Warwick, Wales, MALFORMATIONS OF THE URETHRA. 893 and others, simplifying the apparatus, and permitting the employment of sunlight instead of artificial illumination. Though changes of color in the urethral mucous membrane are readily recognized with the endoscope, it has not been found to add much to the information which can be acquired by careful exploration with the sound or catheter, and has proved less useful in practice than was at first anticipated. Malformations of the Urethra. The urethra may be partially or completely occluded, or may be par- tially deficient, an abnormal opening existing on its upper or lower surface. When the opening is above, the deformity is called epispadias, and when below, hypospadias. Partial Occlusion, or Congenital Narrowing of the Urethra, occurs at or near the external meatus ; the treatment consists in restoring the calibre of the part by an incision with a probe-pointed bistoury, recon- traction being prevented by the subsequent use of a bougie. Complete Occlusion of the Urethra produces retention of urine which usually proves fatal within a few hours of birth ; if the condition should be recognized during life, the occluding membrane, which is usu- ally but a few lines in thickness, should be divided with a sharp bistoury or punctured with a trocar and canula, the opening being maintained by the occasional passage of a bougie. Should the point of occlusion be so far back as to render it impossible to reach, it from the meatus, it would, I think, be the surgeon's duty to open the urethra behind the seat of obstruction, if this could be done from the perineum, or to puncture the bladder by one of the operations which have already been described. Epispadias, or Deficiency in the Roof of the Urethra, may be com- plete or partial. Complete epispadias is seldom met with except in con- nection with exstrophy of the bladder; the latter deformity having been remedied in the way already described, the epispadias may be relieved by a plastic operation, as has been clone by J. Wood (see page 811). Partial epispadias is but a lesser degree of the same deformity, the abnormal opening extending from near the pubes to the end of the penis; it may be treated in a similar manner, by turning down a narrow flap from the hypogastric region, and covering it in with a bridge of skin dissected from the scrotum. This operation, which originated with Ne- laton in 1852, has been since repeated, both by himself, by Follin, and by J. Wood, with good results; it is the operation after which was modelled Richard's method of treating exstrophy of the bladder (see page 810). Hypospadias, or Deficiency in the Floor of the Urethra, is a com- paratively common affection. The abnormal opening, which is usually much smaller than that of epispadias, is commonly found at the base of the fraenum, more rarely at the point of junction of the penis and scro- tum, and occasionally, it is said, in the perineum. Complete hypospa- dias, associated with cleft scrotum, constitutes one form of hermaphro- dism, so called. When the opening is placed far back, the deformity, beside causing inconvenience in micturition, interferes with the ejacula- tion of semen, and thus renders the patient practically sterile; under these circumstances the malformation (which is usually unimportant) 894: DISEASES OF URETHRA AND URINARY FISTULA. may call for surgical treatment, which consists in endeavoring to restore with knife or trocar the natural passage from the meatus to the urethra aboArethe hypospadiac orifice—the latter being subsequently closed by a plastic operation such as will be described under the head of urethral fistula. Prolapsus of the Urethra. This is said by Guersant to be a not unfrequent affection in female children. The prolapsus, which results from straining efforts in cough- ing or in defecation,,forms a rose-colored tumor at the urinary meatus, apparently proceeding from the interior of the canal, but having in its centre an opening which admits the catheter and thus reveals the nature of the affection. If unrelieved, the prolapsus leads to vulvitis, and gives rise to a burning and smarting sensation in the act of micturition. The treatment recommended by Guersant is excision with curved scissors: hemorrhage after the operation is to be checked by the application of the perchloride of iron or ice. Urethritis. Inflammation of the Urethra may arise from injury, from gastric or intestinal disorder, from exposure to cold, from the contact of irritating injections, from an acicl or ammoniacal condition of the urine (as in cases of long-standing stricture or prostatic enlargement), from onanism, from prolonged or violent coitus, or from contact with the menstrual fluid or with leucorrhoeal or gonorrhoeal discharges. Whatever its origin, its course and symptoms are the same, and it requires the same treat- ment. This has already been described at page 422. Spasm of the Urethra. Spasm, or, as it is usually called, Spasmodic Stricture of the Urethra, rarely occurs except as a complication in cases of permanent or organic stricture, or in those of inflammation of the urethra. I do not mean to deny the frequent existence of muscular contraction in a healthy urethra, which is indeed often felt closing around a catheter or bougie, the canal, as it were, grasping the instrument; but it is very seldom, indeed (ex- cept in the cases mentioned), that this contraction is sufficient to mate- rially hinder the flow of urine, or to impede the entrance of a catheter. The chief causes of spasm, beside organic stricture and urethral inflammation, one or both of which are present in the large majority of instances, are (1) the irritation caused by the impaction of a calculus, by an acid or ammoniacal condition of the urine, or by certain substances which are eliminated by the kidneys, as the oil of turpentine, Spanish fly, and some varieties of wine or other liquor; (2) voluntary neglect to empty the bladder at the right time ; (3) exposure to cold; (4) immode- rate indulgence in coitus; (5) diseases of or operations on the lower bowel; and (6) disorders of the digestive apparatus or of the nervous system. To the latter cause is to be referred the urethral spasm, some- times culminating in temporary retention, which occurs in the course of fevers, or after severe traumatic injuries or surgical operations. Usually an attack of spasmodic retention is traceable to a combination of causes; thus it not unfrequently happens that a patient with slight organic stricture, or slight urethral or prostatic inflammation, dining out or SPASMODIC AND CONGESTIVE STRICTURE. 895 joining some party of pleasure, and indulging more freely than usual in the delights of the table, perhaps also neglecting to obey the call of nature at the proper time, finds at length, when an opportunity to empty the bladder is presented, that the power of micturition is gone. Slight spasm may occur at any part of the canal, but the common seat of the affection is at the membranous portion, from the action of the compres- sor urethrse muscles. The symptoms of spasm of the urethra are the sudden occurrence of great diminution in the size of the stream, with great pain and strain- ing in the act of urination, which is often accompanied with a feeling of weight and fulness in the perineum, and with, irritation of the lips of the meatus, showing that with the spasm there exists a certain degree of urethral and prostatic inflammation. The treatment varies according as there is or is not complete reten- tion. In the first case, relaxation of the spasm may usually be induced by the administration of an enema of laudanum, and by placing the patient in a warm bath, a full dose of castor oil being given as soon as the bladder is relieved. Another remedy which has acquired a good deal of reputation in these cases, is the muriated tincture of iron, given in doses of ten or twenty minims every quarter of an hour. The recur- rence of spasm must be obviated by seeking for and removing the cause, and by attention to the state of the general health. When there is great acidity of the urine, alkalies may be administered, such as the bicarbonate of soda, or the liquor potassae, in combination with tinc- ture of hyoscyamus and spirit of nitrous ether. If, as is usually the case, there is some permanent constriction of the urethra, this must be remedied by the systematic use of bougies. In a case of complete retention of urine from spasm of the urethra, it is, I think, better to resort at once to the catheter. Apart from the patient's suffering, which is extreme, there is positive risk in allowing the bladder to remain distended ; atony of this organ, or cystitis, with all its consequences, may result, or rupture of the urethra, or even of the bladder itself, may follow, leading to urinary extravasation, or even to fatal peritonitis. A rather small catheter—No. 5 or 6 (English)'— should be employed; and a gum-elastic is commonly preferable to a metallic instrument, as producing less pain. If catheterization fail, the patient should be put into a hot bath, opium administered, and (if there be much inflammation) leeches applied to the perineum, when the blad- der will either relieve itself, or it will be found that the instrument can be readily introduced. Severer measures, such as opening the urethra in the perineum, or puncture of the bladder, can only be required when the spasm is a mere complication of tight organic stricture, or of decided enlargement of the prostate. Brodie and Thompson have each recorded a case in which urethral spasm occurred periodically, and ultimately disappeared under the use of quinia. Congestive Stricture. This term is ordinarily, but incorrectly, applied to the temporary interference with the flow of urine which is due to inflammatory swell- ing of the prostate and adjacent parts. It is, in fact, a condition of subacute prostatitis, a disease which, as already mentioned, seriously 1 The numbers given in this chapter refer to the English scale, because, though not the best, it is the most familiar to the majority of American surgeons. 896 DISEASES OF URETHRA AND URINARY FISTULA. impedes micturition, and occasionally produces absolute retention (p. 819). It is not unfrequently observed as a complication of gonor- rhcea, caused by exposure to cold, or by imprudence of various kinds. (See p. 424.) When occurring in cases of organic stricture or enlarged prostate, spasm is often superadded. The treatment consists in the administration of laxatives, with laudanum enemata, and the hot bath. Leeches to the perineum will often be of service. If the urine be unduly acid, alkalies may be given, and strict attention should be paid to the state of the patient's general health. If gonorrhoea be present, this must be treated in the way described in previous pages, and benefit will often be derived, under these circumstances, from the occasional introduction of a bougie. The catheter may be required if absolute re- tention should occur. Stricture of the Urethra. Stricture of the urethra, or, as it is often called, in contradistinction to the temporary forms of obstruction last mentioned, Permanent or Organic Stricture, may result from long-continued urethritis (whether gonorrhoeal or otherwise), from mechanical injury (Traumatic Stric- ture), or from the contraction which attends the healing of chancroidal or other ulcers. The congenital defect which has been already described as Partial Occlusion of the Urethra, is sometimes not detected until adult life, when it may, for all practical purposes, be regarded as a form of organic stricture. Age.— Traumatic stricture may occur at any age. I have seen one case in a boy of 11, who died from urinary extravasation following the giving way of the urethra behind the seat of stricture. This case, which was one of great interest, has been fully reported by Dr. Charles C. Lee, of New York.1 The other forms of stricture, of which the gonorrhceal is by far the most common, are rarely, if ever, met with before the age of puberty; and, as several years usually elapse between the occurrence of the gonorrhcea and that of the stricture to which it gives rise, the latter is most commonly observed for the first time in men from 25 to 40 years of age. Locality.—The seat of stricture is, in the large majority of cases (over two-thirds), at the sub-pubic curvature of the urethra. This has been conclusively established by the laborious and careful investigations of Sir Henry Thompson. The most common position is at the posterior or bulbous part of the spongy portion of the canal (Fig. 499), the lia- bility of the urethra to constriction diminishing as it is traced back- wards. The next most frequent seat of stricture is at, or within two and a half inches of, the meatus, and after this comes the central part of the spongy portion. Stricture in the posterior part of the membranous por- tion is very rare, while in the prostatic portion it probably never occurs, though the contrary has been maintained by very eminent authorities. Number.—Usually—in more than three-fourths of all cases—there is but one stricture, but occasionally two or three distinct constrictions are found in the same urethra, and cases are described in which there 1 American Journ. of Med. Sciences, July, 1862, p. 108. STRICTURE OF URETHRA. 897 are said to have been still larger numbers. When several strictures coexist, one is almost invariably found at the sub-pubic curve. Fig. 499. Fig. 500. ture, and dilated and reticulated membranous Strictures near the orifice of the urethra. and prostatic portions behind it. Morbid Anatomy.—The tissue chiefly affected is the submucous areolar tissue, which, as the result of the inflammatory process, becomes the seat of lymph-formation, partial organization following, and gluincr together the mucous and submucous tissues, and often involving the sub- stance of the corpus spongiosum. The contraction which ensues dimin- ishes the calibre of the canal, often throwing the lining membrane of the urethra into folds or ridges, and at the same time lessens the natural elasticity of the part, and, of course seriously impedes the exercise of its functions. Another form of stricture is described by some writers, as consisting in the deposit of a pseudo-membranous substance on the mucous membrane itself. Such a condition, if it exist at all, must be extremely rare. Classification.—Strictures are variously classified, according to—1, their anatomical character; 2, the degree of contraction which they cause; and, 3, the symptoms which they present. 1. Classification according to Anatomical Character—(1.) A linear, bridle, pack-thread, or valvular stricture is one in which the obstruction is produced by a thin fold of mucous membrane perforated in the centre, or forming a crescentic septum at one side only of the canal, or passing across from one side to the other in the form of an isolated band or bands. These bands or fraena are, according to Erichsen, probably formed artificially, by the perforation of a crescentic mucous fold with the point of a catheter. (2.) An annular stricture resembles the variety last described, except 57 898 DISEASES OF URETHRA AND URINARY FISTULA. in the circumstance that the canal is obstructed for a greater extent, the appearance being that which would be produced by tying a string or tape around the urethra. (3.) Indurated annular stricture is the name given by Thompson to that form of constriction in which the tissues around the canal are indu- rated to the depth of from half a line to a line. The contraction is usually greatest at the central portion of the stricture, giving the part an hour-glass appearance. The induration is commonly most dense at the floor of the urethra. (4.) Irregular or tortuous strictures embrace all the more complicated forms of the disease. 2. Classification according to Degree of Contraction.—A very im- portant classification of strictures, as regards their treatment, is into permeable and impermeable. In one sense of the word, every stricture is permeable; that is to say, no stricture is so tight but that a drop or two of urine will occasionally find its way through;' but that every stricture which allows the passage of urine is, as has been asserted, necessarily permeable to a catheter or bougie, if used with sufficient skill and patience, I cannot admit. Doubtless one surgeon will succeed where another fails, but from all that I have seen, either in my own practice or in that of others, I am prepared to fully indorse the state- ment of Prof. Bumstead, that no surgeon of any considerable experience can honestly maintain that he has never seen an "impassable stricture." Liston and Syme, who were the great advocates of the doctrine that no stricture was impermeable, were both foiled in their later years in the attempt to pass an instrument, and even Sir Henry Thompson, who, in his clinical lectures, published in 1868, declared of the "operation for impermeable stricture" (perineal section), that he had never had occa- sion to perform it, and doubted if the necessity for it ever existed—in his more carefully written essay, in the second edition of Holmes's System of Surgery, acknowledges that the "general rule" of permea- bility admits of a " very few exceptions," and confesses that he has twice had occasion to perform the operation in question. 3. Classification according to Symptoms.—Strictures are further clas- sified, according to their symptoms, into the simple stricture, the irri- table stricture, and the contractile or recurrent stricture. The signifi- cance of these terms will appear in the sequel. Symptoms of Stricture.—One of the earliest symptoms of stric- ture, in many cases, is the presence of a slight gleety discharge; there is, besides, pain in micturition, referred to the part of the urethra behind the stricture, and the calls to empty the bladder recur with increased frequency. The stream is diminished in size, and often altered in form, being curiously forked or divided. As a consequence of the small size of the stream, a longer time is required to empty the bladder, and the involuntary straining which attends the act often leads to great irrita- tion of the rectum, with perhaps piles or prolapsus, and, in extreme cases, a discharge of the rectal contents whenever urination is attempted. Retention of urine may occur at any moment, from spasm or conges- tion, or from the occlusion of the narrow passage by a pellet of mucus or a calculous concretion, but more usually the stream gradually les- sens until the urine escapes in drops, the bladder slowly becoming dis- 1 Obliteration of the urethra may result from severe laceration of the part, the urine all flowing through a fistulous opening in the perineum; but such a condition is not, properly speaking, a stricture. URETHRAL FEVER. 899 tended, until the condition described as retention with overflow is estab- lished. The retained urine undergoes decomposition, becoming am- moniacal, and producing cystitis, with deposit of phosphatic matter. Hematuria is an occasional symptom of stricture, the blood being usually of urethral, but sometimes of vesical origin. Ulceration of the bladder, or of the urethra behind the point of stricture, not unfrequently takes place, and, under these circumstances, rupture of the part may result from the straining efforts of the patient, leading to peritonitis or urinary extravasation. In other cases the ureters and pelves of the kidneys become dilated, and chronic renal disease supervenes. Ab- scesses often occur in the perineum, and more rarely in connection with the anterior portions of the urethra, leading to the formation of urinary fistulae. There is, usually, not much constitutional disturbance in the early stages of stricture ; cases are, however, occasionally met with, in which grave nervous symptoms, with general depression, follow upon very trivial causes—such as the passage of a catheter, slight exposure to cold, etc. These symptoms, which are grouped together under the name of urethral fever, are chiefly, but not exclusively, met with in cases of irritable stricture, so called, in which catheterization produces great and persisting pain. In the advanced stages of stricture, the con- stitution always suffers, the digestion being impaired, and the patient becoming emaciated and feeble. When the kidneys are seriously affected, convulsions or coma may ensue. Urethral Fever is a not infrequent sequel of operations on the urethra, and may even occur after the simple introduction of a catheter. This affection is said by Thompson to be most common among the in- habitants of warm climates. It is characterized by the occurrence of rigors (occasionally attended by syncope), with headache and vomiting, followed by febrile reaction. The symptoms, which sometimes return periodically, like the paroxysms of intermittent fever, may immediately follow the introduction of the catheter, but are usually delayed until after the first subsequent act of micturition, and thus appear to be due to the contact of urine with the tender, and perhaps abraded, surface of the urethra. The affection rarely causes death, though it may do so, particularly in cases complicated by the existence of renal disease, pos- sibly, as suggested by Thompson, from the sudden arrest of the func- tion of the kidney. Urethral fever is occasionally followed by inflam- mation and suppuration of the joints, or of the muscular or areolar tissues, and, indeed, is in many respects analogous to gonorrhoeal rheu- matism. It is, I believe, like that affection, a mild form of pyaemia. (See page 429.) It is maintained by Sedillot, Beltz, and other writers, that the occurrence of urethral fever is due to the absorption of urine, but this is at least not proved, while the fact that (1) the affection may, and does occur in cases in which there is not the slightest reason to believe that any laceration of the urethra exists, and that (2), on the other hand, it does not occur in cases of urinary extravasation or infil- tration (as after lithotomy), would seem to justify a contrary opinion. The treatment of urethral fever consists in the administration of nutri- tious food and stimulants, with tonics, especially quinia, and opium. The patient should be kept in bed, and great caution should be exer- cised in the employment of instruments. As a prophylactic, in patients predisposed to attacks of urethral or (as Holt calls it) stricture fever, quinia and opium may be given at regular intervals after each intro- duction of the catheter. 900 DISEASES OF URETHRA AND URINARY FISTULA. Diagnosis of Stricture.—This is made by exploration with a sound or catheter, and may be aided in some cases by the use of the endo- scope. When the existence of stricture is suspected, the surgeon should introduce a medium-sized catheter—No. 7 or 8 of the English scale— and if, on several trials, the instrument is invariably arrested at the same point in the membranous or spongy portion of the urethra, the fact that there is a stricture may be considered as established. It is important, in this exploration, to use a catheter of sufficient size, for a small one may lead to error on the one hand, by catching in a lacuna, or, on the other, by passing readily through the stricture, if this be not very tight. To ascertain the degree of contraction which exists, the surgeon may desire the patient to make water, when the size of the stream will afford some information upon this point. It often happens, however, that the patient is unable, from a nervous feeling, to urinate when asked to do so, and the surgeon must then try in succession smaller and smaller catheters, until one is found which enters the con- stricted part of the urethra. In seeking for the mouth of the stricture, it is well to have some regular course of proceeding ; the catheter is not to be thrust blindly in various directions, but should be first carried along the roof of the urethra, and in the median line, then to either side, and finally along the floor of the canal. By means of the bougie a boule, the surgeon can ascertain, not only the position and tightness of the stricture, but its extent as well. Formerly wax bougies were employed, with the notion that, by pressing the instrument against the stricture, a mould might be obtained that would show its form and direction; but this mode of exploration has not proved very satisfactory, and is rarely employed at the present day. Treatment of Stricture. The Constitutional Treatment of stricture should never be neglected. The diet should be regulated, and the digestive functions brought into a good condition. Cystitis, if present, should be treated in the way already described, and the general health maintained by the administra- tion of tonics, and by attention to the hygienic state of the patient. Rest in bed for a few days is often a valuable preliminary to instrumental treatment, by relieving the congestion of the parts, and diminishing the tendency to spasm. The Local Treatment embraces the application of various methods, which may be classified under the five heads of dilata- tion, rupture, the use of caustics, and internal and external incision. The use of caustics in the treatment of stricture is rarely resorted to at the present day, having been properly superseded by other and safer methods. The articles which have been chiefly employed are the nitrate of silver and the potassa fusa, the cauterizing agent being applied by means of an instrument resembling a catheter with a cup-like depression at its beak, or being simply fixed on the end of a wax bougie. I shall consider the treatment of stricture under the heads of per- meable stricture, impermeable stricture, and stricture complicated with retention of urine. I. Treatment of Permeable Stricture. This may be conducted by means of—1, gradual dilatation; 2, con- tinuous dilatation ; 3, rapid dilatation, or rupture; 4, internal urethro- tomy ; and 5, external perineal urethrotomy with a guide (Syme's opera- tion). TREATMENT OF STRICTURE BY DILATATION. 901 1. Gradual Dilatation is by far the best mode of treatment in any instance in which it is applicable, and should be given a fair trial in every case of permeable stricture. An instrument (usually a flexible one) of sufficient size to enter and be fairly grasped by the stricture, should be employed, without using such force as to cause pain or lead to hemorrhage; such an instrument having been carried through the stric- ture and passed into the bladder, may be allowed to remain for a few minutes—not more than five—when it should be gently withdrawn. After a few days, it may be passed again and followed by a larger instru- ment, this process being continued until the urethra has, in the course of a fortnight or so, been dilated sufficiently to receive a No. 11 or 12 catheter, which will be found, in ordinary cases, as large as the canal can accommodate. The dilatation must be subsequently maintained by the introduction of the catheter at gradually lengthening intervals. The mode in which gradual dilatation effects the cure of a stricture, is pro- bably by inducing absorption of the imperfectly organized lymph which infiltrates the submucous tissue. This plan of treatment will be found satisfactory in the majority of .cases of gonorrhceal stricture. The great requisites for success are gentle manipulation and patience: no violence is to be used, lest a false passage be made; but the instrument is to be gently engaged in the mouth of the stricture, and held there with the slightest pressure for a few minutes, when it will ordinarily slip through; if not, it should be withdrawn, and a smaller one substituted. The dila- tation must also be very gradual; if a number five has been passed at one visit, it will be quite sufficient to get in a number six at the next, and no advantage can be derived from attempting to progress more rapidly; for, by so doing, an attack of urethral fever may not improbably be induced, which, beside endangering the patient's life, necessitates an abandonment for the time of all treatment for the relief of the stricture. False Passages result from the employment of too much force, par- ticularly in the use of small metallic instruments ; the usual situation of false passages is at the lower part of the urethra, and to one or other side. At the moment of the instrument's deviating from the proper channel, the patient feels a sharp pain, and is usually con- scious of something having given way; the sur- geon at the same time perceives that the instru- ment has slipped from the urethra, by the grating sensation which is produced ; and upon placing the finger in the rectum, probably feels the instru- ment in close proximity to the intestinal wall; if a catheter has been used, blood is pumped through it at everv motion, and, whatever instrument has been employed, rather profuse hemorrhage may follow its withdrawal. Should the surgeon be so unfortunate as to make a false passage, he should, if possible, introduce a catheter into the bladder, by keepino- its point closely to the roof of the urethra, leaving it in place for a few days, until the laceration has had time to heal. Even if this cannot be done, there is, however, not much risk of urinary extravasation occurring, doubtless on ac- count of the false passage running in the oppo- site direction to that of the outflowing stream Old false passages often give a great deal of Fig. 301. False passage*. 902 DISEASES OF URETHRA AND URINARY FISTULA. trouble in the treatment of strictures by dilatation, the catheter tending constantly to slip into the wrong channel. This may be obviated by using a well-curved instrument, and by keeping its point away from the orifice of the false passage, the position of which is soon ascertained; assistance may be also derived by tilting up the beak of the instrument by pressure with the finger introduced into the rectum. 2. Continuous Dilatation.—This requires the confinement of the patient to bed; it is effected by introducing a catheter, which is then secured in the bladder, and replaced in the course of a couple of days by a larger one, and so on until sufficient dilatation has been accom- plished. This is an efficient mode of treatment for cases in which catheterization gives great pain (irritable strictures), or in which the stricture manifests a tendency to recontract after ordinary dilatation (contractile or recurrent strictures). It may also be properly employed when, from the existence of false passages or other circumstances, special difficulty has been experienced in the first introduction of the instrument. In the employment of continuous dilatation flexible cathe- ters are*invariably to be preferred. 3. Rapid Dilatation or Rupture.—The methods which are in- cluded under these heads may be properly classed together, as the differ- ence in their modes of action is one of degree rather than of kind. De- sault, Buchanan, Hutton, Maisonneuve, and Wakley, endeavored to effect rapid dilatation of urethral strictures by introducing first a narrow sound or catheter as a guide, and then sliding over it tubes of gradually increasing sizes. Wakley's instrument,-which is probably the best of this kind, consists of a small silver catheter which is first introduced into the bladder, a steel rod being then screwed into its outer extremity, so as to form an unerring guide over which the dilating tubes of gum- elastic or silver are subsequently passed. Fluid pressure was employed by Arnott, and the expanding properties of the laminaria digitata have been recently utilized by Reeves and others; but, upon the whole, the best means of effecting rapid dilatation is by using instruments consisting of two or more blades, which can be made to diverge when in the urethra by a screw arrangement in the handle, or by introducing between them plungers, which act on the principle of the wedge. Luxmoor (in 1812), Civiale, Leroy d'Etiolles, Perreve, Lyon, Pancoast, Thebaud, Voillemier, and others, have devised ingenious instruments for carrying out this object, but I shall only describe those which are chiefly advocated at the present day, viz., Sir II. Thompson's instrument for " over-distending," and Mr. Holt's for " splitting" strictures. Thompson's instrument consists of two blades, which are joined at either end, and which can be separated at. an intermediate point by turn- Fig. 502. Thompson's stricture expander. ing a screw in the handle; an index serves to show the extent to which expansion has been carried, the figures corresponding to the numbers of the English catheter scale. The distending force is to be applied rather INTERNAL URETHROTOMY. 903 slowly, so as to overstretch rather than rupture the morbid tissues, and when the instrument is withdrawn, a full-sized gum catheter is passed, and allowed to remain twenty-four hours. Dilatation is subsequently maintained by the occasional introduction of a large sound. Holt's instrument (a modification of Perreve's), in its present im- proved form, consists of two blades joined at their lower extremity, and Fig. 503. Holt's instrument for splitting strictures. fixed in a handle containing a screw which can be set so as to limit the amount of expansion. A guiding rod (made hollow so as to serve for a catheter, and furnished with a stylet to keep it free from clots) passes between the blades, and when the instrument is introduced, a dilating tube, or plunger, of the required size, is slipped over the guide and quickly thrust down in such a way as to split or rupture the stricture; the plunger is next rotated upon the guiding rod, to insure separation of the split, when the whole instrument is removed, and the water drawn off with a full-sized catheter; no instrument is left in the bladder in ordi- nary cases, but a catheter is passed every other day for a week, and after- wards at longer intervals. The patient should go to bed after the opera- tion, and take two grains of quinia with ten minims of laudanum, every four hours until six doses have been taken. Mr. Holt believes that by this instrument the submucous tissue is split, but the mucous membrane of the urethra itself uninjured ; but that such is not always the case, is shown by the fact that the operation is occasionally followed by rather free bleeding. My own experience with Holf s method is as yet limited, but, so far as it goes, is favorable. I regard it as an excellent mode of treatment in cases of dense cartilaginous stricture of the sub-pubic region, as well as in those of the irritable and contractile varieties. It is, however, not free from risk, urethral fever and death having occasion- ally followed its employment. Until recently, the application of either of these methods was neces- sarily delayed until the stricture had been dilated sufficiently to admit the instrument, which could not be made of a smaller size than a No. 3 or 4 English catheter; but it is now possible, by resorting to the inge- nious contrivances suggested by Prof. Van Buren, of New York, and by Charriere, of Paris, to employ the over-distension or rupture treatment at once, for any stricture which is permeable to the smallest filiform bougie. Yan Buren's method consists in obliquely perforating the ex- tremity of the instrument which is to be used, so as to make an " eye" by which it can be threaded over a delicate whalebone bougie, pre- viously introduced; while in the French plan, which has been extensively employed by Bumstead, the surgeon makes use of an ordinary filiform gum bougie provided with a metallic cap, which can be screwed on to the extremity of whatever instrument is to be employed; the bougie being introduced the instrument is attached to its end, and is thus readily guided through the stricture, the bougie itself passing on and becoming coiled up in the bladder. 4 Internal Urethrotomy.—This mode of treatment, which was employed by Allies and Physick, in the last century, and by John and 904 DISEASES OF URETHRA AND URINARY FISTULA. Charles Bell, in the early part of this century, is particularly applicable to strictures in the anterior part of the urethra, but may also be used for those situated in the sub-pubic region—though for such, the treatment by rupture is, I think, preferable. For strictures at or near the external meatus, a probe-pointed bistoury guided by a small, straight staff, or grooved director, will answer every purpose, but for strictures in other localities more complicated instruments are required. These, which are called urethrotomes, whatever their exact form (and a great many have Fig. 504. Civiale's urethrotome. been invented by different surgeons), consist essentially in a sound or catheter carrying a concealed blade, which can be made to project by means of a spring in the handle, and which is designed to cut from before backwards, from behind forwards, or in both directions. Urethrotomy from Behind Forwards, with such an instrument as Civiale's (Fig. 504), is, upon the whole, the safest method, but requires previous dilatation of the stricture, up to the calibre of a No. 3 or 4 catheter: it is particularly applicable to strictures in the penile portion of the urethra. Urethrotomy from Before Backwards can only be safely performed by first introducing a guide through the stricture. Of the large number of urethrotomes of this kind now before the profession, those of Maison- neuve, Wood, Thompson,, and Trelat are probably the best. These instruments vary in their details, but all act -by first securing the intro- duction of a small staff or catheter, grooved on the convex surface, as a guide, upon which is subsequently passed the blade which divides the stricture. Wood's instrument combines cutting with dilatation, while Trelat's has the advantage of enabling the surgeon, if he thinks proper, to enlarge the incision as the urethrotome is withdrawn. Whatever method be employed, the incision should invariably be made on the lower and not the upper side of the stricture; a flexible catheter should be kept in the bladder for twenty-four hours, and dilatation sub- sequently maintained by the occasional passage of a sound. Internal urethrotomy may be performed in the same classes of cases as Holt's operation; but the latter is, I think, to be preferred for strictures behind the scrotum, the former being reserved for those situated anteriorly. 5. External Perineal Urethrotomy with a Guide, or the Ope- ration by External Division or External Incision (Syme's Method), is very commonly confused1 with the old operation of perineal section, which is, however, only applicable to cases of impermeable stricture, • A good deal of this confusion is, I think, owing to the fact that Prof. Syme reported as examples of his own operation, several cases, in which, having failed to introduce his staff, he cut into the perineum, guiding the subsequent course of the instrument by placing his finger in the wound. By so doing he really converted the operations into old-fashioned perineal sections, the only difterence»being that he cut down upon a small staff instead of a large one, and then slipped the same small staff through the stricture, instead of substituting a grooved director. SYME'S OPERATION. 905 505. whereas, a prerequisite for this method (which was introduced by Prof. Syme in 1844),1 is that a staff shall be passed through the stricture into the bladder. Syme's staff varies in size from that of a No. 1, to that of No. 6 catheter, and is grooved at the lower third on its convex surface; at the point where the grooved portion joins the rest of the shaft, there is a distinct shoulder, which is made to rest against the face of the stricture, and thus guide the surgeon in his incisions. The operation is thus performed: the patient, being etherized, is secured in the lithotomy position, and the staff introduced (in the case of a very tight stricture, by either of the methods described at page 903) ;2 the surgeon then makes an incision about an inch and a half in length, exactly in the median line of the perineum, and feeling for the staff, introduces the knife, with its back towards the rectum, into the urethra behind the stricture, which is then divided by cutting in the groove of the instrument from behind forwards. A broad grooved director is then slipped into the bladder, and upon this as a guide, a No. 7 or 8 catheter introduced and secured in the usual way; the instrument is retained for a couple of days, after which a sound must be occasionally passed to prevent recontraction ; the perineal wound usually heals without difficulty. Syme subsequently gave up the introduction of a catheter through the urethra, substituting a short perineal tube, so as to afford a free outlet for the contents.of the bladder, while Yan Buren, Gouley, and other American surgeons, have gone stilr further and dispensed with the catheter alto- gether. The results of this operation are, on the whole, very satisfac- tory; 219 cases, collected by Thompson, show a mortality of less than 7 per cent., which is a small death-rate in view of the nature of the cases in which it is ordinarily performed. The operation by external division is particularly indicated incases of dense and cartilaginous stricture (particularly when of traumatic origin), and of irritable or contractile stricture, when complicated by the exist- ence of perineal fistulae. In cases, however, in which there is no fistula, Holt's operation is, I think, usually preferable. Syme's method was also recommended by its distinguished author for the treatment of strictures in the anterior part of the urethra, but for such cases internal urethrotomy seems to me a better method. Syme's staff, for ex- ternal division of ure- thral stricture. 1 A similar procedure had been previously resorted to, and was described by Desault as one variety of the " boutonniere," but "to Syme is due the credit of making the operation generally known, and of indicating the circumstances under which it should be employed. 2 In order to avoid the entrance of the staff into a false passage, Prof. Gouley pro- ceeds as follows: The urethra being filled with olive oil, an attempt is made to intro- duce a probe-pointed whalebone guide, the point of which is rendered temporarily spiral by immersing it in boiling water, twisting it around a small staff, and suddenly cooling it. If the point of the guide becomes engaged in a lacuna, it is slightly with- drawn and carried onward with a rotatory movement. If it enters a false passage, it is retained in situ, with the left hand, while another is passed by its side, this pro- ceeding being repeated until the false passage is filled up, when at last one guide enters the bladder- the others are then withdrawn, and an "eyed catheter staff" threaded over that'which is retained, in the way described at page 903. 906 DISEASES OF URETHRA AND URINARY FISTULA. II. Treatment of Impermeable Stricture. Cases are occasionally met with in which, from traumatic causes, the urethral canal is at some part totally obliterated, the urine escaping altogether through a fistula behind the point of injury; beside these cases, there are others which are more properly called strictures, in which, though a few drops of urine make their way through the meatus, yet no instrument—not even a filiform bougie—can be introduced. For such cases Boyer, and afterwards Mayor, recommended forced catheteriza- tion (a proceeding which was attended with the gravest risks, and is now happily abandoned), while Stafford proposed to cut through theimpassa- Fig. 506. Stafford's lancetted catheter. ble stricture with a " lancetted catheter." This plan might perhaps be adopted if a stricture in the anterior part of the urethra were so tight as to forbid the safer operation of internal urethrotomy. Such a case must, however, be extremely rare. There remain to be described the Operation for Impermeable Stric- ture, Perineal Section, or as it is more accurately called by Prof. Gouley, External Perineal Urethrotomy without a Guide, and the operation recently recommended by Mr. Cock. The first is often spoken of as the boutonniere or button-hole incision; but that name appears, from the writings of Desault, to have been indiscriminately applied by French surgeons to any or all operations which had for their object the establish- ment of an opening from the perineum into the bladder, and thus would include (beside the ordinary perineal section) the u external division" of Prof. Syme, Cock's operation in which the urethra is opened behind the stricture, and even the now obsolete procedure of puncturing the bladder through the perineum. 1. External Perineal Urethrotomy without a Guide.—The first formal operation of external urethrotomy for the relief of stricture, unaccompanied, by retention, appears to have been performed about the year 1652, by an English surgeon, named Molins, upon a patient not too respectfully referred to by Wiseman, who gives an account of the case, as "an old fornicator." The urethra had been opened behind the stric- ture, on account of retention of urine, some time previously, but this not satisfying the patient, Mr. Molins placed him in the lithotomy posi- tion, and, giving one testicle in charge to his servant and the other to Wiseman, " with his knife divided the scrotum in the middle, . . . and cutting into the urethra, slit it the whole length to the incision in peri- neo." This rather heroic procedure appears to have been followed by no unpleasant consequences, though it was not successful in curing the perineal fistula. The operation of perineal section was subsequently resorted to by various surgeons, chiefly, however, in cases of retention, but does not appear to have been generally recognized as a legitimate mode of treating stricture unaccompanied by that complication, until the publication of papers by Arnott, in 1823, and Jameson, of Balti- PERINEAL SECTION. 907 more, in 1824, followed some years later by Mr. Guthrie's well-known work on the "Anatomy and Diseases of the Urinary and Sexual Or- gans." The latter surgeon recommended that the urethra should be opened behind the stricture, which was then to be divided by cutting for- wards upon the point of a catheter or sound previously introduced, but most operators have, in all essential particulars, followed the practice of Jameson and Arnott, cutting directly upon the point of the sound, and then cautiously dissecting backwards in the median line. External perineal urethrotomy without a guide may thus be per- formed : The patient being etherized and secured in the lithotomy posi- tion, a full-sized catheter, or, which is better, a staff grooved on its convexity, is passed down until its beak rests upon the face of the stric- ture, taking care that it does not enter a false passage. The staff is then confided to an assistant, who holds it steadily in one position, while the surgeon makes an incision from an inch and a half to two inches in length, exactly in the median line of the perineum. This incision should go through the skin and superficial fascia, and should reach to within about half an inch of the anus. The surgeon next feels for the groove of the staff and cuts into it, thus fairly opening the urethra in front of the stricture. The sides of the canal (the mucous surface of which is easily recognized) are now held apart with tenacula, forceps, or loops of thread—one passed through each margin of the urethra, as advised by Avery—and the part may be still further exposed by turning out the end of the sound through the wound, and thus drawing the urethra forwards, as recently recommended by Wheelhouse, of Leeds. In most instances it will be found possible to slip a small grooved director, a probe, or even a fine whalebone bougie, through the stricture, the mouth of which is thus brought into view; in which case all that remains to be done is to slit up the contracted tissues upon the guide which has been intro- duced, pass a broad director into the bladder, and upon this a full-sized catheter, which may be left in place for about 48 hours.1 If the open- ing in the stricture cannot be found, the surgeon must cautiously dissect backwards, with very light touches of the knife, and keeping strictly in the median line, until the dilated portion of the urethra behind the stric- ture is laid open. This, of course, is the only plan which can be fol- lowed in the rare cases, already referred to, of traumatic obliteration of the urethra. The after-treatment consists in the occasional passage of a sound to prevent recontraction. This operation is certainly a much more difficult one than that of Prof. Syme, and appears to have been more often followed by death ; yet, in view of the otherwise hopeless nature of the cases in which it is performed, it must be considered to give, upon the whole, very satisfac- tory results. Of 35 cases collected by Boeckel, in which the operation was performed by French or German surgeons, 8 terminated fatally, giving a mortality of nearly 23 per cent.; but in the hands of American surgeons, the results, according to Prof. Gouley, have been much better. Indeed, the operation, if carefully performed, is not in itself very dan- gerous and in the majority of fatal cases death has resulted from pre- viously existing disease of the bladder and kidneys. Perineal section, which has, in this country, always been a favorite mode of treating ob- stinate strictures, is adapted to precisely the same classes of cases as Syme's method, except that, to justify the former operation, the stricture • This is considered unnecessary by Yan Buren, Gouley, and many other Ame- rican surgeons. 908 DISEASES OF URETHRA AND URINARY FISTULA. must have resisted all attempts to introduce an instrument. The opera- tion is also indicated in some cases of stricture accompanied by retention, in cases of ruptured urethra in which catheterization cannot be accom- plished (see page 375), and in some cases of traumatic obliteration of the urethra—though it is a question whether it might not often be better under these circumstances to make no attempt to restore the continuity of the canal, but to simply dilate the fistulous orifice which always exists behind the point of occlusion, or to make a direct open- ing into the posterior part of the urethra, in the way recommended by Mr. Cock. 2. Tapping the Urethra at the Apex of the Prostate, unas- sisted by a Guide Staff) is the name given by Mr. Cock, of Guy's Hospital, to a variety of the old " bouttonniere" operation which was frequently practised by Wiseman and others for the relief of urinary retention, but which Mr. Cock recommends in cases of impassable stric- ture,even when not thus complicated. The operation consists in open- ing the urethra behind the stricture, very much in the way it was done by Guthrie, in his mode of performing perineal section; but, whereas Guthrie insisted (and I think with reason) on the propriety of always completing the operation by dividing the stricture itself, Mr. Cock urgently advises that the stricture should not be touched, but that the patient should rather be allowed to recover with a perineal fistula. The following are Mr. Cock's directions for the performance of this operation: The patient being in the lithotomy position, the left fore- finger of the operator is placed in the rectum, with its tip at the apex of the prostate, the relations of which should be carefully ascertained. A double-edged knife is then plunged steadily but boldly into the me- dian line of the perineum, and carried in a direction towards the tip of the left forefinger which lies in the rectum, while, at the same time, by an upward and downward movement, the incision is enlarged in the median line to any extent that is considered desirable. The lower ex- tremity of the wound reaches within about half an inch of the anus. The knife is pressed steadily onwards towards the apex of the prostate, until its point can be felt in close proximity to the tip of the left fore- finger, and is then made to pierce the urethra, by advancing it obliquely either to the right or left. The finger is still kept in the rectum, while the knife is withdrawn, and a probe-pointed director introduced through the wound into the urethra, and passed into the bladder. The finger is then withdrawn, and the director held in the left hand, while a canula or female catheter is slid along its groove into the bladder, where it is retained for a few days. This operation, which I consider a very excellent one in cases of uri- nary retention, seems to me inferior to the perineal section (either by Arnott's and Jameson's, or by Guthrie's method), for cases of stricture in which that complication does not exist. III. Treatment op Stricture Complicated with Retention op Urine. When permanent narrowing of the urethra exists, a very slight cause may at any moment lead to complete retention (see p. 898). Under such circumstances, the sufferings of the patient are very great, and it becomes necessary to adopt prompt and efficient means to evacuate the bladder. The best course to be pursued is, I think, at once to etherize the patient, and when full relaxation has been obtained, to ascertain the RETENTION OF URINE FROM STRICTURE. 909 exact locality of the stricture, by the introduction of a No. 7 or 8 cathe- ter, and then attempt to pass a small flexible or metallic instrument, trying various sizes in succession, and taking every precaution not to produce laceration of the urethra. If a catheter cannot be passed, per- haps a small bougie may be made to enter the stricture, and it will often happen that when this is withdrawn, after remaining a few minutes, a small stream of urine will follow. The same end may also be attained, in some instances, by pressing for a few minutes with a sound against the face of the stricture. If a filiform bougie can be introduced into the bladder, a catheter can readily be made to follow, in the way described at page 903, when the urine can be drawn off, and the surgeon may at once proceed to treat the stricture by either rupture or internal urethrotomy. Sir Henry Thomp- son has devised, for use in these cases, a probe-pointed catheter, the beak of which is as slender as the most delicate metallic probe. The instru- ment is doubtless an efficient one in- skilful hands, but seems to me less adapted for general employment than the filiform bougie used in the way which has been described. If, after patient trial for half an hour or so, no instrument can be introduced, or if prolonged but fruitless attempts at catheterization have been already made by another surgeon, the patient should be placed in a hot bath until faintness is induced, and then put to bed, and wrapped in blankets, with hot fomentations to the pubes and perineum. He should be brought thoroughly under the influence of opium, or, if this drug be for any reason contra-indicated, may take the muriated tincture of iron in the way directed at page 895. Under this treatment the bladder will, in the large majority of in- stances, relieve itself in the course of a few hours, but should it not do so, the patient must again be etherized, and the attempt to afford in- strumental relief carefully renewed. If the surgeon's efforts are still unsuccessful, more decided measures must be adopted. No precise rule can be given as to the length of time during which delay is justifiable in these cases, nor can the surgeon judge accurately of the degree of vesical distension by the size of the tumor which the bladder forms in the supra-pubic region; for, in cases of long-standing stricture, the organ is often thickened and contracted, and may be dangerously distended by an amount of urine which, under other circumstances, would be in- significant. The clangers of delay are very great, and I believe exceed those entailed by a skilfully performed operation. Apart from the risk of rupture of the bladder or urethra, serious injury cannot but be in- flicted upon the ureters and kidneys, by the damming up, even for a few hours, of" the urinary secretion. The operations which may be employed for the relief of retention de- pendent upon organic stricture, are forced catheterization, perineal sec- tion, tapping the urethra behind the stricture (Cock's method), and tapping thelbladder—through the rectum, above the pubes, or through the pubic symphysis. The first method (forced catheterization) is now, happily, seldom resorted to ; it is very uncertain, and extremely dan- gerous—and should, in my judgment, be utterly banished from practice. The operative procedures employed in all the other methods mentioned have already been described, anel it only remains to indicate the parti- cular cases which call for one mode of treatment rather than for another. If swelling or other signs of inflammation in the perineum lead the surgeon to suppose that ulceration or rupture of the urethra may have already occurred, and that urinary extravasation is therefore imminent, 910 DISEASES OF URETHRA AND URINARY FISTULA. if, indeed, it has not actually taken place, one or other of the perineal operations should be preferred, and the choice between these should, I think, rest upon the origin of the stricture, whether gonorrhceal or trau- matic. For the former, Cock's operation may be resorted to, as being easier, and, under these circumstances, quite as satisfactory as the peri- neal section; for, by diverting the course of the urine for a short time, the stricture will, in all probability, become quite amenable to dilata- tion, or to one of the other methods used in the treatment of permeable stricture. If, however, the stricture is of traumatic origin, it is, I think, better to perform perineal section; for this form of the disease is always very intractable, and it is, therefore, better to employ a radical remedy at the outset. If, on the contrary, there is no reason to fear urinary extravasation, it is, I think, better, in most instances, to resort to puncture of tbe blad- der through the rectum—which is usually, in these cases, an easy and safe operation j1 after a few days the stricture can be dealt with by either dilatation, rupture, internal urethrotomy, or external division, as may be thought proper. If, from the size of the prostate or the contracted state of the bladder, the rectal puncture should be considered unde- sirable, the next best course would be to open the urethra behind the seat of stricture; or, if the disease were of traumatic origin, the perineal section might be preferred, for the reasons already mentioned. Ruptures of the Bladder and Urethra are among the gravest sequelae of retention of urine from organic stricture. Rupture of the Bladder (which is very rare) may give rise to peritonitis, or, if the rent be at a part uncovered by the peritoneum, to extravasation of urine within the pelvis; in either case the accident is usually, though not invariably, followed by death. Rupture of the Urethra almost invari- ably occurs at the membranous part of the canal, the urine which is extravasated then making its way into the tissues of the perineum, scrotum, groin, and anterior abdominal parietes, and more rarely pass- ing backwards into the tissues of the ischio-rectal fossae and buttocks. The treatment of these accidents has already been described at pages 373 and 375. Stricture of the Female Urethra is a very rare affection. It may result from gonorrhoea, or from the cicatrization of a chancre or chancroid; but is more apt to be caused by the inflammation following traumatic injuries, particularly from the use of forceps, or the pressure of the foetal head in childbirth. The seat of the stricture is usually at or very near the meatus. The treatment consists in dilatation, aided, if necessary, by a slight incision with a probe-pointed knife. In a case of stricture of the female urethra complicated with retention, in which catheterization proved impossible, Curling resorted to puncture of the bladder through the vagina. Introduction of the Female Catheter.—The female catheter is shorter and less curved than the instrument used for the male urethra, and should be provided with rings, at its open extremity, to prevent the possibility of its slipping into the bladder. The catheter should be introduced without any exposure of the person, and this may be most 1 Cock reports forty cases with eight deaths; but none of the fatal results ap- pear to have been justly attributable to the operation (Med.-Chir. Trans., vol. xxxv., p. 153). TUMORS OF THE URETHRA. 911 conveniently done while the patient is in bed, with the thighs flexed and somewhat separated from each other. The surgeon stands on the patient's left side, and passing his left hand beneath the flexed limb, introduces his forefinger between the nymphse, bringing it from behind forwards until it touches the space between the entrance of the vagina and the orifice of the urethra, the prominence of which is easily recog- nized by the touch ; the catheter is then introduced with the right hand above the flexed limb, and, guided upon the left forefinger, slips without difficulty into the bladder. The whole operation is done under the cover of the bedclothes. In cases of malformation or obstruction, the introduction of the catheter may prove more difficult, and may even be impracticable without the exposure of the part; should retention occur under such circumstances, no false sense of modesty should prevent the adoption of whatever course may be necessary for the patient's relief. Tumors op the Urethra. The older writers attributed most cases of urinary obstruction to the existence of tumors of the urethra, which they called caruncles or car- nosities; but in the light of modern pathology, true tumors of this part must be considered very rare. In many instances, what have been called Fig. 507. Papillary tumor of female urethra. tumors, are merely clusters of prominent vascular granulations, which, as in other mucous membranes, occasionally result from long-continued inflammation. True urethral tumors are, however, occasionally met with, belonging chiefly to the papillary and fibro-cellular varieties. The papillary growths are principally seen near the meatus, and are much less common in the male than in the female sex, while the fibro-cellular or polypoid tumors are chiefly limited to the prostatic part of the male 912 DISEASES of urethra and URINARY FISTULA. urethra. Tuberculous and cancerous deposits, also, are occasionally seen in the urethra; but are usually secondary to similar formations in the kidney, bladder, or prostate. The treatment of the vascular papil- lary growths which are seen near the meatus, and which alone are likely to be recognized during life, consists in excision, ligation, the application of caustics, or the use of the actual or galvanic cautery. The latter is probably the best remedy for the vascular tumors of the female urethra, excision being undesirable in this locality, on account of the risk of hemorrhage. If the hot iron is used, the surrounding parts should be protected with a wooden spatula. Urinary Fistula in the Male. Urethral Fistula.—Fistulous communications between the male urethra and the external surface of the body are not unfrequently met with in cases of long-standing stricture. There may be one or several external openings, and these may be situated in the perineum, scrotum, or lower surface of the penis, or even in the thighs, buttocks, or abdominal wall. Fig. 508. Urinary fistulae in the male. The treatment must be directed in the first place to the cure of the stricture, for the abnormal openings cannot be expected to heal while any obstruction to the natural course of the urine remains. Simple difatation will in many cases be sufficient, and it often happens that when the normal calibre of the urethra has been restored, the fistula will heal of itself. If the stricture is very hard and cartilaginous, or pecu- liarly irritable, or if, though easily dilated, it constantly tends to recon- tract, it will usually be advisable to resort at once to external division (Syme's method), which promises better results under these circum- stances than either rupture or internal urethrotomy. If the stricture be impermeable, the perineal section must be performed as a last resort. If the fistula still persists after the cure of the stricture, special means must be adopted for its treatment. It is often recommended to retain a catheter in the bladder, in these cases, so as to prevent any urine from escaping through the fistula; but the plan very seldom succeeds, for the reason that a small quantity of urine invariably trickles alongside of the instrument, and thus defeats the object in view. It is much better to teach the patient to use a gum-elastic catheter for himself, when, if he can be induced to co-operate with the surgeon by not under any circum- URETHROPLASTY. 913 stances, urinating except through the instrument, the fistula will proba- bly heal without difficulty under simple dressing. The special treatment of urethral fistulae varies according as they are seated in the perineal, scrotal, or penile portions of the urethra. 1. Perineal Fistula.—If of small size, a perineal fistula may be induced to heal by introducing a fine probe coated with nitrate of silver, or (which is probably the most efficient means) by the application of the galvanic cautery. If there be several external openings, a good plan is to connect them together, with an oakum thread, introduced by means of an eyed probe; while, if this fail, it may be necessary to lay open the smaller sinuses by incision upon a grooved director. If the fistula be a large one, its edges may be touched with strong nitric acid, so as to make a superficial slough, which, when detached, will leave healthy granulating surfaces; or the edges may be deeply pared, and brought together with metallic sutures. 2. Scrotal Fistula, on account of the lax condition of the parts, usually requires to be freely laid open, when it will probably heal by granulation; or the edges may be deeply pared and the adjacent tissues dissected up, so as to form broad and thick flaps, which are then to be accurately brought together in the median line with deep and superficial sutures. 3. Penile Fistula is the most intractable form of urethral fistula, and can seldom be cured without a plastic operation. In some cases, however, success may be obtained by touching the edges with nitric acid, and holding the granulating surfaces together with serre-fines, after the detachment of the slough. The contact of urine must be prevented by keeping a full-sized catheter in the bladder, or, which is usually better, by the frequent introduction of a flexible.instrument. Dieffenbach's lace- mture may also be applied with advantage in some cases. The edges of the fistula are first blistered with the tincture of cantharides, and the cuticle scraped off with a scalpel. By repeated introductions of a small curved needle, a waxed silk thread is next carried subcutaneously around, but not across, the fistula, at a distance of about a quarter of an inch from its margin, when, by drawing upon both ends of the thread, the opening is puckered up like the mouth of a purse, and secured with a knot. The suture may be removed after three or four days. 4. Blind Urinary Fistula is the name given to suppurating tracks opening into the urethra, but having no external orifice. The treatment consists in laying open the sinus, and then proceeding as in the case of an ordinary urethral fistula. Urethroplasty.—The simple urethroplasty operations occasionally required in cases of perineal and scrotal fistula, have just been mentioned. More complicated procedures are, however, often needed in the treat- ment of fistulas in the penile portion of the urethra. 1. A good plan is to freshen the edges of the fistula and dissect up long, bridge-like flaps, which are then stitched together over a slip of India-rubber, or, which is better, a piece of thin lead ribbon (Fig. 509), so as to prevent the contact of urine. This operation is said to have originated with Dieffenbach. 58 914 DISEASES OF URETHRA AND URINARY FISTULA. 2. Alliot, Segalas, Nelaton, and others, have succeeded in curing penile fistulae by dissecting up the integuments around the opening and sliding them over the latter, after freshening its edges. Fig. 510. Urethroplasty ; Dieffenbach's method. Urethroplasty ; Le Gros Clark's method. 3. Astley Cooper operated by paring the edges of the fistula, so as to form a quadrilateral wound, which was then closed with a flap of similar form, borrowed from the scrotum. 4. Le Gros Clark pares the edges of the fistula, and closes it by dis- secting up flaps from each side and joining them in the middle line by means of the clamp or quilled suture. Whatever plan be adopted, it may, perhaps, be thought advisable to divert the course of the urine for a tew days, by puncturing the bladder through the rectum, or, better, by opening the urethra in the perineum. Vesico-rectal and Urethro-rectal Fistulas have already been considered (see pages 801, 802). Urinary Fistula in the Female. Of this there are four varieties, the urethro-vaginal, the vesico-vaginal, the vesico-utero-vaginal, and the vesico-uterine fistula. The locality of the fistula in each case is indicated by the name. The causes of these fistula? are direct injury, abscess, ulceration, and sloughing due to pres- sure, as from the child's head in labor—the latter being by far the most frequent origin of the affection. The consequences of this condition are extremely annoying to the patient; incontinence of urine is almost constantly present, leading to excoriation of the genital organs and thighs, and giving rise to an ammoniacal odor which renders the patient an object of loathing to herself, if not to all around her. The diagnosis can be made by placing the patient on her elbows and knees, and ex posing the part by drawing away the opposite wall of the vagina with a Sims's or Bozeman's duck-billed speculum (Fig. 511); if the fistula be very small, it may elude detection unless the bladder is injected, which may be done with simple water, milk, or a weak infusion of madder or indigo. OPERATIONS FOR URINARY VAGINAL FISTULA. 915 The consideration of the treatment of the vesico- Fig. 511. vaginal and other varieties of urinary fistula met with in the female sex, belongs rather to the depart- ment of Gynaecology than to that of General Sur- gery, and I shall, therefore, content myself with indicating the principles upon which the various modern operations for the relief of these affections are founded, referring the reader for more detailed information to the excellent works of Simpson, Sims, Brown, Emmet, By ford, Thomas, Agnew, and other writers on these subjects. Until within a few years, these affections were generally considered incurable, and it is chiefly through the labors of American surgeons, that the operative treatment of vaginal fistulae, from being the opprobrium of our art, has been made one of the most successful procedures in the whole range of surgical practice. Without wishing to make invidious distinctions, I Duck-biiied speculum. may refer particularly to the early labors of Hay- ward, of Massachusetts, and Mettauer, of Virginia, and to the brilliant successes more recently obtained by Marion Sims, who, in 1852, as justly remarked by Thomas, combined the essentials of success, and placed the operation at the disposal of the profession. Since this time the subject has been illustrated both at home and abroad, by Bozeman, Emmet, Agnew, Simpson, Brown, Bryant, Wells, Simon, Ulrich, Neugebauer, and many other surgeons. If a urethrovaginal or vesico-vaginal fistula be very small, an attempt may be made to effect its closure by the application of the actual or galvanic cautery, or by touching the edges with nitric acid and holding them together with serre-fines, a plan which has been recently recom- mended in some cases by Spencer Wells. The large majority of fistulae, however, require an operation, which essentially consists in paring the edges of the opening, and approximating the raw surfaces in a trans- verse direction by means of sutures, which are left in place until firm union has occurred. Operations for Urinary Vaginal Fistula?.—The points which require special consideration are—1. The position of the patient; 2. The mode of exposing the fistula; 3. Paring the edges ; 4. Introduction of the sutures ; 5. Fastening the sutures ; 6. Use of the catheter during the after-treatment; and 7. The time at which the sutures should be removed. The patient should be prepared for the operation by attending to the state of the general health, by subduing local inflammation, and by dividing any cicatricial bands that might interfere with the success of the treatment. A dose of castor oil should be administered the night before, and an enema given on the morning of the operation, while to avoid the suffering, both physical and mental, to which this would other- wise necessarily give rise, the patient should invariably be anaesthetized, unless there be some special reason to the contrary. 1. Position of the Patient.—The best is, I think, a modification of that known as the knee-elbow position, the patient being supported upon pillows or on a well-padded double-inclined plane, with the hips elevated and the head and shoulders depressed, the thighs widely sepa- rated and held apart by assistants; Sims and Emmet, however, prefer 916 DISEASES OF URETHRA AND URINARY FISTULA. a semi-prone position, the patient lying partly on the left side with the thighs flexed—the right rather more than the left—and the breast resting upon the table, while Simon, of Rostock, adopts the supine position, with the hips and thighs much raised, and Wells recommends the ordinary lithotomy position, with the hands and feet fastened together with band- ages or straps. Fig. 512. 2. Exposure of the Fistula.—This may be done with an ordinary Sims's speculum, held by an assistant, but may be more conveniently effected by means of Emmet's modification of that instrument, if the semi-prone posi- tion is chosen, or by a similar modification described by Wells, if the patient be placed either on her back or in the position here recommended. These modifications of Sims's speculum consist in the adaptation of a fenestrated blade, which fits over the but- tock or sacrum of the patient, and thus keeps the instrument in place without the aid of an assistant. A bright light is neces- sary for the operation, the best illumination being afforded by placing the operating table near a high window; if this cannot be ob- tained, an Argand lamp and reflector may be substituted. 3. Paring the Edges.—This may be done with either knives or scissors, according to the fancy of the operator; a convenient form of Fig. 513. Emmet's speculum. Knife for vesico-vaginal fistula. knife is one with a double-edged blade, bent at an angle with the shaft (Fig. 513). The sides of the fistula may be steadied by means of suitable forceps, or one or more hooks with long handles, while the paring is effected by transfixing the part with the knife, and cutting first in one, and then in the opposite direction, so that a complete ring is denuded. In doing this, some surgeons cut perpendicularly to the plane of the vesico-vaginal septum, while others bevel the edges by cutting in an oblique direction, so as to spare the mucous membrane of the bladder. Langenbeck again, and, more recently, Collis, of Dublin, have advised that the edges of the fistula should be split, so as to obtain a broad raw sur- face without cutting away any tissue whatever. Provided that a broad surface is obtained for adhesion, it probably makes little difference which particular plan is adopted. ■ Before proceeding to the next step of the operation, all bleeding should be checked by torsion, by pressure with a piece of sponge mounted on a handle or " sponge-holder," or by throw- ing in a stream of cold water with a syringe. 4 Introduction of the Sutures.—The material generally chosen for the suture, in this country, is, in accordance with the practice of Sims and Bozeman, silver wire; and this seems to me, upon the whole, OPERATION FOR VESICO-VAGINAL FISTULA. 917 preferable to the other substances used for the purpose. Simon, how- ever, employs a silken, and Ulrich, of Vienna, a hempen suture; while Wells considers, and probably with good reason, the choice of material much less important than has been commonly supposed. Wutzer em- ployed the harelip pin and twisted suture, and the same plan with vari- ous modifications has been since adopted by Metzler, of Prague, Mastin, of Mobile, and Watson, of Edinburgh. The sutures, whether of silk or metal, may be conveniently introduced with short well-curved needles held by suitable forceps, or with needles eyed near the point, and mounted in handles like the ordinary naevus needle. Sometimes the silk or wire may be threaded upon two needles, each of which is introduced from the vesical surface of the fistula; or an eyed needle, threaded, may be passed through one margin, and a notched needle, unthreaded, through the other—the loop of the thread being then caught in the notch and thus drawn through ; or, again, the surgeon may ado|it a plan similar to. that of Mr. Avery, in the operation for cleft palate (see p. 722). Special needles have been de- vised for this operation by Druitt, Startin, and others, but I am not aware that they possess any superiority over the simpler implements above recommended. The passage of the needle from within outwards may be aided by steadying the part to be transfixed with a blunt hook bent at an angle to its shaft, and when wire is used, advantage may be derived from drawing it over a notched " feeder," which prevents it from cut- ting through the margin of the fistula. When the edges have been bevelled or split, the sutures should be passed so as not to encroach upon the vesical mucous membrane, but this maybe included when the fistula has been pared perpendicularly to the septum. The sutures should be passed about half an inch from the free margin of the fistula, and should be about a sixth of an inch apart. The fistula should invariably be closed in a transverse direction, so as to form a cicatrix at right angles to the long axis of the vagina. A single set of sutures may be used, or a deep and superficial set, accord- Fig. 515. ing to the fancy of the operator. 5. Fastening the Sutures.—If of silk, the sutures are to be tied in an ordinary surgeon's knot, all the knots being made on the same side of the fistula; wire sutures maybe conveniently twisted Fig. 516. Introduction of sutures for vesico-vaginal fistula. Bozemau's button suture. Coghill's wire twister. 918 DISEASES OF URETHRA AND URINARY FISTULA. with the fingers, or, if the fistula be high up, with the " wire twister" devised by Coghill (Fig. 515); or the ends on either side may be passed through a metallic plate and secured with clamped shot (as in Sims's earlier operations); or Bozeman's ingenious modification, known as the '•button suture," may be substituted (Fig. 516); or the surgeon may employ one of the many shields and splints, which have been devised by Simpson, Brown, Agnew, and others. In the majority of cases, how- ever, the simple interrupted suture will, I think, be found more satis- factory than any other. As a test of the accurate closure of the fistula, an attempt may be made to pass a probe between the stitches, and the bladder may be injected with milk or colored water. 6. The Catheter.—It is by the large majority of writers thought very important to introduce a catheter—Sims's "sigmoid" instrument (Fig. 452) is the best—immediately after the operation, and to keep it in place during the after-treatment. Simon, however, has discarded the catheter altogether, except in cases of retention, when he introduces the instrument at intervals of three or four hours; while Wells introduces at first a small vulcanite catheter, but removes it as soon as it causes any irritation or discomfort. If the catheter is used, great care must 'be taken not to let it become clogged with mucus. 7. Removal of the Sutures.—This maybe done while the patient is in the semi-prone position. Silk sutures should be withdrawn about the 6th or 7th day, and wire sutures from the 8th to the 14th; it is better to retain them unnecessarily than to remove them prematurely. The bowels should be locked up with opium for about two weeks, and cleanliness insured by daily syringing of the vagina. If the urine be ammoniacal, the bladder may be washed out through a double catheter. Modifications Required in Special Cases.—When the fistula is placed in the upper part of the vesico-vaginal septum, care must be taken not to implicate the ureters in the operation. Neglect of this precaution may lead to failure, from the ureter opening into the va- gina above the cicatrix, or even to death, from occlusion of the ureter and consequent uraemia. In cases of vesicoutero- vaginal fistula, the anterior lip of the uterus, or possibly the posterior lip, must be utilized in closing the opening: in the latter case, the patient is rendered sterile, and the menses escape through the urethra. In cases of vesico-uterine fistula, the anterior lip of the uterus must be slit up until the opening is exposed, when its edges may be freshened and united with sutures. In cases of very great deficiency of the vesico-vaginal septum the operation of transverse obliteration of the va- gina (Fig. 518),as employed by Simon and Bozeman, may be necessary: this consists in paring the an- terior lip of the fistula, and attaching it to the pre- viously denuded posterior wall of the vagina, so as to completely close the orifice of this canal; the menses subsequently escape through the urethra, but the patient is rendered sterile and unfitted for sexual congress. Hence, when applicable, a better Fis. 517. Operation for vesico- uterine fistula. MALFORMATIONS OF THE PENIS AND SCROTUM. 919 Fig. 518. plan, also suggested by Bozeman, is to endeavor to lessen the antero- posterior diameter of the fistula, by daily dragging down the neck of the uterus, with forceps, for some weeks prior to the operation, which is then performed as in an ordinary case of vesico-utero-vaginal fistula.1 CHAPTEE XLVII. DISEASES OF THE GENERATIVE ORGANS. DISEASES OF THE MALE GENITALS. Malformations of the Penis and Scrotum. Congenital Adhesion.—The penis is sometimes bound down to the scrotum by a web of skin extending from the lower surface of the organ 1 In the above pa^es I have drawn freely from the excellent Treatise on the Diseases of Women, V Prof. T. G. Thomas of New York and from a valuable paper on the treatment of vaginal fistulae, by Mr. T. Spencer Wells, in St. Thomas's Hosp. Reports, N. S., vol. i., 1870. 920 DISEASES OF THE GENERATIVE ORGANS. to the raphe; the treatment consists in dividing the web, and bringing the edges of the wound together in a longitudinal direction (as success- fully done by Bouisson), or, if this be impracticable on account of tbe shortness of the attachments, in carefully dissecting the penis from its abnormal position and raising it towards the belly, the gap in the scrotum being then filled with a flap borrowed from the groin or thigh, as suggested by Holmes. Incurvation of the Penis (with hypospadias) is occasionally met with, and may seriously interfere with procreation : the treatment may consist (1) in subcutaneous division of the contracted tissues, as prac- tised by Bouisson; (2) in excising a wedge-shaped piece from the dorsum of the organ by transverse incisions, and bringing the sides of the wounds together so as to raise the glans penis, as advised by Pancoast; or (3) in amputating the head of the organ, and enlarging the hypos- padiac orifice, as suggested by Holmes. Fissure, or Cleft of the Scrotum, occurring in connection with malformation of the penis and complete hypospadias, constitutes a variety of so-called hermaphrodism; the cleft scrotum represents the labia majora, and the deformed penis the clitoris, and if the testes be retained within the abdomen the resemblance to the female organs is tolerably complete. These cases seldom admit of operative interference, but the surgeon may be called upon to express an opinion as to the sex of the child, and to advise as to the mode in which it shall be brought up. The diagnosis of sex can usually,, but by no means always, be made by simultaneous rectal and vesical exploration; if no trace of a uterus be found, and if the supposed vagina open directly into the bladder, the probability is that the subject belongs to the male sex. In a case of doubt, it would probably be judicious, as advised by Holmes, to bring the child up as a boy. Phimosis. Phimosis may be cither congenital or acquired. This condition con- sists in an elongation of the prepuce, with contraction of its orifice, pre- venting the foreskin from being drawn back so as to expose the glans penis. Congenital Phimosis.—In congenital cases the contraction is most marked in the inner or mucous layer of the prepuce, which adheres more or less closely to the surface of the glans, while the skin of the part is comparatively lax. Phimosis is often the source of great inconvenience, if not of positive disease. In childhood, it may form an impediment to the flow of urine, leading to irritation of the urethra and bladder, and often giving rise to symptoms of vesical calculus. In adult life, it may similarly interfere with the discharge of semen, and thus render *the patient practically sterile, while, by preventing the retraction of the prepuce, it causes an accumulation of smegma, producing great irrita- tion of the part, and exposing the patient to repeated attacks of balano- posthitis. Phimosis, moreover, apparently renders its subjects more liable to the various forms of venereal infection, and becomes a serious complication when venereal diseases are acquired. It also, in the opinion of Hey, Holmes, and others, predisposes to the development of malignant disease of the part. TREATMENT OF PHIMOSIS. 921 Acquired Phimosis may result from thickening of the prepuce, following gonorrhoeal or chancroidal inflammation, or may be dependent upon the existence of fissures or excoriations of the part. In some in- stances, phimosis is complicated with a condition of solid oedema of the prepuce, constituting a state of hypertrophy, which, like the analogous hypertrophy of the clitoris, seems, occasionally, to be due to constitu- tional syphilis. Treatment of Phimosis.—In some cases it is sufficient to divide the mucous layer of the prepuce, which is, as has been mentioned, the part chiefly affected in congenital phimosis, but in many instances it will be necessary to adopt severer measures, which may be classified under the heads of incision, excision, and circumcision. 1. Division of the Mucous Layer of the Prepuce may be accomplished in several ways :— (1.) Sudden dilatation or rupture of the mucous layer may be effected by introducing the blades of an ordinary pair of dressing forceps be- tween the prepuce and glans penis, one on either side, and then quickly withdrawing the instrument with its blades widely separated ; the fore- skin is then drawn back, and kept retracted for about forty-eight hours. This plan is said to have originated with Hutton, of Dublin, and has been, lately, highly commended by Cruise, of the same place, who has devised a special instrument for the operation. A three-bladed forceps is employed for the same purpose by French surgeons. Erichsen recommends, in cases of acquired phimosis depending upon fissures of the preputial orifice, gradual dilatation, effected by means of a two-bladed urethral dilator, such as is used in the operation of lithec- tasy in the female. (2.) The surgeon may employ a small pair of scissors, the lower blade of which is probe-pointed, introducing this blade between the prepuce and glans, and thrusting tbe other or sharp-pointed blade between the layers of tbe prepuce. The contracted mucous layer can now be divided at a single stroke, the foreskin being then retracted, as in the previous method. This mode of operating appears to have originated with Dr. Edward Peace, of this city, formerly one of the surgeons to the Penn- sylvania Hospital. (3.) Faure's method consists in forcibly drawing backward tbe skin of the penis, and dividing the mucous layer of the prepuce, which is thus made tense, by a succession of notches with a pair of probe-pointed scissors. 2. Incision.—This maybe done either at the upper or lower surface of the penis; probe-pointed scissors may be used, or the surgeon may introduce a grooved director, and upon this a sharp-pointed curved bis- toury, which is then made to transfix the prepuce and cut from within outwards, scissors being employed, if necessary, to complete the division of the mucous membrane. Another plan is to dispense with the director, guarding the point of the bistoury with a small piece of wax until it has reached the desired point, when it is made to transfix and cut its way out as before. If the incision be made below, the fraenum, if too short, may be at the same time divided. This method is attended with the disadvan- tage of leaving a wing-like projection of preputial tissue on either side of the penis, constituting an unseemly deformity, and, if, as often happens, 922 DISEASES OF THE GENERATIVE ORGANS. the prepuce subsequently becomes thickened and hypertrophied, inter- fering with coitus. 3. Excision.—The prepuce having been divided with a bistoury along the dorsum of the penis, as in the operation by incision, the flaps on either side may be seized with forceps and cut off in an oblique di- rection, so as to make an oval wound; the mucous membrane is then attached to the skin with silk or lead sutures, and the part covered with a cold water-dressing. This operation gives a very good result, and is I think, particularly applicable to those cases in which the prepuce is in a state of solid oedema and hypertrophy. Other plans are to excise the fraenum, together with a V-shaPe(l portion of the prepuce, as in the operations of Taxil anel Jobert (de Lamballe), or to remove with scis- sors a semilunar flap, as in the method of Lisfranc. 4. Circumcision is, I think, ordinarily the best mode of treatment. The prepuce should be drawn forwards, so that the portion which corre- sponds, in the ordinary condition, to the. line of the corona glaudis shall Fis. 519. Circumcision. be entirely in front of the penis; a pair of narrow-bladed forceps is then applied in an oblique direction (so as not to encroach too much upon the fraenum), and firmly held*by an assistant, while the surgeon with knife or scissors removes the part of the prepuce which is in front; when the instrument is removed, it will be found that more of the skin has been taken away than of the mucous membrane, and it is, therefore, usually necessary to slit this along the dorsum of the penis—when the flaps thus formed may be excised, and the operation completed by uniting the skin and mucous membrane with silk or lead sutures, or with serre-fines. This operation is commonly attended with some little hemorrhage, which, if metallic sutures are used, can be conveniently checked by transfixing each of the bleeding vessels with one of the stitches ; under other circumstances, ligatures may be required. An in- genious modification of this operation is that which was introduced by PARAPHIMOSIS. 923 Ricord, who has devised for the purpose a fenestrated forceps, through which the suture threads may be introduced before the prepuce is cut off • the forceps *being removed, the mucous membrane is, if necessary, slit along the dorsum, and each thread divided in the middle, so as to form a suture on either side. This modification of the ordinary operation of circumcision has proved very satisfactory in several cases in which I have employed it. No operation for phimosis should, as a rule, be performed in any case complicated with chancroid, lest the whole wound should become in- oculated. Paraphimosis. This is the name given to the condition in which the prepuce has been drawn up above the corona glandis and cannot be replaced. The glans soon becomes swollen and oedematous, from the constriction exercised by the preputial orifice, and, if relief be not afforded, ulceration or sloughing may occur. Paraphimosis is chiefly met with in boys, but may occur at any age if the prepuce be contracted. The treatment con- sists in effecting reduction, which may be sometimes aided by prelimi- nary scarifications, or by the application of the cold douche or of ice. Reduction may usually be accomplished by the surgeon's fingers, combining Fig. 520. traction upon the prepuce with com- pression of the glans, which should be well oiled and covered with a small rag, to prevent the fingers from slipping. The surgeon first compresses the glans firmly for five or ten minutes with the fingers of the right hand, so as to squeeze the blood out of the part, and then encircling the prepuce with the left hand, as shown in Fig. 520, gradually draws the part into its normal place, aiding the ma- noeuvre by trying to insert the right thumb-nail beneath the edge of the pre- putial orifice. Other plans are to com- press the glans by surrounding it with a tape or strip of adhesive plaster, or by applying broad-bladed forceps; or to raise the preputial ring upon a director, wmle the glans is pushed up beneath the Reduction of paraphimosis. instrument. If these means fail, a small bistoury must be introduced flatwise beneath the edge of the preputial orifice, which lies at the bottom of the groove behind the swollen glans, and then turned with its edge upwards so as to nick the constricting tissues at one or more points of their circumference ; the tension being thus relieved, reduction can be accomplished without difficulty. Inflammatory Affections of the Penis and Scrotum. Diffuse Inflammation of the Areolar Tissue of the Penis and Scrotum may result from erysipelas or urinary extravasation, or may occur as a sequela of certain fevers—particularly variola and scarlatina. The parts become greatly swollen, constituting the con- 924 diseases of the generative organs. dition often spoken of as inflammatory oedema, and gangrene is apt to ensue. The treatment consists in making free incisions, and in elevating the parts and applying warm fomentations ; quinia and iron may be given in pretty large doses, while the strength of the patient is kept up by the administration of concentrated food and stimulants. Gangrene of the Penis is a serious affection which may result from either phimosis or paraphimosis, as it may, likewise, from traumatic causes, such as the introduction of the organ into a ring, the impaction of a calculus in the urethra, wounds of the cavernous bodies, etc. Gan- grene of this part has also been observed as the result of phagedaenic ulceration, of phlebitis of the dorsal vein, and of urinary extravasation; and has been seen in the course of low fevers. Usually the prepuce only is affected; but occasionally the skin of the whole penis or even the entire organ may be implicated. When either the prepuce or the glans is threatened with gangrene, no time should be lost in slitting up the former, so as to relieve the part from tension. When gangrene has actually occurred, little can be done beyond supporting the strength of the patient, and facilitating the separation of the" sloughs- as they be- come detached. Demarquay speaks favorably of the actual cautery as a means of preventing the spread of the disease. The affection may prove directly fatal, through simple exhaustion, through the develop- ment of pysemia, or through the occurrence of secondary hemorrhage; or may indirectly cause death, according to Demarquay, from the patient falling into a state of marasmus, caused by the impairment of the generative powers. In other cases, in spite of the loss of considerable portions of the penis, the procreative powers of the patient have not been at all diminished. Herpetic and Aphthous Ulcerations on the penis are chiefly interesting on account of the probability of their being mistaken for chancroids (see p. 432). The treatment consists in the use of astringent applications, such as the oxide of zinc in powder, or lotions of borax, and in attention to the state of the general health. Balanitis and Posthitis have already been considered (see p. 426). Structural Changes in the Penis and Scrotum. Hypertrophy of the Prepuce may result from long-continued irritation of the part, or may be due to a condition of Elephantiasis Ara- bum (see pp. 467, 500)—in which case the subcutaneous tissues of the penis are commonly affected in a similar manner, as may be also the scrotum. The treatment consists in the excision of the enlarged pre- puce and of a V-shaped piece from the dorsum of the glans penis, the sides of the wound being brought together with stitches. Hypertrophy or Elephantiasis of the Scrotum is chiefly seen in warm climates. The disease anatomically resembles what has been described as the fibro-cellular outgrowth (p. 467), and can only be re- moved by excision. When of moderate dimensions, the hypertrophied scrotum can be removed with little risk; but when, as not unfrequently happens, the part forms a pendulous tumor weighing from 40 to 60 or even 80 pounds (as in one of Fayrer's cases \ the operation becomes one of a formidable nature. To diminish the loss of blood, which is always malignant diseases of the penis. 925 considerable, the tumor should be elevated above the rest of the body for some hours before the operation, as advised by Brett and O'Ferrall, and the neck of the tumor may be compressed with a clamp, as recom- Fig. 521. mended by Fayrer, or with a run- ning noose, as ingeniously suggest- ed by Dr. Mactier. If a hernia be present, this should first be fully reduced. The operation may be performed by introducing a director down to the penis, which lies at the bottom of a sinus, deeply buried in the mass, and upon the director a cat- lin, which is made to transfix the superincumbent tissues and cut its way outwards. The penis is now carefully dissected out and held up towards the abdomen, when inci- sions are made on each side so as to expose the testes, which are similar- ly dissected out and turned up until the operation is completed. The tu- nicae vaginales, if diseased, are to be cut away, and then the whole mass separated by cutting across its base close to the perineum. Hemorrhage is next to be suppressed, 50 or 60 ligatures being sometimes required for this purpose, and the wound is then to be simply dressed with oiled lint and allowed to heal by granu- lation. The testes and penis quickly become covered, and cicatrization is usually completed in from six weeks to two months. If, in the case of a very large tumor, it is found that the dissection of the testes would prolong the operation beyond from three to five minutes, Fayrer advises that the attempt to save these organs should be abandoned, and the whole mass swept away as quickly as possible. Of 28 patients operated on by Fayrer, 22 recovered and 6 died, one from shock, and the other 5 from pyaemia. Vegetations or Warts on the penis, Venereal Warts, as they are often, though incorrectly, called, have already been referred to (see p. 495). Malignant Diseases of the Penis.—The penis may be the seat of either epithelioma or scirrhus, the former, which is the more common affection, ordinarily beginning in the prepuce, while scirrhus usually originates in the body of the penis, in the depression behind the corona glandis. Both of these forms of disease appear to be more common in the subjects of congenital phimosis than in those who are not thus affected, which is of itself a sufficient reason to induce the surgeon to recommend circumcision in all cases of preputial contraction. Epithe- lioma of the penis may possibly be mistaken for exuberant vegetations Hypertrophy or elephantiasis of the scrotum, in a Hindoo. 926 diseases of- the generative organs. or for chancre. From the former it may be dis- tinguished by the indurated and infiltrated con- dition of tbe parts, which is characteristic of the malignant affection, and from the latter by the his- tory and course of the disease, the comparatively late implication of the inguinal lymphatic glands, and the negative effect of antisyphilitic treatment. Treatment.—In the case of epithelioma, if the nature of the affection be recognized before the glans has become involved, it may be possible to remove the whole mass of disease by circumcision; but at a later period amputation of the penis is the only resource which offers a prospect of benefit, and the same operation is required when the growth is of a scirrhous character. Amputation of the Penis, if performed at an early period, before the lymphatic glands have become involved, is quite a successful pro- ceeding, and often gives a long respite from the disease, if indeed it does not effect a permanent cure. The operation may be performed either with the ecraseur or with the knife. The disadvantage which attends the use of the former instrument, is that the contraction which ensues in healing is apt to diminish the calibre of the urethra, and thus lead to difficulty in micturition; to avoid this, it has been recommended to introduce a flexible catheter, cut through this with the chain of the ecraseur, and leave the remnant in place during the process of cicatrization; but it is not always very easy to sever the catheter in this manner, and, unless great care be exercised, the end of the instrument may escape from the surgeon's grasp and slip into the bladder. Upon the whole, the opera- tion with the knife seems to be preferable under ordinary circumstances, though if it be necessary to amputate the organ very high up, the ecra- seur may answer a better purpose. To prevent hemorrhage, in the use of the knife, a tape may be tied tightly around the root of the penis, and an assistant should grasp the part with his fingers to prevent the stump from being retracted beneath the pubes. The surgeon now takes the glans, wrapped in lint, in his left hand, and draws the organ forwards, so as to put its integument on the stretch ; he then cuts off the part to be removed with a sharp knife, either at a single stroke, or, which I think better, divides first the cavernous bodies, and then allows the organ to retract before severing the urethra, which is thus left rather longer than the rest of the penis. Bleeding is next to be checked, about five ligatures usually being required, when the operation should be completed according to Ricord's plan, by splitting the projecting portion of the urethra at three or four points and evert- ing its mucous membrane, which is then attached to the skin by means of the interrupted suture. Another plan, suggested by Watson, of Edinburgh, is to make a slit in the integument of the dorsum of the penis, and to pass the projecting urethra through this slit, so as effectu- ally to prevent the occurrence of contraction during the healing process. Unless the amputation be done very near the root of the organ, the procreative powers of the individual do not seem to be impaired by the operation. Non-malignant Tumors of the penis are occasionally met with, Fig. 522. Epithelioma of the penis. malformations, and malpositions of testes. 927 and may be removed without infringing upon the integrity of the rest of the organ. Epithelioma of the Scrotum is chiefly observed in chimney-sweepers,1 whence it has been called chimney-sweeper's or soot cancer; it appears to be produced by the irritation caused by the contact of soot, beginning as a scaly or incrusted wart which soon ulcerates, and perhaps ultimately involving the whole scrotum, the testis, and the inguinal and pelvic lymphatic glands. The treatment consists in complete excision of the growth, at as early a period as possible. Malformations and Malpositions of the Testes. Complete Absence of one or both Testes has occasionally been observed, but a more common condition is an Arrest in the Normal Descent of the Organ, the gland remaining in the abdominal cavity or in some part of the inguinal canal. In other cases a testis may pass through the femo- ral ring, may be found in tbe perineum, or, though lodged in the scro- tum, may be inverted, so that the epididymis is placed in front of the body of the organ. Retained testes are liable to become inflamed, and are peculiarly predisposed to structural degeneration. It would appear also, from the researches of Godard and Curling, that a retained testis either secretes no fluid, or that its secretion is destitute of spermatozoa ; hence a monorchid, or person with one undescended testis, depends for his procreative power upon the single gland which has reached the scro- tum, while a cryptorchid, or person with both testes retained, though capable of coition, is necessarily sterile. Treatment.—The treatment of malpositions of the testis is in most cases limited to palliative measures. If the gland be still within the abdomen at the end of the first year of life, Curling advises the applica- tion of a truss to insure its permanent retention. When the testis is above the external ring, it requires no treatment, unless it becomes in- flamed, or is the seat of structural degeneration. When at or just outside of the external ring, the gland is liable to slip backwards and forwards, and causes a good deal of pain when pinched in the inguinal canal. Under such circumstances a truss should be used, tbe pad being applied if possible between the testis and ring; if this cannot be done, the gland may be pushed into the canal and held there with a truss provided with a suitable obturator, as advised by Curling, or a truss with a con- cave or ring pad to receive the gland, may be employed, as recommended by J. Wood. If a testicle which is retained in the inguinal canal becomes inflamed, the affection may at first sight be mistaken for strangulated hernia, but may commonly be distinguished in the way described at page 776. The treatment consists in the application of leeches, followed by ice or hot fomentations, as most agreeable to the patient, with the internal administration of laxatives and saline diaphoretics. If the gland be subject to repeated attacks of inflammation, the question of excision may properly be considered; the operation is usually successful, but is 1 In the only cases seen by the late J. C. Warren, of Boston, however, the patients were not chimney-sweepers. Fig. 523. Epithelioma of the scrotum. 928 DISEASES OF THE GENERATIVE ORGANS. attended with a certain amount of risk, from the proximity of "the peri- toneum. Excision is always required in case of structural degenera- tion of a retained testicle, and may also be practised when the organ is situated in the perineum, in which position it is constantly exposed to injury. Inversion of the Testicle is chiefly interesting when accompanied with hydrocele, the fluid then being found behind the organ, instead of in front of it, as is usually the case. H. Lee has recorded a curious instance of Temporary Disappearance of the Testicle, the organ having slipped up through the inguinal ring, which was dilated by the presence of a hernia. The patient was directed to go without his truss for a few days, when the missing gland reap- peared. Dr. Humphry refers to a case in which the organ similarly vanished, during the act of masturbation, but in this instance the dis- appearance was unfortunately permanent. Orchitis. Orchitis, or Inflammation of the Testicle, may result from traumatic causes, from rheumatism, from mumps, or from the spread of gonor- rhceal or other inflammation from the urethra. In the latter cases the epididymis is commonly the part primarily affected, constituting the affection known as Epididymitis, Hernia Humoralis, or Swelled Tes- ticle, which has already been described at page 425. The symptoms of orchitis are those of inflammation in general, the pain being very intense, and often radiating up the course of the spermatic cord. There is usually effusion into the tunica vaginalis (acute hydrocele), and there is often a great deal of constitutional disturbance. The treatment is essentially the same, no matter what may be the origin of the affec- tion. When the symptoms are very acute, I know of nothing which will afford such rapid relief as the puncture of the tunica albuginea, in the way recommended by Vidal (de Cassis) and H. Smith. In less acute cases, it may be sufficient to confine the patient to bed, and to keep the scrotum elevated and covered with cold lead-water and laudanum. Laxatives and anodyne diaphoretics, followed at a later period by quinia, may be administered inter- nally. In chronic cases, in which the enlargement of the organ continues after the subsidence of all acute symptoms, strapping of the testicle may be resorted to with advantage. This may be done with simple adhesive plaster, or with the plaster of ammoniac and mercury if there be any suspicion of a syphilitic taint. Strapping the Testicle.—The scrotum having been carefully washed and shaved, the surgeon draws the skin of the affected side upwards, so that the part which covers the testicle is tensely stretched over the organ. A strip of plaster is then applied circularly above the gland and drawn pretty closely, so as to isolate the part and prevent the other strips from slip- ping. These are now applied, in an imbricated manner, alternately in a longitudinal and transverse direction, until the whole organ is covered in and firmly and evenly compressed, no one strip, however, being drawn strapping the testicle, so tightly as to produce excoriation. Wheu properly Fig. 524. NEURALGIA OF THE TESTIS. 929 applied, the effect of strapping in promoting absorption, and thus re- ducing the size of the part, is very striking. The dressing commonly requires renewal every day or every other day, and upon each occasion the scrotum should be well washed with Castile soap and water, so as to keep the skin in a healthy condition. Abscess and Hernia of the Testicle.—Abscess is an occasional sequel of orchitis, the pus being usually formed in the tissues of the scrotum rather than in the testicle itself, but sometimes originating beneath the tunica albuginea, in the proper gland structure. In the former case the affection is of but little consequence, the abscess healing without difficulty after the evacuation of its contents; but when the testicle itself is the Fig. 525. seat of suppuration, a fistulous opening is apt to remain, through which a portion of the seminiferous tubules may protrude, in the form of a vascular, fungoid mass. The treat- ment of this Hernia of the Testis, as it is called, consists in the topical use of stimulat- ing astringents, such as the red oxide of mer- cury, with pressure—which may be applied with adhesive strips, or, better, as recom- mended by Syme, by making elliptical inci- sions around the protruding mass and loosen- ing the surrounding integument, which is then united over the protrusion with sutures—thus Hernia of the testicle. making the skin of the part exercise the requisite compression. If one testicle only be affected, and the patient's health begins to fail under the long continuance of the dis- ease, castration may occasionally be justifiable. Neuralgia of the Testis. The seat of pain may be the epididymis, the body of the testicle itself, or tbe spermatic cord. The part is usually extremely sensitive to the touch, and there may be slight swelling without any evidence of posi- tive disease. The pain is often of a paroxysmal character. The affec- tion is sometimes associated with an irritable condition of the urethra, and with the occurrence of involuntary seminal discharges. In other cases it depends upon the existence of varicocele, or may be sympa- thetically excited by hemorrhoids. Often, however, neuralgia of the testicle exists without any apparent cause. The treatment consists in removing any source of irritation that can be discovered, and, in cases of obscure origin, in the administration of tonics and antispasmodics, and in the topical use of sedatives and anodynes. Gal van ism has occa- sionally proved serviceable in these cases. Castration has been recom- mended, and is often desired by the patient. It is, however, an unjusti- fiable operation under these circumstances, as being totally uncalled for in cases of local origin, and only capable of affording temporary relief, if any, in those of a constitutional nature. Hydrocele and Hematocele. Hydrocele of the Tunica Vaginalis, or simply Hydrocele, consists in a collection of serous fluid in the tunica vaginalis. Several varieties of 59 930 diseases of the generative ORGANS. the disease are described by surgical writers, as the congenital, the ac- quired, and the encysted hydrocele. Inguinal hydrocele is a name used by Holthouse for hydrocele occurring in connection with an undescended testis. Congenital Hydrocele results from an imperfect closure of the communication between the tunica vaginalis and the peritoneal cavity. This form of hydrocele is observed in infants, and may be recognized by the fluid flowing back into the abdominal cavity when the scrotum is elevated or compressed. Congenital hydrocele usually undergoes a spontaneous cure by the closure of the vaginal process of peritoneum; if, as often happens, the hydrocele be accompanied with hernia, a truss should be worn to prevent the descent of the intestine. Should a con- genital hydrocele not disappear spontaneously, discutient remedies, such as a lotion containing muriate of ammonia, or the tincture of iodine (diluted), may be applied to the scrotum, or acupuncture may be tried, or the fluid may be evacuated with an exploring trocar and canula, and a little alcohol injected while compression is maintained upon the in- guinal canal. This plan, which is recommended by Richard, is, however, necessarily attended with some risk of peritonitis. Acquired Hydrocele may originate in an attack of orchitis, which, as has been mentioned, is usually accompanied with effusion into the tunica vaginalis, but more commonly begins as a chronic affection, some- times following a blow, but often being assignable to no particular cause. It may occur at any age, but is probably most common in infants, and in adults about the middle period of life. The symptoms are swelling, beginning at the lower part of the scrotum, and attended with a sensation of weight and dragging, but rarely with pain. The swelling is at first (usually) soft, fluctuating, and elastic, but ultimately becomes tense and hard, and assumes a pear-like shape which is very characteristic. The size varies from that of a hen's egg to that of a large orange, sometimes even exceeding the latter measurement. As the swelling creeps up the cord to the external abdominal ring, it covers over and partially conceals tbe penis. The diagnosis can usually be made without difficulty, by noting the pyriform character of the tumor, and by observing that the swelling of hydrocele is translucent when examined by transmitted light. For this test the patient should be in a dark room, and the surgeon should grasp the neck of the hydrocele with one hand, so as to put the integument on the stretch, while the edge of the other hand is applied to the convexity of the swelling so as to shade it from side rays; arlighted candle or lamp being then held by an assistant close behind tbe tumor, this will in the large majority of cases be found translucent. Tmis test may, how- ever, occasionally fail, either from the dark color of the contained liquid, or from the thickness of the superincumbent tissues ; under sucrRcircum- stances an exploratory puncture or incision may be required to reveal the true nature of the affection. For the diagnosis from hernia, see page 776. The fluid of a hydrocele varies in quantity in different casfes, the amount being usually from six ounces to a pint, but occasionally reach- ing to several quarts; it is commonly of a straw color and limpid, and is albuminous, coagulating sometimes into a solid mass when heated; in other instances it is of a dark brown color, from the admixture of blood, and it then usually contains cholestearine. In some rare cases it coagu- lates spontaneously. The tunica vaginalis, or Sac of the Hydrocele, and hydrocele. 931 its other coverings, are usually thinned by distension, but otherwise normal; in some cases, however, the sac is thickened—becoming the seat of a pseudo-membranous formation which may send prolongations across the cavity in the form of bands or septa—or more rarely undergoes calci- fication ; in these cases the resulting pressure may cause atrophy of the testicle, but in most instances this organ is normal or slightly enlarged. The position of the testis, in hydrocele, is almost always at the lower and posterior part of the scrotum, but it may occasionally be in front (from congenital inversion of the organ), or its position may be altered by the formation of adhesions between the opposing surfaces of the tunica vaginalis. The position of the testis should always be, if possible, ascertained (by examination with transmitted light) before resorting to operation. The two tunicae vaginales are affected with about equal fre- quency, and double hydrocele is occasionally observed ; in this case the existence of a communication with the abdominal cavity may always be suspected. The treatment of acquired hydrocele may be either palliative or radi- cal. In infants and young children, a cure may often be effected by the application of discutients, or by acupuncture, as in the congenital form of the affection; and, even in adults, a single tapping (which constitutes the palliative mode of treatment) will occasionally afford permanent relief, though, more commonly, the effusion returns after each tapping, the hydrocele re-acquiring its original size in the course of a few months. Occasionally the intervals between the successive returns of the disease become gradually longer, until, after repeated tappings, the affection ulti- mately disappears. Tapping a Hydrocele, or the Palliative Operation, is attended with very little risk, though, in aged subjects, death may occasionally follow from the occurrence of diffuse inflammation of the connective tissue of the part. The surgeon, having determined the position of the testicle, grasps the hydrocele with his left hand so as to make the skin tense, and choosing a point which is at the opposite side from the gland, and free from subcutaneous veins, introduces, with a quick plunging motion, a small trocar and canula, at about the junction of the middle and lower thirds of the scrotum. The instru- ment should be at first thrust di- Fig. 526. rectly backwards, but as soon as the point has entered the sac should be inclined in an upward direction (Fig. 526), so as to avoid wounding the testicle—an accident which, though rarely followed by any evil result, should, if possible, be avoided. The trocar is then withdrawn, when the fluid escapes through the canula, and is caught in any convenient recepta- cle. The operation is attended with very little pain, and the patient need not therefore be etherized; he may be placed in the recumbent position, or,' which I prefer, if the hydrocele is not a very large one, may sit on the edcre of a high chair, or stand, leaning against a table. The surgeon Bhouldexamine his trocar before using it, to make sure that it has a good Tapping for hydrocele; a, introduction of tro- ar ; b, position of canula. 932 diseases of the generative organs. point, and that it fits and slips easily in the canula; from neglect of this precaution, I have seen a surgeon introduce his instrument, and then find that the trocar could with great difficulty be extricated from the canula into which it was firmly rusted. After the withdrawal of the canula, a piece of sticking-plaster may be put over the puncture, but no further after-treatment is required. The palliative treatment may be properly employed if the patient cannot spare the requisite time from his ordinary avocations to undergo the operation for the radical cure, and in the case of very old or feeble men who might illy support the risk of the operation. Simple tapping may also be employed once or twice as a preliminary to the radical treatment, which is most apt to succeed when the disease is in a chronic condition. Radical Treatment of Hydrocele.—Various operations are per- formed with a view of effecting a permanent cure of hydrocele, those most worthy of mention being the methods by injection, by the-forma- tion of a seton, by incision, and by excision of the tunica vaginalis. 1. Injection.—The fluid of the hydrocele having been evacuated with the trocar and canula, some irritating substance may be injected through the latter, so as to excite inflammation in the tunica vaginalis. The modus operandi of injections, in cases of hydrocele, appears to be in most cases the formation of inflammatory lymph, which glues together more or less completely the opposing surfaces of the sac; in some instances, however, no adhesions have been found on dissection, and the cure has appeared, therefore, to be due to some intangible change in the tunica vaginalis itself. The injection treatment is very rarely followed by suppuration. Various substances have been employed for the injection of hydrocele, the best being the tincture of iodine, as originally sug- gested by Sir J. Ranald Martin. Some surgeons use the tincture largely diluted, allowing the injected fluid to flow out again through the canula before the latter is withdrawn; but Syme's plan, which I have always followed, and which, when properly carried out, almost never fails, is to inject a small quantity of the pure tincture (f5j to iij, according to the size of the swelling), and allow it to remain in the sac. The injection may be made with an ordinary penis syringe; or, which is more con- venient, a gum-elastic bag with a nozzle and stopcock ; and it is better to use a platinum canula instead of one made of silver, as the latter metal may be corroded by the contact of the iodine. After the injec- tion, the canula should be cautiously withdrawn, so as to prevent the escape of the fluid, which should then be diffused over the whole sur- face of the sac by giving the part a shake. A good deal of pain usually follows the operation, and the scrotum commonly swells to its original size in the course of a few days, the swelling then gradually subsiding until the cure is complete. In this stage of the treatment, the progress of the cure may be hastened by systematically strapping the part with adhesive plaster. The patient should be confined to bed, or at least to a lounge, for two or three days; but after that may resume his ordinary occupations. 2. The Seton.—Should the injection treatment fail (which, I may re- peat, will very seldom happen if the surgeon use the pure tincture of iodine, and allow it to remain in the sac), the next best plan is to estab- lish a seton. This may conveniently be done by replacing the trocar in the canula, after evacuating the contents of the sac, and then making a counter-puncture from within outwards; the trocar is now withdrawn, and an eyed-probe, carrying two or three strands of silk, passed through hydrocele of the spermatic cord. 933 the canula, which is finally removed, leaving the threads in place. The ends are then loosely knotted and the patient sent to bed. The threads may, in most instances, be removed the next day, or the day after; but occasionally must be left a week or even longer, to produce the required amount of inflammation. The use of wire was recommended by Simp- son, with the expectation that it would be less apt to excite troublesome suppuration than the seton made with silk. The experience of surgeons generally has, however, shown that such is not the case, while it has been found that the wire seton is by no means a certain remedy. 3. Incision.—This consists in laying open the sac and stuffing the wound with lint, so as to induce suppuration. Though an efficient mode of treatment, this is in most cases unnecessarily severe, and is not entirely free from risk. It is particularly adapted to cases in which the thickness of the sac prevents the diagnosis from being made by the ex- amination with transmitted light; if such a case be really one of hydro- cele, the incision will suffice for its cure, while, if it turn out to be one of solid tumor, the wound can be utilized for the operation of castration. 4. Excision.-—This consists in laying open the sac, and carefully dis- secting out the tunica vaginalis. If the operation succeeds, the cure is necessarily permanent; but the procedure is a dangerous one, and should be kept as a last resort for cases that resist all other modes of treatment. Encysted Hydrocele (Spermatocele)—In this affection the fluid is not contained, properly speaking, in the tunica vaginalis, but in an independent cyst projecting from the surface of the testicle, or more commonly from the epididymis. In the latter case, the fluid of the cyst differs from that of an ordinary hydrocele in being watery or milky, and in containing spermatozoa ; and the name spermatocele is therefore properly applied to these, which belong to the class of seminal cysts (see p. 463). Those comparatively rare specimens of encysted hydrocele, however, in which the cyst projects from the body of the testis, cannot be so classed, as they do not appear to contain spermatozoa—their fluid being of a serous character like that of the common hydrocele. The diagnosis of the encysted, from the other forms of hydrocele, can usually be made by observing the position of the testis in relation to the sac, which, in the encysted variety of the disease, commonly projects from the surface of, but does not surround the gland. The treatment is the same as for the ordinary acquired hydrocele. Fibrous or Fibro-cartilaginous bodies are sometimes found in the sac of a hydrocele; they resemble in structure the rice-like bodies found in synovial bursae, and, if recognized during life, may be removed by a simple incision. Hydrocele of the Spermatic Cord.—Three varieties are described by systematic writers, viz.: (1) the simple hydrocele of the cord, which consists in an accumulation of serous fluid in the cavity which often persists in the funicular portion of the vaginal process of the perito- neum ; (2) the encysted hydrocele of the cord, in which the fluid is contained in an independent cyst developed in this situation; and (3) the diffused hydrocele of the cord, a rare affection, referred to by Pott and Scarpa which appears to consist in an oedematous infiltration of the areolar tissue of the part. For the diagnosis of hydrocele of the cord from hernia see page 776. The treatment of the simple and encysted 934 DISEASES OF THE GENERATIVE ORGANS. varieties, consists in tapping, followed, if necessary, by the injection of iodine, or the formation of a seton. For the diffused hydrocele__if any treatment were required—the external use of iodine or other sorbe- facients might be resorted to. • Hematocele.—Of this there are three varieties, viz.: (1) haematocele of the tunica vaginalis, consisting in an effusion of blood into this sac, and often supervening upon an ordinary hydrocele; (2) encysted haematocele, in which the blood is effused into the sac of an encysted hydrocele ; and (3) haematocele of the cord, in which the effusion occupies a position corresponding to that of a hydrocele of this part. Haematocele may result from traumatic causes—such as a blow or squeeze, or possibly the wound of a small vessel inflicted in the operation for hydrocele—or may originate spontaneously from the rupture of a spermatic vein. In the spontaneous cases, which are comparatively rare, the haematocele some- times attains a very large size, and the affection is, under these circum- stances, attended with considerable danger. The blood of a haematocele is at first of course fluid, and may continue in this state for many years; in other cases, it undergoes partial coagulation, the clots sometimes assuming a laminated arrangement like that seen in the sac of an aneu- rism ; or the blood corpuscles may become disintegrated, when the fluid of the haematocele has a dark and grumous appearance, and often con- tains cholestearine; if decomposition of the blood occurs, suppuration of the sac may ensue, and perhaps lead to fatal consequences. The symptoms are much the same as those of hydrocele, except that the part is not translucent when examined by transmitted light. The diagnosis, in the early stages of the affection, can commonly be made by observing that the swelling occurs rapidly, and usually after a blow— and yet is obviously not due to orchitis—while the absence of translu- cency, and the existence of ecchymosis, serve to distinguish the affection from hydrocele. When haematocele has passed into a chronic condi- tion, the diagnosis is more difficult, and in many cases the disease has been mistaken for cancer, and vice versa. Humphry points out that the cancerous testis steadily increases in size, while the growth of a haematocele is irregular, and the swelling sometimes even undergoes diminution. The diagnosis from hernia has already been given at page 776. Treatment.—In many cases haematocele undergoes a spontaneous cure; the hemorrhage ceases, and absorption then gradually occurs as in the case of blood effused in other parts of the body. Hence, in the early stages of the affection, the treatment should be merely palliative, consisting in the enforcement of rest, with elevation of the scrotum, the application of cold, etc. After a few days, the patient may go about with a suspensory bandage. If, however, the haematocele be in a chronic state, tapping may be resorted to, and will occasionally effect a cure; should the sac refill, its contents will probably be thinner and more serous than at first, and the case will thus gradually become assimilated to one of hydrocele, when it may be treated with iodine injections. If the haematocele contain a large proportion of coagulum, it will probably be necessary to lay the sac open and allow it to heal by granulation. This should not, however, be done during the early stages of the affection, particularly in a case of the spontaneous variety, lest dangerous or even fatal hemorrhage should take place from the ruptured vein, which is sometimes very much enlarged. Before either puncturing or incising a haematocele, the surgeon should, if possible, determine the position of the testis: this cannot be ascertained, as in the case of VARICOCELE. 935 hydrocele, by examination with transmitted light, but much information may often be gained by tracing clown the cord, and by noting the sensa- tions of the patient, who usually experiences a characteristic, sickening pain when pressure is made on the testicle. Varicocele. Varicocele, or Cirsocele {varicose enlargement of the veins of the sper- matic cord), is a very common affection, existing, according to Hum- phry, in about ten per cent, of all male adults. The causes of varico- cele are those of varix in general; the anatomical peculiarities of the spermatic veins render them particularly susceptible to the affection, which is chiefly seen in those of lax and feeble habit, and is often heredi- tary. Varicocele is much more frequently seen on the left side than on the right: this appears to be due to a combination of causes, such as the position of the left testicle, which is usually more dependent than the right; the obstacle to the return of blood which exists on the left side, from the left spermatic vein joining the renal vein at a right angle, instead of opening directly into the vena cava, as is done by the right spermatic vein; the comparative deficiency of valves in the left spermatic vein as compared with the right (first pointed out by Dr. J. H. Brinton, of this city); and the exposure of the left spermatic vein to pressure, from accumulations of fecal matter in the sigmoid flexure of the colon. Symptoms.—Varicocele forms a pyramidal swelling in the scrotum, with its base downwards, and its apex extending upwards towards the inguinal canal. The swelling has a peculiar knotted and convoluted feel, and the sensation conveyed to the hand is often compared to that which would be given by a bunch of earthworms. The tumor increases when the patient stands or walks, and almost if not quite disappears when he lies down. It is sometimes, but by no means always, attended with a feeling of weight and even pain, which is increased by exercise, and is apt to be worse in summer, when the scrotum is more relaxed and pendulous than at other seasons. Varicocele sometimes attains a considerable size, filling the scrotum and enveloping the testicle, which may undergo diminution in bulk from the pressure of the overlying veins. Rupture of a varicocele may occur from a blow or other injury, causing great effusion of blood; Erichsen mentions a case of this kind in which, the tumor having been opened, the patient died from venous hemorrhage. The diagnosis of varicocele from hernia (the only affection with which it is likely to be confounded) has been given at page 776. Treatment.__In the large majority of cases, no treatment whatever is required; the patient may wear,ail elastic suspensory bandage, to support the part and relieve the feeling of weight which sometimes accompanies the affection, but even this apparatus is in many instances voluntarily thrown aside. To lessen the capacity of the scrotum, its lower part may be drawn through a soft metallic ring covered with leather or one of vulcanized India-rubber; this plan, which was sug- gested by Wormald, would certainly be attended with less risk than that by which it appears to have been suggested, viz., excision of the lower portion of the scrotum, as recommended by Cooper and Briggs, and more recently by M. H. Henry, of New York, who has devised an 936 DISEASES OF THE GENERATIVE ORGANS. ingenious clamp for the prevention of hemorrhage during the operation. But the best palliative remedy for varicocele is, I think, the application of a light truss, as recommended by Curling, so as to break the column of blood in the spermatic veins (without compressing the artery), and thus remove the pressure from the dilated vessels. Radical Cure of Varicocele.—In a few cases, more energetic mea- sures may be required; a great many operations beside that of Cooper, above referred to, have been proposed for the radical cure of varicocele, the best, probably, being those of Ricord, Vidal (de Cassis), H. Lee, and J. Wood. (1.) Ricord's Method consists in introducing subcutaneously, in oppo- site directions but through the same apertures, two double ligatures, one beneath the spermatic veins (isolated from the vas deferens), and the other above them, so that there shall be a loop and two ends of liga- ture on each side ; the ends are then threaded through the corresponding loops, and attached to a light yoke provided with a screw, by daily turning which they are constantly drawn tight—thus effectually strangu- lating and ultimately cutting through the veins, from which the ligatures drop in the course of the second or third week. (2.) Vidal's Operation consists in passing a steel pin perforated at both ends below the veins and between them and the vas deferens, and through the same apertures a silver wire above the veins, and between them and the skin; the wire is threaded through the perforations at each end of the pin, which is then .rotated in such a way as to twist the wire and roll up and firmly compress the veins. The wire is twisted more and more tightly each day until the veins are cut through (usually at the beginning of the second week), when the pin and wire are easily with- drawn together. (3.) Lee's Method consists in passing two Vidal's operation for vari- needles beneath the veins, and between them and coceie. the vas deferens, about an inch apart—pressure being then made by means of elastic bands passed over the extremities of the needles. The veins, which are thus acu- pressed at two points, are next divided subcutaneously between the needles, which may be removed on the third or fourth day after the ope- ration. Should the division of the veins be followed by bleeding, which may happen from some vessel being cut that was not included by the needles, the hemorrhage can be readily arrested by the introduction of a third needle—below the point of division if the bleeding be venous, and above, if it be of an arterial character. (4.) Wood's Method is an ingenious modification of Ricord's, in which the veins are surrounded subcutaneously with a metallic ligature; the ends of the ligature pass through and are secured to a light instrument, containing in its handle a spring, by the action of which the wire is constantly drawn tight. These operations (of which Lee's seems to me upon the whole the best) are all attended with some risk, and can only be justifiable in exceptional cases. sarcocele and tumors of the testis. 937 Sarcocele and Tumors of the Testis. Sarcocele is a general term, commonly but rather unfortunately applied to all solid enlargements of the testicle. Surgeons speak of several varieties of sarcocele, as the simple, the tuberculous or scrofulous, the syphilitic, the cystic, and the malignant. Simple Sarcocele is the chronic enlargement of the testis which results from inflammation of the organ. The affected gland is moderately increased in size, smooth and rather hard to the touch, though occa- sionally semi-fluctuating in parts, and somewhat painful and tender; the cord also is, in most cases, thickened and indurated. When cut into, the testis is found to be infiltrated with lymph in various stages of organization or fatty degeneration, the latter condition giving the appearance of yellowish spots which are often mistaken for tubercle. Suppuration occurs in some cases, and may be followed by hernia of the testis. Simple or inflammatory sarcocele is often accompanied with effusion into the tunica vaginalis, constituting Hydro-sarcocele. The treatment consists in strapping the testicle, with the occasional applica- tion of a few leeches, and attention to the state of the general health; hernia of the testis is to be treated as described at page 929. Tuberculous Sarcocele.—A deposit of true tubercle in the testis is, I believe, a less common affection than is ordinarily supposed, many of the cases which are called tuberculous sarcocele being really instances of simple enlargement from chronic inflammation, occurring in persons of a scrofulous diathesis. In the simple inflammatory sarcocele, as remarked by Humphry, the inter-tubular areolar tissue and fibrous septa of the testis and epididymis are first affected, but in tbe disease now under consideration, as shown by the observations of Curling and Sal- leron, the tubular structure itself is primarily involved. Causes.—The causes of tuberculous sarcocele are involved in some obscurity. It is ordinarily said to follow gonorrhoea or sexual excess, or to be due to some traumatic injury of the part; but, according to Salleron (who has published an elaborate memoir on the subject, based upon an analysis of 51 cases), the true tuberculous sarcocele never fol- lows these affections, which are common causes of the simple sarcocele, except as a coincidence. His theory is, that tubercle is deposited in the testis in infancy, as a manifestation of the tuberculous diathesis, but that the affection is not called into activity until after the period of puberty, when the generative organs become subject to functional excitement. Symptoms.—Tuberculous sarcocele commonly begins in the epididy- mis, but ultimately involves the whole testis, forming a large, nodulated, and usually indolent mass. In some cases, however, the enlargement is uniform, smooth, and semi-elastic. In the nodulated variety of the'dis- ease, one or more of the nodules gradually inflame and become adherent to the skin, abscesses forming, and perhaps leading to the occurrence of fungous protrusions, or herniae of the testis, and the greater part of the gland thus being, in some instances, gradually extruded from the scrotum. Both testicles are usually successively involved. The vasa deferentia, vesiculae seminales, and prostate, are often simi- larly affected, and the patient may present evidences of phthisis, or of scrofulous disease of the lymphatic glands or other organs. The affec- tion may be complicated with hydrocele. 938 DISEASES OF THE GENERATIVE ORGANS. Fie. 528. Treatment.—The treatment consists in attention to the state of the general health, in regulation of the diet, and in the administration of cod-liver oil, iron, iodine, etc. The patient should live as much as pos- sible in the open air. The part should be supported in a well-fitting suspensory bandage, and advantage may be derived from the occasional application of iodine, or of local sedatives if there be much cutaneous inflammation. Humphry recommends that, in very bad cases, the sinuses should be laid open, the scrofulous matter turned out, and the parts stimulated to healthy action by the application of nitrate of silver. Castration can be justifiable only when the general health is evidently suffering from the drain caused by the local affection. Syphilitic Sarcocele, in both of its varieties, has already been de- scribed (p. 447). The treatment is that of syphilis in general—mercury being particularly applicable in the early or " interstitial," and iodide of potassium in the late or "gummy" form of the disease. Cystic Sarcocele.—This, which was called by Sir Astley Cooper the " Hydatid Testis," belongs to the fibro-cystic variety of tumor (see p. 469). The cysts themselves originate, as shown by Curling, in dilatations of the tubes of the rete testis, and may be classified according to the na- ture of their contents, as serous, sanguineous, or cutaneous proliferous cysts. The cystic sarco- cele is often associated with cartilaginous growths, and occasionally with medullary cancer. Diagnosis.—Cystic sarcocele is very seldom met with in persons under 20 years of age, and may commonly be distinguished from hydrocele (the affection with which it is most likely to be con- founded) by observing its shape, which is globular rather than pyriform, and its want of translucency when examined with transmitted light. From ma- lignant sarcocele it may be distinguished by its slower growth, and the absence of glandular im- plication and of cachexia. In some instances, however, the diagnosis can only be made by puncturing the growth with a trocar and canula— when, if the case be one of cystic sarcocele, a few drops of serous fluid will probably be evacuated by each puncture, from the successive opening of different cysts—or even by microscopical examination after removal. Treatment—This consists in castration, which may be performed as soon as the nature of the case has been ascertained. Cystic sarcocele. Congenital Dermoid Cyst.—Another form of cystic disease of the testicle is the congenital dermoid cyst, which usually contains bone, teeth, or hair, and is believed by many writers to be an example of the mal- formation known as "foetal inclusion." Cases of this affection, which is one of great rarity, have been recorded by several surgeons, among others by Prof. Van Buren, of New York. In the case observed by this distinguished surgeon, the patient, a child 2| years old, had been treated (for what was supposed to be a hydrocele) by the establishment of a seton, which led to much suppuration and the protrusion of a large fungous mass. The treatment consists in castration, unless, as occa- MALIGNANT SARCOCELE. 939 sionally happens, the growth be entirely external to the testicle, when excision of the tumor alone would be sufficient. Other Non-malignant Growths are occasionally found in the tes- ticle, as the fibrous, fibro-cellular, cartilaginous, etc. The diagnosis from the simple and syphilitic forms of sarcocele, with which alone they are apt to be confounded, can be made by watching the effect of remedies, which, in the case of tumor, would of course be negative. The treatment con- sists in castration. Fatty tumors have been observed in the spermatic cord, from which situation they may be removed by excision. Malignant Sarcocele, or Cancer of the Testis, is almost always of the encephaloid variety, though both scirrhous and mela- notic growths have been occasionally met with in this organ. In malig- nant sarcocele the body of the testis is usually first involved, and the organ, when cut into, exhibits masses of medullary cancer, in various stages of growth or degeneration, often mingled with cysts or cartila- ginous nodules. The affection may occur at any age, but is most common in youth and early adult life. The symptoms are the presence of a rapidly growing solid tumor—its growth is much more rapid than that of any other form of sarcocele— the mass being smooth, and at first uniformly firm to the touch, but after- wards soft, elastic, and semi-fluctuating in spots, with enlargement of the scrotal veins, and ultimately turgescence and thickening of the cord. The deep iliac and lumbar lymphatic glands are involved at an early stage of the disease, the inguinal glands not being affected until a later period. The tunics of the testis become very much distended by the enlarging tumor, and ultimately give way—when the growth becomes adherent to the scrotum; ulceration then follows, and allows the pro- trusion of a fungous mass. This stage of the disease is comparatively seldom seen at the present day, because the nature of the case is recog- nized, and castration resorted to, at an earlier period. The growth is attended with very little pain at any time, and the general health of the patient does not suffer in the early stage, though cachexia is ulti- mately developed. One testicle only is commonly affected. The diagnosis from the other forms of sarcocele can usually be made by observing the very rapid growth of the tumor, its unilateral character, the enlargement of the scrotal veins, and the want of benefit from treatment; but the diagnosis from cystic sarcocele is often impossible until after removal, and even then without careful microscopical ex- amination. From opaque hydrocele and from haematocele, malignant sarcocele may be distinguished by observing its weight and the sense of fluctuation which it affords in spots, and, if necessary, by an exploratory incision ; this is better than puncture with a trocar, because, as pointed out by Humphry, the quantity of blood which flows through the canula from an encephaloid testicle may be so great as to lead to the supposi- tion that the case is one of haematocele. The prognosis is very unfavorable, death commonly taking place within two years, from the implication of the deep-seated glands, and from the occurrence of secondary deposits in the lungs and other viscera. The only treatment which offers the slightest hope of benefit is cas- tration and this operation is, as a rule, justifiable only in the early stages of the affection, before the pelvic and lumbar glands have become 940 DISEASES OF THE GENERATIVE ORGANS. involved—a point which can be determined by careful palpation of the abdomen. Castration.—The operation of castration, or removal of a testicle, is thus performed : The part having been shaved, and the patient etherized, the surgeon grasps the posterior part of the tumor with his left hand, so as to make the scrotum tense in front; a longitudinal incision is now made from opposite the position of the external abdominal ring to near the bottom of the scrotum, which is then peeled off, as it were, by a few strokes of the knife, until the gland hangs merely by the spermatic cord. The division of the cord is the Fig. 529. most important part of the ope- ration; this may be conveniently done with the ecraseur, but may be equally well accomplished with the knife—bleeding in the latter case being prevented by previously ligating or acupress- ing the cord en masse; or the cord may be firmly held by an assistant, and its arteries tied separately after division. The precise point at which the cord is divided is of no consequence in the excision of non-malignant growths, and hence the surgeon may, if it be found more con- venient, secure the cord before completing the dissection of the tumor. In castration for ma- lignant disease, however, it is Division of spermatic cord in castration. important to CUt the COrd at as high a point as possible, and in these cases it is therefore better to dissect out the testicle, and carry the dissection up to the abdominal ring—then transfixing the cord with a double ligature, tying it in two halves, and dividing it a little lower down, in the way already described. It is sometimes recommended that an elliptical portion of the scrotum should be removed, if the tumor be large ; but the skin of this part shrinks so much after the operation, that such a course can rarely be necessary. The after-treatment consists in simply bringing the edges of the wound together, with or without stitches, as may be preferred, and in applying cold water dressing. Functional Disorders of the Male Generative Apparatus. Impotence may result from several different conditions, of which some are, while others are not, remediable. 1. Malformation or Mutilation of the Genital Organs may cause im- potence, occasionally curable by operation (see page 920), but more commonly irremediable. 2. Debility of the Nervous Centres, following severe illnesses, or at- tendant upon diseases in which the general nutrition is impaired, may render the patient temporarily or permanently impotent. The treatment consists in the adoption of means to improve the general health, the SPERMATORRHOEA. 941 exhibition of tonics, such as iron, quinia, strychnia, and phosphorus, sea-bathing, etc. 8. Traumatic or other Lesions of the Cerebro-Spinal Nervous System. —Impotence from this cause is commonly permanent; the treatment would be that of the particular affection to which the impotence was due. 4. Temporary, or rather imaginary impotence, may arise from Mental Perturbation or Over-excitement. This condition is chiefly met with in first attempts at coitus, whether sanctioned or not by the matrimonial tie. The affection is, I believe, never permanent. 5. Morbid Excitability of the Genital Organs, attended with involun- tary semiiral emissions (spermatorrhoea), occasionally gives rise to im- potence, and is a very intractable affection, simply because it is often impossible to prevent the continued activity of the causes to which it is originally due. The commonest cause of this condition is probably onanism ; though it may also arise from premature or excessive indulg- ence in venery—and is kept up by impure habits of thought or conversa- tion, reading obscene books, or gloating over lascivious pictures—while in its milder forms it may originate from irritation of neighboring organs, as the bladder or rectum. Seminal Emissions are by no means necessarily a sign of disease; indeed, during early manhood, an occasional discharge of spermatic fluid during sleep, is an almost unavoidable attendant upon virtuous celibacy; but when the emissions occur in the day as well as at night, and are very frequently repeated, they certainly indicate an unnatural state of debility and irritability of the sexual apparatus. In the worst cases the patient is rendered impotent, by the emission taking place without any or with such slight erection that penetration is impossible. Spermatorrhoea, as this affection is called—rather unfortunately, for the seminal flux is a mere symptom—is chiefly met with between the periods of puberty and early adult life, and is most common in young men of feeble frame and of sedentary habits. In advanced stages the patient's general health suffers, and he often falls into a state of great mental depression. At the same time, there can be no doubt that, in many cases, ill health and various nervous affections, such as epilepsy or insanity, are attributed without sufficient reason to morbid excita- bility of the genital organs and to onanism—when in point of fact the supposed causes are really the effects; physical debility often exists where the sexual appetite is fully if not inordinately developed, and an excitable disposition, or an ill-balanced mind, renders its possessor less able to resist temptation, and more apt to fall into habits at which the moral sense revolts, than he who is blessed with both a healthy body and a healthy mind. The frightful pictures drawn by Tissot, Alibert, and other writers are no doubt strictly correct; but the unfortunate victims whose histories they narrate were not insane from onanism, they were onanists because they were insane. The diagnosis of spermatorrhoea from chronic prostatitis (prostator- rhcea) is readily made by microscopic examination of the discharge (see page 880). , .. . . . L . The treatment, as far as the use of remedies is concerned, consists in diminishino- the'irritability of the genital organs, and in improving the general condition of the patient. The food should be abundant, but wholesome and particular care should be taken not to overload the stomach at ni*ht- alcoholic stimulants and spices should, as a rule, be avoided The* patient should take plenty of exercise in the open air, 942 DISEASES OF THE GENERATIVE ORGANS. walking being better than riding or driving, as the motion of the horse or carriage sometimes excites the venereal orgasm; he should sleep on a hard mattress—lying on either side rather than on the back—and should not be too warmly covered. Tonics, especially iron, quinia, strychnia, phosphorus, and occasionally cantharides, may be administered with ad- vantage, while cold hip-baths, the cold douche or shower-bath, and sea- bathing (if this can be procured) will also prove of service. Bromide of potassium may be given in a full dose at bedtime, and will often procure sound rest, undisturbed by seminal emissions; the hydrate of chloral has been recently recommended for the sarfie purpose. The application of nitrate of silver in substance or solution (gr. xx-xl to H§j) to the prostatic and bulbous portions of the urethra, may be of service in cases in which these parts are found by external pressure to be morbidly sen- sitive; the application may be made with a porte-caustique or syringe- catheter (as in cases of chronic prostatitis), and may be repeated at inter- vals of ten days or two weeks. The course of treatment above described is addressed to the morbidly irritable condition of the genital organs, and may be employed with every prospect of success, provided that the causes of that condition have ceased to act, or can be removed. In cases originating in irritation of neighboring parts—as from hemorrhoids, from the presence of ascarides, or from an abnormal condition of the urine—this can be readily done; but when the unnatural irritability of the generative apparatus is kept lip by constant excitation of the part, whether physical or mental, the prognosis is less favorable, because the removal of the cause is more diffi- cult. Chastity in thought as well as deed is necessary to insure recovery; but to attain this grace requires a prolonged struggle with temptation, which needs all the patient's fortitude and resolution. The treatment in these cases must be more moral than physical, and even when a purely physical cause, such as onanism, is to be dealt with, surgery offers reme- dies of but doubtful efficacy ; the application of blisters to the penis, or the operation of circumcision, may be of use in compelling at least a suspension of a bad habit; but the benefit will be evanescent, unless the moral nature of the patient can be reached in the interval. In their despair at continual relapses, victims of onanism have, it is said, occa- sionally made Abelards of themselves, with the hope that they would thus effectually banish temptation ; and surgeons, even, have been in- duced to castrate their patients, in obedience to the earnest solicitations of the latter. The operation has, however, in the large majority of cases, proved as unsuccessful as it is unphilosophical; there is no reason to believe that the testes are particularly at fault, and the disease is in all cases more of the mind than of the body; moreover, the gain to the moral nature of the individual is not in cowardly fleeing from, but in manfully resisting temptation. The benefit which has been apparently derived, in some instances, from this heroic mode of treatment, has been, in all probability, such merely as might have been obtained from any great and sudden shock to the nervous system. The surgeon is occasionally called upon for an opinion as to whether an individual, who has suffered from frequent seminal emissions, and who, perhaps, fears that he is in consequence impotent, may properly enter into matrimonial engagements. The question is rather a delicate one, and no rule can, of course, be given which would be of universal application; but it may probably be safely said, that though, if under- taken merely with the selfish hope of effecting a cure for himself, with- out regard for the happiness of his partner, marriage will, in all proba- DISEASES OF THE FEMALE GENITALS. 943 bility, disappoint the man's expectations, yet the happy circumstances of a union founded on mutual preference and pure affection, will offer the very best prospects of recovery. Sterility in the male may exist in connection with impotence, or independently. It most frequently arises from some local source of obstruction to the passage of the spermatozoa—as from induration and thickening of the globus minor as the result of epididymitis, or from urethral stricture—but may also depend upon retention of* the testes within the abdominal cavity, upon absence of spermatozoa from the semen, or upon obscure changes in the chemical constitution of that fluid, the nature of which is not very well understood. The only hope of cure would be in the removal of any disease of the genito-urinary apparatus which might be detected. DISEASES OF THE FEMALE GENITALS. The limits of this volume will merely admit of a brief reference to those diseases of the Female Generative Apparatus which require opera- tive, or distinctively surgical, treatment; nor is a more extended account of these affections here necessaiy, for the whole subject properly belongs to the domain of Gynaecology, and is ably discussed in the numerous valuable works on Diseases of Women which are now accessible to the student. Malformations. The external genitals are subject to various malformations of very different degrees of severity. Imperforate Vulva.—This, which is the slightest form of imperfo- rate vagina, consists in a congenital occlusion of the vagina at or just in front of the nymphae. The septum is at first very delicate, and, if the condition is recognized soon after birth, can be readily ruptured.by simply separating the parts with the thumbs, one placed upon each of the labia ruajora, or may be torn across with a probe or director, a strip of oiled lint being interposed to prevent reunion. At a later period a little dissection with the scalpel may be required, but the affection is always readily amenable to treatment. Adhesion of the Vulva is a condition precisely similar to the above, except that it is not congenital, but arises from adhesion of the opposing surfaces of mucous membrane, as tbe result of inflammatory action. The treatment consists in dissecting through the obstruction, and pre- venting its recurrence by the introduction of a tent. Imperforate Hymen.—The hymen may be partially perforate, or completely imperforate. 1. Partially perforate hymen allows the escape of the menstrual fluid, but interferes with sexual intercourse—the thickness and rigidity of the membrane preventing penetration. In some instances pregnancy has occurred in spite of this obstacle, and the condition of parts has been first recognized from the effect of the dense hymen in hindering partu- rition, by°arresting the passage of the foetal head. The treatment of 944 DISEASES OF THE GENERATIVE ORGANS. partially perforate hymen consists simply in incising the part with a probe-pointed bistoury, dilatation being completed by means of a sponge- tent or bougie. 2. Imperforate hymen is a much more serious condition. If it were recognized before the age of puberty, it could be readily remedied by making a crucial incision, and by excising the flaps which would thus be formed; but unfortunately the malformation is seldom discovered until menstruation has repeatedly occurred, and until the vagina and uterus have become distended, sometimes to a great extent, by the accu- mulating secretion—forming a large, elastic, fluctuating tumor in the hypogastrium. The operation for the relief of this condition is easily and quickly performed, but is not unfrequently followed by serious and even fatal consequences. Death may result from endometritis and septi- caemia, clue to decomposition of the uterine contents; or from peritonitis, due to the escape of blood through a laceration of the Fallopian tubes, or even through their natural orifices, into the abdominal cavity. To prevent these accidents, it is recommended by Bernutz and Goupil that the hymen should be punctured with a small trocar and canula, a piece of tubing being attached to the latter, so that the contents of the uterus shall slowly drain away. The puncture should be made eight or ten days after a menstrual period, and no pressure should be made upon the abdomen during the process of evacuation. Imperforate Vagina.—This may vary in degree from the slight affection already referred to as imperforate vulva, up to complete ab- sence of the vagina, accompanied, perhaps, with absence or imperfect development of the uterus. By simultaneous exploration with a sound in the bladder and a finger in the rectum, the thickness of tissue between those parts can be estimated, and, if it be such as to render the existence of the uterus and upper part of the vagina tolerably certain, an effort may be properly made to reach the upper part of the tube during early childhood, when operations on these organs are less dangerous than in adult life. If, however, the bladder and rectum be in such close contact as to render the existence of a uterus doubtful, it will be proper to wait until the period of puberty, when the nature of the case will probably become more evident. In many instances the existence of malformation is not suspected until after puberty, when the attention of the patient and of her friends is aroused by the non-appearance of the menses, although the menstrual molimen may recur at regular intervals. The treatment to be pursued under such circumstances is a matter worthy of the gravest consideration. Any operation in such a case will be attended with considerable risk, and yet if the womb is becoming every month more and more distended with menstrual fluid, an operation is absolutely necessary—for while unrelieved the patient is in constant danger of peritonitis (from leakage backwards through the Fallopian tubes), or even of rupture of the uterus. The treatment of imperforate vagina varies according to the condition of the uterus. (1.) If the presence of an elastic fluctuating tumor in the region of the uterus, perceptible by rectal exploration and by abdominal palpation, shows that there is an accumulation of menstrual fluid in the womb, there can be no question as to the propriety of an operation. It has been proposed to evacuate the uterine contents by puncture with a trocar and canula through the rectum, but, beside the risk of wounding the peri- toneum in such an operation, the relief would probably be but temporary, and re-accumulation would occur. Hence, it is better in such a case IMPERFORATE VAGINA. 945 to attempt the formation of a vagina, by placing the patient in the lithotomy position, and, after making a small transverse incision, work- ing cautiously upwards with the finger and handle of the knife in the septum between the bowel and urethra (taking care not to open either of these), and guiding the dissection by keeping a sound in the bladder, and a finger in the rectum. When the sac containing the menstrual fluid is reached, it should be opened through a speculum with a small trocar, with the same precautions as in the case of imperforate hymen. The size of the newly-formed vagina must be subsequently maintained by the use of a bougie. In Amussat's method, which is preferred in these cases by Bernutz and Goupil, the knife is dispensed with altogether, and the vagina formed by simply stretching the vulvar mucous membrane and pushing apart the rectum and urethra with the fingers; the operation occupies several days, dilatation being maintained in the intervals be- tween the sittings by the introduction of tents. (2.) If there be no uterine tumor, the course to be pursued is more doubtful. The menstrual molimen, it must be remembered, depends upon the ovaries, and not upon the uterus; and a patient may suffer intensely at every monthly period, while having no womb, or at least none capable of menstruating, and therefore no menstrual accumulation. If in a case of this kind it be ascertained by careful rectal exploration, conjoined with abdominal palpation, that there is a well-formed womb— even though not distended—an operation such as was described in the last section might be justifiable, though full of danger from the risk of opening the peritoneal cavity. If, however, it be found that there is no womb, or merely a rudimentary uterus (as in a case which was recently under my care at the Episcopal Hospital), no operation whatever should be performed. A good deal is sometimes said in these cases about fitting a young woman for matrimony, enabling her to be a wife, etc__ but, in point of fact, a woman to whom.nature has denied a womb can never be adapted for marriage, though she may be fitted for prostitu- tion. The surgeon's art may, indeed, enable her to be a man's mistress, but can never fit her to be his wife and the mother of his children. Prof. Gross speaks none too strongly when he says that, in such cases, "nothing is to be done . . . ; the woman is impotent, and therefore dis- qualified for marriage." Non- Congenital Obliteration of the Vagina results from adhesion of the vaginal walls after sloughing or severe inflammation ; it is most common in married women after labor, but may occur in young girls or children. The diagnosis from congenital absence of the vagina can be readily made by simultaneous rectal and vesical exploration, which will, in a case of non-congenital obliteration, reveal the existence of a dense septum, three-quarters of an inch or more in thickness—whereas, in a case of imperforate vagina, the instrument in the bladder and the finger in the rectum seem almost to be in apposition, and are evidently separated by a very thin layer of tissue. The treatment of the affection now under consideration consists in endeavoring to re-establish the canal, by cautious dissection between the urethra and rectum in the way already mentioned. The operation is attended with a great deal of danger, but is the only resource—and becomes imperatively necessary, when the uterus is distended by the menstrual accumulation. 60 946 DISEASES OF THE GENERATIVE ORGANS. Surgical Diseases of the Vulva. Hypertrophy of the Labia Majora is usually an inflammatory condition, depending, as in the case of the lips, upon the presence of a fissure or excoriation, and slowly disappearing when that is healed. Hypertrophy of the Labia Minora is occasionally met with, resembling anatomically what has been described as the "fibro-cellular outgrowth." In warm climates this condition is comparatively common, and in some localities is said to be almost universal. The treatment, when the hypertrophy increases so much as to produce annoyance, consists in excision; this operation is sometimes attended with a good deal of hemorrhage, which may be conveniently arrested, as advised by Hutchinson, by transfixing the base of the labium with harelip pins and applying figure-of-8 ligatures, so as to acupress the pedicle, as it were, en masse. Hypertrophy of the Clitoris is usually, I believe, the result of constitutional syphilis. The organ sometimes attains a very large size, and produces a great deal of irritation, requiring excision, which may be performed either with the knife or with the ecraseur. The bleeding in this operation maybe quite profuse, and may possibly require the application of the actual cautery. Excision-of the Clitoris, or Clitoridectomy, has been most unphilo- sophically proposed and practised-as a remedy in cases of epilepsy and insanity. The operation has been forcibly and properly condemned by the almost unanimous voice of the profession. Vegetations, the so-called venereal warts, are often seen upon the vulva, and require extirpation with the knife or scissors. Tumors of various kinds are met with in the labia, the most com- mon being the cystic tumor, though fatty, fibrous, and vascular growths are also met with in this situation. Two kinds of cyst are met with in the neighborhood of the.labium ; one consists in a dilatation of Cow- per's gland, and is curable by making a simple incision, and stuffing the cavity with lint, while the other is a serous cyst, which is developed in the labium itself, and sometimes attains a very large size. The treatment of the latter consists in excision, the operation requiring a rather troublesome dissection, and being attended with a good deal of bleeding, which can, however, always be checked by pressure and the use of a T bandage. Fibrous and fatty tumors of the labium also re- quire excision, while naevi in this part may be conveniently treated by ligation. Hydrocele of the Canal of Nuck is a rare affection, which was referred to in speaking of pudendal hernia (page 186). The treatment consists in the formation of a seton, or in the injection of iodine. Malignant Disease of the External Genitals may be primary— in which case it is usually epitheliomatous—or secondary to cancer of the vagina or uterus, either of the scirrhous or enceplialoid variety. The vulva is also, sometimes, the seat of rodent ulcer. The sole treatment for any of these affections is excision, which is, however, only justifiable when the disease is so limited as to admit of complete extirpation. SURGICAL DISEASES OF THE VAGINA. 947 Vulvitis, in whatever way arising, presents the same symptoms, and demands the same treatment, as when of gonorrhceal origin. (See page 427.) Noma Pudendi has already been referred to at page 389. Surgical Diseases of the Vagina. The Speculum is an instrument constantly required for exploration of the upper part of the vagina and the cervix uteri. For ordinary purposes, the best instruments are the simple cylindrical speculum, made of glass, coated like a mirror with quicksilver or tinfoil, and covered with India-rubber (Fig. 530), and the bivalve speculum, of which the best form is that known as Cusco's (Fig. 531). For special cases, other Fig. 531. Cylindrical speculum. Cusco's speculum. instruments may be required, such as the duck-billed speculum (Fig. 511), either in its original form, or with the ingenious modifications of Emmet, Pallen, Thomas, and others; Thomas's telescopic speculum; Ellis's expanding speculum; or the somewhat similar ingenious con- trivances of Dr. Albert H. Smith and Dr. J. S. Hough, of this city. The speculum should always be introduced (well warmed and oiled) under cover of the patient's garments or bedclothes, without any expo- sure of the person. For ordinary examinations, the obstetric position on the left side will be satisfactory, but for the application of caustics, removal of polypi, etc., it will usually be more convenient to place the patient on her back, with the lower limbs separated and supported upon chairs. The introduction of the speculum may be conveniently effected by separatino- the vaginal walls with the fore and middle fingers of the left hand and slipping in the instrument beneath and between them. Painful Ulcer or Fissure of the Vagina.—This affection is closely analogous to the painful ulcer of the rectum or anus, and re- quires precisely similar treatment. (See page 806.) Polvnoid Growths, belonging to the class of fibro-cellular tumors, are occasionally met with in the vagina, and may be treated by avulsion 948 diseases of the generative ORGANS. (if the pedicle is very small), ligation, the ecraseur, or the wire loop and galvanic cautery. Cystic and other Tumors in the walls of the vagina are to be treated as similar affections of the vulva. Prolapsus of either the front or back wall of the vagina, may take place, constituting, in the former case, a variety of hernia of the blad- der or cystocele, and, in the latter case, a similar condition of the rec- tum, rectocele. In most instances, sufficient relief may be afforded by the use of a suitable pessary or bandage, but occasionally a more radical measure may be required; this may consist in denuding a circular strip of the vagina near its orifice, and bringing the sides together with su- tures, so as to obtain adhesion of the labia majora for the lower three- fourths of their extent, or, if the case be complicated with prolapsus of the uterus, in denuding a longitudinal strip on either side of the vagina, and then bringing the raw surfaces together, so as to reduce the calibre of the canal through its entire length. The former operation is known as Episiorrhaphy, and the latter as Elytrorrhaphy. Vaginismus is the name given by Sims to an affection which con- sists in a hyperaesthetic condition of the nerves distributed to the vagi- nal mucous membrane at the position of the hymen, leading to a spas- modic contraction of the sphincter vaginae muscle, which renders coitus intensely painful, and, indeed, usually impossible, and thus practically makes the patient sterile. The spasm of the sphincter may be elicited by the slightest touch of the finger, or even of a camel's hair brush. Vaginismus may be an idiopathic affection occurring in persons of a hysterical temperament, or may be due to some local cause, such as fissure of the vagina or rectum, papillary tumor of the meatus, inflam- mation of the womb or vagina, eczema or prurigo of the vulva, neuralgic tumors, etc. The treatment consists in removing the cause, if this can be ascertained, and in the administration of tonics, and the local use of sedatives. Attempts may be made to relieve the spasm by the use of vaginal dilators, or, if necessary, by a resort to operative treatment. The simplest operation for vaginismus consists in sudden dilatation or partial rupture of the sphincter vagina? muscle, effected by introducing the thumbs and forcibly separating them (the patient being etherized), as in Kecamier's and Van Buren's method of treating fissure of the anus. If this fail, the remains of the hymen may be excised, and the sphincter partially divided by a deep incision on either side of the peri- neal raphe (as recommended by Sims), or the pudic nerve maybe cut—by direct incision, as originally recommended by Burns—or subcutaneously, as preferred by Simpson. These operations sometimes afford only tem- porary relief, and the constitutional treatment appropriate to neuralgia must therefore not be neglected after their employment. Tumors of the Uterus. Fibrous or Fibro-muscular Tumors (Uterine Fibroids, Myo- mata).—These, which are the most common of the uterine tumors, may occupy any portion of the structure of the womb. They may project on the outer surface of the organ beneath its peritoneal investment; may grow inwards, filling the uterine cavity, and perhaps descending through the vagina and protruding between the labia; or may be developed in the tumors of the uterus. 949 midst of the uterine wall. They are classified according to their situa- tion into subserous or sub-peritoneal; submucous; and interstitial or intermural fibroids. They are but loosely attached to the surrounding tissues, and sometimes attain a very large size. In the majority of cases palliative treatment only is required; it is somewhat doubtful whether the absorption of uterine fibroids can be obtained by medical treatment, but they certainly seem to disappear spontaneously in some instances; or they may become detached, and may be expelled by the contractions of the womb. In cases of small submucous fibroids near the cervix uteri, excision or avulsion maybe practised, but if the growth be attached by a somewhat narrow pedicle (constituting the fibrous polypus of the uterus), it will usually be better to remove the tumor by means of the ecraseur, for the chain of which a wire rope may be substituted, as recommended by Braxton Hicks. The ecraseur may be applied by the aid of the ingenious "porte-chaine" of Dr. Marion Sims; or the simpler form of instrument devised by Dr. Emmet, may be substituted; or a ligature may be first thrown around the pedicle with a double canula, and the chain of the ecraseur subsequently drawn into place. Fibro-cellular uterine polypus with long pedicle. In the case of interstitial growths, enucleation has been resorted to by Amussat, Atlee, Fordyce Barker, and others. The operation con- 950 diseases of the generative organs. Fig. 533. sists in dilating or incising the cervix uteri, laying bare the tumor by cutting through its capsule, and then turning it out of its bed with the fingers or suitable instruments. This procedure has not unfrequently proved fatal, from hemorrhage, peritonitis, or pyaemia, and, though doubt- less justifiable in exceptional cases, cannot be recommended as a general mode of treatment. Mr. I. Baker Brown has modified this operation by simply incising the tumor, or even the mouth and neck of the uterus, so as to destroy the vitality of the growth, and promote its expulsion by sloughing. According to Braxton Hicks, an intermural fibroid may sometimes be converted into a polypus by the administration of ergot. Subserous uterine fibroids have, in a number of instances, been removed by abdominal section, the operation sometimes involving the extirpation of the entire uterus and both ovaries (see page 824). This mode of treatment under any circumstances is replete with danger, and can only be justifiable in exceptional cases. Polypi of the UteruS usually belong to the fibro-cellular or myxo- matous varieties of tumor, and are often very vascular, and accompanied with an increased develop- ment of the glandular struc- tures of the part. The hard or fibrous polypus, a variety of the uterine fibroid, has already been referred to. Polypi are usually attended by more or less profuse hem- orrhage, which exhausts the patient and urgently de- mands surgical interference. The treatment consists in effecting the extrusion of the polypus from the uterus by drawing it down with for- ceps, or, if this cannot be clone, by dilating or incising the neck of the womb and administering ergot, and in then dealing with the growth by excision, avulsion, liga- tion, or the use of the ecra- seur, in the way already mentioned (page 949). It may be occasionally neces- sary to attack the polypus while still within the uterus, but the operation is under such circumstances attended with great danger. Amputation of the neck of the uterus by means of the Myeloid and ReCUr- tcraseur. a. Shows the neck of the organ dragged to the rent Fibroid TuniOlS vulva by means of forceps, e, d. The chain of the instru- (Spindle-Celled Sarcomata) ment passed round the part at its base. have been occasionally ob- amputation of the cervix uteri. 951 served in the uterus; the treatment would consist in excision, if the growth could be entirely extirpated without too much risk to the patient. Malignant Tumors of the Uterus may be either cancerous or epitheliomatous. Cancer of the uterus is usually of the encephaloid variety, though scirrhous and colloid growths are also met with in this organ ; the treatment should be merely palliative, total extirpation being almost impossible, and partial excision worse than useless. Epithelioma commonly attacks the os and cervix uteri, and may appear in one of two forms, viz.: as the so-called " corroding ulcer," or as the " cauliflower excrescence." The treatment consists in amputation of the neck of the uterus, if the affection be recognized sufficiently early to allow of com- plete extirpation, or, if not seen until a later period, in cauterization of the surface of the growth with caustics or the hot iron. Amputation of the Cervix Uteri may be performed by the aid of cutting instruments, by means of the ecraseur (Fig. 533), or by the use of the wire loop and galvanic cautery. When the first method is resorted to, the part to be removed should be fully exposed by means of a duck-billed speculum; the neck of the womb is then slit up on either side, and its lips successively excised with suitable scissors, the uterine mucous membrane being finally drawn forward (as advised by Sims), and attached to that of the vagina, by means of silver sutures. The subjects of Lacerations of the Female Perineum, Vaginal Fistulas, Ovarian Tumors, and Diseases of the Mammary Gland, have already been referred to in previous portions of the volume. INDEX. ABDOMEN, contusions of, 365 injuries of, 365 operations on, 816 tapping the, 816 wounds of, 368 Abdominal abscesses, 826 aneurism, 550 muscles, rupture of, 365 organs, diseases of, 816 parietes, abscess of, 365 tourniquet, 130 Abernethy, ligation of external iliac artery, 202, 552 ossification of muscle, 502 Abortion from injury to pregnant uterus, 376 Abortive treatment of gonorrhoea, 422 Abrasion, 40 Abscess, acute or phlegmonous, 378 chronic or cold, 381 disappearance of, by absorption, 380 hemorrhage into, 381 metastatic or multiple. See Pysemia. residual, 382 after arthritis, 576 varieties of, 378 Abscess, abdominal, 826 of abdominal parietes, 365 alveolar, 711 of antrum, 713 areola of breast, 734 in auditory meatus, 676 biliary, 826 of bone, 558 breast, 735 cornea, 639 fecal or stercoraceous, 827 of frontal sinus, 696 gum, 711 hepatic, 826 iliac, 632 ilio-pelvic, 827 intra-cranial, trephining for, 319 mammary, 735 mediastinal, 242, 356 of orbit, 674 ovarian, 827 palmar, 503 beneath pectoral muscle, 355 perineal, 425 perinephritic, 826 Abscess — perityphlitic, 827 of prostate, 880 psoas, 632 retro-pharyngeal, 725 spinal, 632 splenic, 826 subperiosteal, 554 of testis, 929 tongue, 707 urethral, 425 Abscission of staphyloma, 642 Absorbents, inflammation of. See Angeio- leucitis. Absorption, interstitial, 45, 47, 560 of spine. See Antero-posterior curvature. of lymph, 38 purulent. See Pyaemia. of pus, in abscesses, 380 Accommodation of ear, 685 eye, 662 Accumulator for making extension, 577 Acetabulum, fracture of, 242 perforation of, in hip disease, 580 Acetic acid in cancer, 488 Acorn-pointed bougies, 889 Acritochromacy. See Color-blindness. Acromion, fracture of, 248 Actual cautery, 86 Acupressure, 187 in amputation, 98 aneurism, 540 comparison of, with torsion and liga- ture, 189 modes of applying, 187 modified, 189 repair of arteries after, 189 in secondary hemorrhage, 193 statistics of, 190 Acupuncturation, 86 in aneurism, 545 for radical cure of hernia, 750 in ununited fracture, 235 Adams, anchylosis of hip, 590 arthritis, chronic rheumatic, 585 club-foot, 621 et seq. ectropion, 670, 671 loose cartilages in joints, 591 repair of tendons, 287 Adapting power of ear, 685 954 IND EX. Addison, T., keloid, 497 Addison, W., origin of pus cell, 40 Adelmann, gastrotomy for foreign bodies, 372 intestinal obstruction, 792 Adenitis, 501 Adenocele. See Glandular tumor. Adenoid tumor, 474. See Glandular tumor. vegetations of nose and pharynx, 689 Adenoma, 474. See Glandular tumor. Adhesion, union by, 141 secondary, 142 of vulva, 943 Adhesions in hernia, 747, 766 ovariotomy, 822 Adhesive plaster, 146 antiseptic, 150 Age, influence of, on results of operations, 64 Agnew, C. R., capsular cataract, 655 mucocele, 674 Agnew, D. H., apparatus for hip disease, 582, 583 radical cure of hernia, 751, 778 ruptured perineum, 377 vaginal fistulse, 915,918 Air in veins, 171 Air-passages, diseases of, 731 foreign bodies in, 345 treatment, 347 Alse nasi, restoration of, 693 Alanson, mode of amputating, 91 Albugo, 640 Albumen in blood, in inflammation, 36 Albuminous degeneration, 231 Alibert, keloid, 497 Alison, iodine injections for ovarian cysts, 820 Allarton, median lithotomy, 861, 862 Allen, osteo-myelitis of tibia, 557 syphilitic disease of skull, 449 Allies, internal urethrotomy, 903 Allingham, colotomy, 793, 794 fistula in ano, 805 prolapsus of rectum, 815 Alliot, urethroplasty, 914 Alopecia, syphilitic, 444, 446, 457 Alteratives in inflammation, 62 Alternating calculus, 832 Althaus, galvano-puncture in aneurism, 545 Altmiiller, ligation of internal iliac artery, 552 ■ Alveolar abscess, 711 cancer. See Colloid. Amaurosis, 656 from extra-ocular causes, 661 treatment of, 662 Amber cataract, 649 Amblyopia. See Amaurosis. Ametropia, 663 Amoebaform or amoeboid movement of cells, 37 Amputation, 90 causes of death after, 111 conditions requiring, 91 contraction of tendons after, 106 Amputation— dressing stump after, 103 elongation of bone after, 105 hemorrhage (secondary) after, 106 history of, 90 instruments used in, 93 intermediate, 109 mortality after, 107 compared with excision, 595 operative procedures used in, 99 relative merits of, 103 position of surgeon in, 99, 101 primary or immediate, 109 results of, circumstances which influ- ence, 107, 108, 109 secondary or consecutive, 109 during shock, 136 v simultaneous or synchronous, 103 statistics of, 108, 109, 110, 111 stumps, affections of, after, 105 Amputation for aneurism, 545 subclavian, 548 for arthritis, 577 burn, 300 cancer in bone, 569 caries, 561 deformity, 109 dislocation, compound, 274 fracture, badly united, 232 compound, 228, 229, 232 ununited, 235 frost-bite, 303 gunshot injury, 164 hemorrhage, secondary, 194 hospital gangrene, 393 joint wounds, 211 lacerated wounds, 151 necrosis, 565 onychia, 497 osteo-myelitis, 558 tetanus, 515 traumatic gangrene,-151 ulcer, 387 Amputation at ankle, 122 of arm, 116 cervix uteri, 950, 951 at elbow-joint, 116 of fingers, 113 foot, 119, 123 forearm, 115 hand, 112, 114, 115 at hip-joint, 128, 131. 607 knee, 126 knee-joint, 125, 126 of leg, 123 metatarsus, 120 penis, 926 above shoulder, 119 at shoulder-joint, 117 eub-astragaloid, 121 of thigh, 126 through trochanters, 127 tarsus, 121, 123 thumb, 114 toes, 119, 120 at wrist-joint, 115 INDEX. 955 Amussat, colotomy, 793 imperforate vagina, 945 torsion, 80 uterine fibroids, 949 Amygdaline chancre, 443 Amyloid degeneration, 231 Anaesthesia, history of, 74 local, 79, 80 various modes of producing, 74, 75, 79, 80 Anaesthetics, 72 cases in which they may be used, 73 in cataract operations, 650 death from, 76 in dislocations, 272 effects of, 75, 76 erotic dreams produced by, 80 in fractures, 220 precautions in use of, 75 results of operations, how influenced by, 73 in strangulated hernia, 761 treatment of dangerous effects of, 76 Ankyloblepharon, 672 Anchylosis, 586 bony, 587 treatment of, 589 continuous extension in, 587, 588 of elbow, 590 false, 587 fibrous, 586 excision in, 589 of hipr 589, 590 jaws, 720 from burns, 301 knee, 588, 590, 591 passive motion in, 587 rupturing adhesions in, 588 of shoulder, 590 in spine disease, 630 of stapes to fenestra oyalis, 685 treatment of, 587 Andrews, apparatus for hip disease, 582, 604 Anel, operation for aneurism, 535 Aneurism or aneurisms, 526 amputation for, 93 by anastomosis, 519, 520 arterio-venous, 545 bruit of, 530 causes of, 527, 528 cirsoid. See Arterial varix. death from, modes of, 534 diagnosis of, 532, 533 diffused, 532 dissecting, 527 erosion of bones by, 531 fusiform, 526 after gunshot wounds, 169 hernial, 196 intra-cranial, from embolism, 528 miliary, in apoplexy, 528 number of, 528 orbital, 674 osteoid, 570 pressure-effects of, 531 irism— pulsation in, 530 racemose. See Aneurism by anasto- mosis. rupture of, 534 sac of, 529 sacculated, 526, 527 secondary, 537 size of, 528 special. See the particular Arteries. spontaneous cure of, 533, 534 structure of, 529 in stumps, 106 symptoms of, 529, 530, 531 terminations of, 533 thrill of, 531 traumatic, 195, 196 after tenotomy, 624 treatment of, 534 by acupressure, 540 acupuncturation, 545 amputation, 545 caustic, 545 compression, 540 advantages and disadvan- tages of, 543 digital, 542 instrumental, 541 rapid, 542 flexion, 544 galvano-puncture, 545 injection of coagulating liquids, 545 ligation, 535 accidents after, 537, 538 on cardiac side, 535 distal side, 539 effects of, 536 failure after, 536 indications and contra-indi- cations, 539 manipulation, 544 medical, 534 by " old operation," 535 strangulation, 546 wire coil, 545, 546 of particular. See special Arteries. tubular, 526 varicose, 197 varieties of, 526 venous, 170 Aneurismal diathesis, 528 needle, 181, 182 varix, 196 non-traumatic, 545 in stumps, 106 Angeioleucitis, 500, 501 Angeioma, 475, 519 Anger, displacement in fractured clavicle, 217 Angular displacement in fractures, 217 extension in dislocated hip, 293 Animals, rabid, bites of. See Bites. Ankle, amputation at, 122 diseases and injuries of. See under Joints. 956 IND EX. Ankle— dislocation of, 295 excision of, 211, 611 for gunshot injury, 167 fracture of, 267 weak, 625 Ankylosis. See Anchylosis. Annandale, excision of tongue, 710 Annular stricture of urethra, 897, 898 Anodynes in inflammation, 58, 62 Anterior splint, Smith's, 261, 262, 266 Antero-posterior curvature of spine, 629 Anthrax. See Carbuncle. Antimony in inflammation, 61 Antiseptic adhesive plaster, 150 collodion, 146 lac, 150 ligatures, 98 treatment of wounds, 149 Antiseptics in inflammation, 59 Antrum, diseases of, 713 Antyllus, operation for aneurism, 535 Anus, artificial. See Fistula, fecal. fissure of, 805, 806 fistula of. See Fistula in ano. imperforate, 795 malformations of, 795 malignant disease of, 801 neuralgia of, 816 occlusion of, 795 pruritus of, 816 sacciform disease of, 815 ulcer of, painful, 806 Aorta, aneurism of abdominal, 550 thoracic, 546 compressor for, 96, 130 ligation of, 201, 550 wounds of, 364 Aphakia, 663 Aphthous ulceration of penis, 924 Aplastic lymph, 37 Apnea, treatment of, 348, 349 in wounds of neck, 343 Apoplexy of marrow, 556 Aqua Conradi, 635 Arachnitis, erysipelatous. See Erysipelas. traumatic, 311 Arendt, ligation of internal iliac artery, 552 Areola of breast, diseases of, 734 Areolar tissue, diseases of, 500 syphilitic, 448 lesions of, in pyaemia, 408 Arlaud, disarticulation for osteo-myelitis, 558 Arlt, entropion, 670 retinitis nyctalopica, 660 symblepharon, 672 Arm, amputation of, 116 contraction of, 619 Armsby, radical cure of hernia, 751 Arnott, anaesthetics, effect of, on results of operations, 73 cold as an anaesthetic, 79 in cancer, 488 fluid pressure for dilatation of stricture, 902 Arnott— fracture of axis, 330 osteomalacia, 566 perineal section, 906 tongue, extirpation of, by ligation, 710 Aromatic wine, 433 Arrow wounds. See Wounds. Arrows, caustic, in cancer, 489 carbuncle, 394 Arterial pyaemia. See Pyaemia. thrombosis, 173. See Thrombosis. transfusion, 90 « varix, 519 Arteriotomy, 89 Arterio-venous aneurism, 545 wounds, 196 Arteritis, 523 Artery or arteries, acupressure of. See Acupressure. aneurism of. See Aneurism, and spe- cial Arteries. atheroma of, 524 calcification of, 525 constrictor for, 181 contraction and retraction of, 176 contusion of, 173 diseases of, 523 structural, 524 treatment of, 526 fatty degeneration of, 524 forceps for, 97 hemorrhage from, 174 injuries of, 173 ligation of, 185 for inflammation, 59 joint-wounds, 212 lines of incision for, 197 secondary hemorrhage after, 194 occlusion of, 523, 524 gangrene after, 194 from injury, 173 remote consequences of, 195 ossification of, 525 in pyaemia, condition of, 408 ruptured, 173 amputation for, 93 in dislocation, 274, 275 fracture, 227 wounds of, 173 in compound fractures, 229 process of repair in, 176 rules for ligation in, 183 Artery or arteries of arm and forearm, aneu- rism of, 549 axillary, aneurism of, 549 ligation of, 200, 549 brachial, aneurism of, 549 ligation of, 201, 549 brachio-cephalic. See Artery, innomi- nate. carotid, aneurism of, 547 ligation of, 198, 547 cerebral disease after, 538, 547 in excision of upper jaw, 717 wounds of neck, 342 INDEX. 957 Artery— facial, ligation of, 199 femoral, common, acupressure of, 552 aneurism of, 652 ligation of, 203, 552 hemorrhage after, 537 deep, aneurism of, 552 ligation of, 203 superficial, aneurism of, 552 diffused, 553 ligation of, 203, 552 gluteal, aneurism of, 551 ligation of, 202, 551 iliac, common, aneurism of, 550 ligation of, 202, 550 external, aneurism of, 552 ligation of, 202, 552 internal, aneurism of, 551 ligation of, 202, 552 innominate, aneurism of, 546 ligation of, 197, 548 intercostal, hemorrhage from, in chest wounds, 357, 360 injury of, in fractured ribs, 240 intra-cranial, aneurism of, 547 intra-orbital, aneurism of, 547 ischiatic or sciatic, aneurism of, 551 ligation of, 202 of leg and foot, aneurisms of, 553 lingual, ligation of, 199 for malignant tumor of tongue, 711 mammary, internal, hemorrhage from, in chest wounds, 357, 360 obturator, relations of, in femoral her- nia, 782 ' occipital, ligation of, 199 peroneal, ligation of, 205 popliteal, aneurism of, 552 diffused, 553 ligation and compression in, compared, 539, 543, 544 ligation of, 203 rupture of, in fractured knee, 227 pudic, aneurism of, 551 radial, ligation of, 201 sciatic. See Artery, ischiatic. subclavian, aneurism of, 547, 548 ligation of, 199, 548, 549 intra-thoracic inflammation after, 538 temporal, ligation of, 199 thyroid, ligation of, 198 for bronchocele, 704 tibial, ligation of, 204 posterior, rupture of, in fracture of knee, 227 ulnar, ligation of, 201 Arthritis, 573 amputation for, 577 causes of, 575 chronic rheumatic. See Arthritis, rheu- matoid. counter-irritation in, 577 excision for, 577, 578 extension in, 577 forcible straightening of limb in, 576 gelatinous, 573, 574 excision for, 578 of hip-joint. See Hip disease. intervertebral joints, 634 residual abscess after, 576 rheumatoid, 585, 586 of hip, diagnosis of, from fracture, 258 of sacro-iliac joint. See Sacro-iliac disease. suppuration in, 576, 577 symptoms of, 575 tenotomy in, 576 traumatic, 210 treatment of, 576, 577 Articular changes in dislocation, 271 neuralgia, 592 Artificial anus. See Fistula, fecal. limb, adaptation of, 105 membrana tympani, 680 pupil, 648 respiration, 348 Ascites, diagnosis of, from ovarian tumor,- 818 Ashmead, amputation at hip-joint, 129 Asphyxia. See Apnea. Aspiration, continuous, 104 Aspirator for tapping chest, 362 Assistants, duties of, in operations, 71 Asthenopia, 664 Astigmatism, 663 Astragalus, dislocation of, 296 excision of, 612 fracture of, 268 Astringents in inflammation, 58 Atheroma of arteries, 524 Atheromasia, 525 Atheromatous ulcer, 524 Atkinson, ligation of internal iliac artery, 552 Atlee, J. L., double ovariotomy, 824 Atlee, J. L., Jr., rupture of trachea, 344 Atlee, W. F., eructation in aortic aneurism, 531 hydrocele of hernial sac, 748 Atlee, W. L., clamp for ovariotomy, 823 enucleation of uterine fibroids, 949 Atlo-axoid joint, arthritis of, 634 Atony of bladder, 877 Atrophic scirrhus of breast, 740 Atrophy, eccentric, 234 Auditory meatus. See Meatus. nerve, lesions of, 686 Aural polypi, 677 speculum, 676 Auricles, diseases of, 675 malformations of, 675 supernumerary, 675 tumors of, 676 Auzias de Turenne, syphilization, 458 Aveling, vaginal lithotomy, 867 Avery, endoscope, 892 staff for lithotomy, 855 staphyloraphy, 722 958 INDEX. Avery— urethrotomy, external, 907 Avulsion of limbs, 147 amputation for, 91 in reducing dislocations, 274, 275 nasal polypi, 690 toe-nail, 497 Axilla, dislocation of humerus into, 279 Axillary artery. See Artery. glands, management of in excision of breast, 742 Ayres, dislocation of cervical spine, 331 extroversion of bladder, 870 BACK, injuries of, 321 Bader, inoculation for granular lids, 637 Balanitis, 426, 924 Balano-posthitis, 426 Balch, wound of heart, 364 Balfour, diversity of venereal diseases, 420 iodide of potassium in aneurism, 534 Balls, encysted, 169 .Barker, E., extroversion of bladder, 871 Barker, F., enucleation of uterine fibroids, 949 Barlow, secretion of urine in intestinal ob- struction, 789 Bartholow, oil of turpentine in hospital gangrene, 392 Bandages, 80 for eye, 647 Bands, extending, in reducing dislocations, 273 membranous, in tympanum, 684 Bar at neck of bladder, 875 Barbadoes leg, 467, 500 Barometer, state of, influencing results of amputation, 107 Barren cysts, 461. See Cysts. Barton, J. K., phagedaenic chancroid, 432 syphilis, 437, 438 Barton, J. R., anchylosis, operations for, 589, 590 bandage for fractured jaw, 238 bran dressing for compound fractures, 231, 266 excision of lower jaw, 718 fracture of radius, 254 recto-vaginal fistula, 802 Barwell, anchylosis, 589, 590 arthritis, 577 rheumatoid, 585 club-foot, 625 hip disease, 582, 583 lateral curvature of spine, 617 strumous synovitis, 573 umbilical hernia, radical cure of, 770 Basedow's disease. &eeGoitre, exophthalmic Bassereau, syphilis, 420, 438, 440 Bastian, concussion of spinal cord, 323, 329 Baudens, amputation at knee-joint, 125 Bauer, hip disease, 582, 583 recto-vesical lithotomy, 863 Bayard, fracture and exfoliation of cervical vertebra, 332, 634 Baynton, strapping ulcers, 385 Bayonet wounds. See AVounds. Beale, acupressure, 189 arteries, repair in wounded, 177 ophthalmoscope, 657 Beans, interdental splint for fractured jaw, 239 Beck, rupture of trachea, 344 B6clard, amputation at hip-joint, 129 Bed, fracture, 223 Bed-sores, 388 after spinal injuries, 327, 334 Beer, abscission of staphyloma, 642 Bell, B., loose cartilages in joints, 592 venereal diseases, 420 Bell, C, air in veins, 171, 172 cancerous cachexia, 480 internal urethrotomy, 904 Bell, G. H., erysipelas, 401 Bell, J., arteries, rules for ligating, 183 lithotomy, 848, 858 ovariotomy, 821 urethrotomy, internal, 904 Bellingham, compression for aneurism, 540 Bellocq, instrument for plugging posterior nares, 688 Bellows for artificial respiration, 348 Belmas, supra-pubic lithotomy, 864 Beltz, urethral fever, 899 Bending of bone, 208 Benique\ catheter, 889 Bennett, fibro-nucleated tumors, 476 Bent, excision of shoulder-joint, 599 Berend, bony anchylosis of hip, 590 Berger, rupture of trachea, 344 Bernard, fracture of sacrum, 243 Bernutz and Goupil, imperforate hymen, 944 vagina, 945 Bibron's antidote, 154 Biceps tendon, displacement of, 281 division of, 619 Bichloride of methylene as an anaesthetic, 75 Bickersteth, excision of elbow, 601 ligation of common iliac artery, 551 Bigelow, brain, iron bar in, 316 dislocation of hip, 288, 292, 293 voluntary, 270 excision of hip, 603 fracture of acetabulum, 242 cervix femoris, 256, 257 ununited, 235, 236, 599 Y ligament, functions of, 287 Bigg's apparatus for bunion, 506 contracted knee, 588, 589 Bilateral lithotomy, 859 Biliary abscess, 826 fistula, 371 Bill, arrow wounds, 153 carbolic acid for local anaesthesia, 80 Billings, trephining for epilepsy, 319 Billroth, arteries, repair of wounded, 177 atheroma, 524 excision of knee, 609 fractures, union of, 221 inflammation, 36, 38 INDEX. 959 Billroth— neuromata, 508 cesophagotomy, 729 pyaemia, 410 secondary fever, 51 staphyloraphy, 721 suppuration, blue, 39 Bird, secretion of urine in intestinal ob- struction, 789 Birkett,.amputation, causes of death after, 112 aneurism, "old operation" for, 553 auricles, supernumerary, 675 breast, diseases of, 733, 734, 735, 739 exostosis, cancellous, of frontal bone, 474 fracture of acetabulum, 242 hernia, 744 et seq. scrotum, wounds of, 375 Bistoury, 96 Bites of rabid animals, 155 snake, 154 Bivalve speculum, 947 Black, use of vaginal suppositories in gon- orrhoea, 427 Black cataract, 649 Blackman, anchylosis of knee, 591 aneurism, 544, 546 dislocations, reduction of old, 275 fracture of patella, 263 Bladder, absence of, 868 atony of, 877 complicating lithotrity, 847 bar at neck of, 875 calculus of. See Calculus, vesical. cancer of, 875 catarrh of, 874 clots in, 876 diseases of, 868 malignant, complicating lithotrity, 847 structural, 874 exploration of. See Sounding. extroversion or exstrophy of, 868 etseq. fistulae of. See Fistulae. foreign bodies in, 374 hemorrhage from, 876 hernia of, 749, 872. calculus in, 868 inflammation of. See Cystitis. after spinal injuries, 326 injuries of, 373 inversion of, 872 irritability of, 873, 879 malformations of, 868 malpositions of, 872 missing the, in lithotomy, 855 neuralgia of, 879 paralysis of, 877 puncture of, 885, 886, 887 for stricture, 910 rupture of, 373 from retention of urine, 910 sacculated, 874 complicating lithotrity, 847 spasm of, 879 Bladder, spasm of— in lithotomy, 856 stone in. See Calculus, vesical. tubercle of, 875 tumors of, 875 washing out the, after lithotrity, 844 wounds of, 373 Blandin, harelip, 703 resection sound, 596 Blear-eye. See Ophthalmia tarsi. Bleeding piles, 807 Blennorrhagia. See Gonorrhoea. Blennorrhcea, 421 of lachrymal sac. See Mucocele. Blepharospasm, 639 Blind fistula in ano, 803 urinary, 913 piles, 807 Blindness, nervous, 656 Blisters in gonorrhoea, 424 indolent ulcers, 385 Blizard, compression of aneurism, 540 Blood calculi, 831 in inflammation, 36 loss of. See Hemorrhage. in pyaemia, 408 transfusion of, 89 Bloodletting, 87, 89 in inflammation, 59, 60 lung wounds, 359 strangulated hernia, 761 Bloodvessels in inflammation, 35 injuries of, 169 in pyaemia, 408 Bloxam, dislocation tourniquet, 273, 292 Blue pus, 39 Blum, pyaemia, 404 Boeck, syphilization, 458 Boeckel, arrested development in joint dis- ease, 594 excision of elbow, 601 external urethrotomy, 907 Boggie, hospital gaugrene, 392 Boil. See Furuncle. Boinet, iodine injection for ovarian cysts, 820, 821 Boker, excision of lower jaw for necrosis, 713 Bond, splint for fracture near elbow, 252 of radius, 255 Bone, abscess of, 558, 559 aneurism in, 570 atrophy of, 566 bending of, 208 cancer of, 568 caries of. See Caries. contusion of, 168, 208 cysts of, 568 death of. See Necrosis. decalcification of, 555 diseases of, inflammatory, 553 non-inflammatory, 566 eburnation of, 555 elongation of, after amputation, 105 excision in continuity of, 167 exfoliation of, 562 960 INDEX. Bone— fracture of. See Fracture. gangrene of. See Necrosis. mephitic, 562, 563 hemorrhage from, 104 hydatids in, 568 hypertrophy of, 566 injuries of, 208 medullization of, 554 necrosis of. See Necrosis. osteo-porosis of, 555 in pyaemia, 408 rarefaction of, 555 in rickets, 418 sclerosis of, 555 scrofula of, 416, 567 suppuration in, 557, 558 syphilitic affections of, 449, 568 tubercle in, 567 tumors in, 568 pulsating, 570 ulceration of. See Caries. Bone-earth calculus, 830 Bone-nippers, 97 Bonnet, tenotomy in club-foot, 622 hip disease, 582- Bony anchylosis, 587, 589 Borborygmus in hernia, 748 Borelli, staphyloma, 643 Bouchon, 176 Bouchut, irreducible hernia, 752 Bougie, Eustachian, 682 medicated, 424 oesophageal, 728, 730 rectal, 799 urethral, 889 Bouillaud, pyaemia, 412 Bouisson, deformities of penis, 920 Bourdelot, direct pressure in aneurism, 540 Bourgeois, malignant pustule, 395 Bouton. See Malignant pustule. Boutonniere operation for urethral stric- ture, 905, 906, 908 Bowditch, empyema, 361 paracentesis thoracis, 362, 363 perinephritic abscess, 825, 827 Bowel. See Intestine. Bow-legs. See Genu-extrorsum. Bowman, instruments for eye, 654, 655, 673 operations on eye, 642 et seq. Boyer, fissure of anus, 806 fracture of scapula, 247 hydrocele of hernial sac, 748 spinal cord, injuries of, 322, 324 stricture of urethra, 906 Bozeman, transverse obliteration of vagina, 918 urinary vaginal fistulae, 914 et seq. Brachial artery. See Artery, brachial. Brachio-cephalic artery. .See Artery, innomi- nate. Brachymetropia. See Myopia. Bracketed splint, 262, 610 Braidwood, pyaemia, 404, 412 Brain, aneurism in. See Arteries, intra- cranial. compression of. See Compression. concussion of. See Concussion. congestion of, from injuries of chest, 356 contusion of, 306 foreign bodies in, 316 fungus of, 627 hernia of. See Hernia cerebri. inflammation of, 311 injuries of, 306, 316 in pyaemia, 408 syphilitic affections of, 448 wounds of, 316 Brainard, anchylosis of knee, 591 fracture, badly united, 232 ununited, 235 ligation of common iliac artery, 551 spina bifida, 629 Bran dressing for compound fracture, 231, 266 Brander, puncture of bladder through sym- physis pubis, 887 Brasdor, operation for aneurism, 540 Breast, abscess of, 735, 737 cancer of, 740 cysts of, proliferous, 738 simple, 737 diseases of, 733 in male, 743 excision of, 741 gathered, 735 hydrocele of, 738 hypertrophy of, 733 inflammation of, 735 milk-tumor of, 733 neuralgia of, 737 painful subcutaneous tubercle of, 739 sero-cystic sarcoma of, 738 strapping the, 736 tumor of, glandular or adenoid, 739 irritable, 477, 739 sero-cystic, 737 Brett, elephantiasis of scrotum, 925 Bridle stricture, 897 Briggs, varicocele, 935 Brinton, J. H., amputation at knee-joint. 125, 126 hospital gangrene, 392 paralysis after gunshot wound, 169 sternum, anatomy of, 241 varicocele, 935 Brinton, W., intestinal obstruction, 788, 790 Bristowe, pyaemia, 406, 408, 410 Broadbent, acetic acid for cancer, 488 bloodletting in aneurism, 534 Broca, aneurism, application of ice in, 535 by anastomosis, 520 innominate, 546 astragalus, excision of, 296 Brodhurst, congenital dislocations, 276 Brodie, bone, abscess in, 659 bunion, 507 calculus, urinary, 839 et seq. head, convulsions in injuries of, 312 INDEX. 961 Brodie— incontinence of urine in children, 878 joint diseases, 570, 573, 577, 593 prostate, enlarged, 881, 883, 885 rectum, diseases of, 800, 805 sero-cystic sarcoma, 463, 738 tumor, 737 spasm of urethra, periodic, 895 spine, injuries of, 324 et seq. white gangrene, 396 Bromfeild, abscess in bone, 559 dislocation of shoulder, 282 Bromine in hospital gangrene, 392 Bronchitis in throat wounds, 343 Bronchocele, 703, 704 Bronchotomy, 350, 351, 352 Brown, fistula, recto-vaginal, 802 urinary vaginal, 915, 918 ovariotomy, 823 ruptured perineum, 377 uterine fibroids, 950 Brown-Sequard, bed-sores, 389 neuroma, 508 reflex paralysis, 206 spinal injuries, 325, 332 Bruise. See Contusion. Bruit in aneurism, 530 Bruns, aneurism by anastomosis, 520 supra-pubic lithotomy, 864 Brush-burn, 151 Bryant, acupressure, 189 amputation, 109, 112 calculus in female, 867 colotomy, 793 ovarian cyst, suppurating, 827 spine, dislocation of, 330 spleen, extirpation of, 826 strangulation, internal, 70S torsion, 180 urinary vaginal fistulae, 915 Bubo, chancroidal, 431, 433 gonorrhoeal, 424 parotid, 705 primary, 432, 442, 501 syphilitic, 441 Bubon d'emblee. See Bubo, primary. Bubonocele. See Hernia, inguinal. Buchanan, cheiloplasty, 699 lithotomy, 854, 862 stricture of urethra, 902 Buck, anchylosis of jaw, 301 knee, 590 excision of knee, 609 laryngeal growths, 732 scapula, 598 prolapsus of tongue, 707 weight extension for fractured thigh, 259 Buffy coat of blood in inflammation, 36 Bujalski, ligation of innominate artery, 548 Bullet forceps, 163 wounds, 158 Bullock, clasp for fractured jaw, 239 Bumstead, gonorrhoea, 421, 423 mercury in primary syphilis, 453 stricture of urethra, 898, 903 61 Bunion, 506 Buphthalmos, 641 Burge, oesophageal forceps, 353 Burges, fracture-bed, 223 Burning pain in nerve injuries, 206 Burns, vaginismus, 948 Burns and scalds, 297 amputation for, 92, 300 anchylosis of jaw from, 301 cicatrices of, 300 keloid in, 302 duodenal ulcer in, 298 of mouth, pharynx, and glottis, 345 treatment of, 299, 300 Burow, plastic operation, 696 Burrall, excision of os calcis, 613 Burr-head drill-, 561 Bursa, hyoid, hygroma of, 706 Bursae, diseases of, 505 injuries of, 208 Busch, excision of scapula, 598 Bushe, needle and needle-carrier for piles, 812 Buszard, staphyloraphy in children, 721 Butcher, amputation at hip-joint, 130 burns, operation for cicatrices of, 301 convulsions after operations in chil- dren, 700 excision of elbow, 601 knee, 608, 609, 610 forceps, knife-bladed, 596, 597 fractured femur, 261 harelip, 702, 703 saw for excisions, 121, 596 Button cautery, 85 suture, 917, 918 Button-hole fracture. See Fracture. By ford, urinary vaginal fistula, 915 CACHEXIA, cancerous, 480 Caecal hernia, 749 Caesarean section, 825 Calcaneum, dislocation of, 296 excision of, 613 fracture of, 268 Calcareous deposits in membrana tympani, 679 Calcification of arteries, 525 Calcis, os. See Calcaneum. Calculus, lacteal or mammary, 733, 734 nasal. See Rhinolite. prostatic, 866, 888 renal, 831 nephrotomy for, 825 urethral, 865 urinary, varieties of, 828 blood, 831 carbonate of lime, 831 cystine, 830 fatty, 830 fibrinous, 831 fusible, 830 mulberry, 829 oxalate of lime, 82'J phosphatic, 830 962 INDEX. Calculus, urinary— saponaceous, 830 silica, 831 urate, 829 uric or lithic acid, 828 xanthine or xanthic oxide, 830 vesical, 832 adherent, 833 age at which occurs, 833 alternating, 832 causes of, 833 diagnosis of, 835 encysted, 833 extra-pelvic, 868 hardness of, 833 localities in which prevails, 833 mode in which originates, 832 nature and size of, suitable for lithotrity, 847 none found in lithotomy, 857 nucleus of, 832 number of, coexisting, 832 prognosis of, 838 proportion of cases requiring li- thotomy, 848 recurrent, 864, 865 second, left after lithotomy, 857 sex, influence of, upon its occur- rence, 833 shape of, 832 size of, 832 situation of, in bladder, 833 sounding for, 835. See Sounding. structure of, 832 symptoms of, 834, 835 treatment of, 838 by lithectasy, 866 litholysis, 838. See Litholysis. lithotomy, 848, 867. S(e Lithotomy. lithotrity, 839, 867. See Lithotrity. weight of, 833 in women, 866 Callender, injuries of head, 306, 308, 310, 312 nerves in fractures, 227 myotomy in staphyloraphy, 722 pyaemia, 406, 407 sprain-fractures, 209 Callisen, lumbar colotomy, 793 Callous ulcer. See Ulcer. Callus, 222 bending and breaking, in badly-united fractures, 232 Canal of Nuck, hernia into, 774 hydrocele of, 946 Canaliculi, obstruction and slitting of, 673 Canalization of veins, 171 Cancellous exostosis, 473 Canula, tracheal, 351, 352 Canula-forceps, 648 Canula-scissors, 655, 656 Canule a chemise in lithotomy, 858 Cancer, 478 chimney-sweeper's or soot, 927 Cancer— colloid, alveolar, or gum, 487 diagnosis of, 488 ^ epithelial. See Epithelioma. fibrous, 470, 487 haematoid, 485 hard. See Scirrhus. local origin of, 487 medullary. See Encephaloid. melanoid or melanotic, 485 nature and general pathology of, 487 osteoid, 485 prognosis of, 488 recurrent, treatment of, 490 scirrhous. See Scirrhus. soft. See Encephaloid. treatment of, 488, 489 villous, 486 Cancer of bladder, 875 bone, 568 breast, 740, 741 ear, 686 jaws, 714, 718 oesophagus, 727- parotid gland, 705 penis, 925 prostate, 887 rectum, 800 testis, 939 tongue, 709 tonsils, 725 urethra, 912 uterus, 951 vulva, 946 Cancer-juice, 481, 484 Cancer-serum, 485 Cancerous cachexia, 480 diathesis, 487 ulcer, 480 Cancrum oris. See Stomatitis, gangrenous. Cannon-ball, wounds by, 158 Canthoplasty, 670 Canthus, slitting the, 670 Canton, rheumatoid arthritis, 585 displacement of biceps tendon, 281 Capillaries in pyaemia, 408 Capillary naevi, 521 Capsular cataract, 649, 655 Capsulo-lenticular cataract, 649 Caput opstipum. See Wry-neck. succedaneum, 304 Carbolic acid, antiseptic treatment by, 149 local anaesthesia by, 80 Carbonate of lime calculus, 831 Carbuncle, 394 facial, 395 Carcinoma. See Cancer. Carden, amputation through condyles of femur, 126 Carditis from contusion of chest, 356 Caries, 560, 561 of orbit, 674 in stumps, 107 syphilitic, 449 of vertebrae. See Spine, antero-posterior curvature of. INDEX. 963 Carnification of marrow, 556 Carnochan, excision of radius and ulna, 601 superior maxillary nerve, 510 ligation of femoral artery for elephan- tiasis, 467 wound of heart, 364 Carotid artery. See Artery, carotid. Carpue, rhinoplasty, 694 Carpus, dislocations of, 286 fractures of, 256 Carron oil for burns, 300 Carte, compression in aneurism, 541 Cartilage in callus, 222 ensiform, fracture of, 241 ulceration of, in arthritis, 575 Cartilages, costal, fractures of, 241 epiphyseal, in rickets, 418 loose, in joints, 470, 591, 592 semilunar, dislocation of, 295 Cartilaginous tumors, 470 Castration, 940 for onanism, 942 radical cure of hernia, 750 tumors of testis, 938, 939 Cataract, 649 capsular and secondary, 655 catoptric test for, 649 diagnosis of, 650 symptoms of, 649 treatment of, 650 by flap operation, 651, 652 linear extraction, 655 modified linear extraction, 653 needle operation, or solution, 654 reclination, depression, or couching, 651 suction, 655 traction, 653 Von Graefe's method, 653 varieties of, 649, 650 Catarrh, vesical, 874 Catarrhal ophthalmia, 634 Catheter, 888 curve of, 889 Eustachian, 682 female, 910 introduction of, 889 by tour de maitre, 891 metallic and flexible, choice between 892 mode of fastening, in urethra, 883 prostatic, 882, 883, 884 sigmoid, 824 use of, in enlarged prostate, 883, 885 fractured pelvis, 242 gonorrhoea, 425 spasm of urethra, 895 spinal injuries, 334 stricture of urethra, 902 et seq. vesico-vaginal fistula, 918 vertebrated, 883, 884 Catlin, 96 Catoptric test for cataract, 649 Caton, migration of white corpuscles, 40 Caustic in aneurism, 545 Caustic— arrows. See Arrows. in cancer, 489 epithelioma, 493 for piles, 813 prolapsus of rectum, 815 Cauterisation en fleches, 489 Cautery, actual, 86 button, 85 galvanic, 86 for laryngeal growths, 731 nasal polypi, 691 in hemorrhage, 180 hospital gangrene, 392 inflammation, 59 ununited fracture, 235 urethral tumors, 912 Cavernous bodies of penis, rupture of, 375 Cazenave, classification of syphilitic erup- tions, 443 Cells, amoeboid movement of, 37 mastoid, inflammation of, 685 new, origin of, 37 Cellular and cellulo-cutaneous erysipelas. See Erysipelas. Cellulitis, 500 Cephalhaematoma, 304 Cerebral complications of head injuries, 306 irritation. See Concussion of brain. Cerumen, accumulation of, in auditory mea- tus, 676 Cervical glands, enlargement of, 706 Chain saw, 596 Chalazion, 672 Chancre. See Syphilis. mixed, 441, 451, 454 soft or non-infecting. See Chancroid. Chancroid, 430 bubo following, 431 cephalic, 430 complications of, 431, 434 diagnosis of, 432 from syphilis, 451 in female, 433 gangrene of prepuce from, 435 localities of, 430 phagedenic, 431, 435 phimosis and paraphimosis with, 434 prognosis of, 432 serpiginous, 432, 435 treatment of, 432 urethral, 433 Charbon. See Pustule, malignant. Charcot, miliary aneurisms in apoplexy, 528 Chassaignac, caries, 561 drainage tubes, 210, 362 ecrasement line"aire, 493, 863 pyaemia, 319, 412 Chaude-pisse, 421 Cheek, diseases of, 696 fistulae of, 341 operations on, 696 wounds of, 341 Cheek-compressor for harelip, 701, 702 Cheever, excision of hip-joint, 605 tonsil, 725 964 IND EX. Cheever— cesophagotomy, 355 osteo-plastic resection of upper jaw, 692 radical cure of hernia, 783 Cheiloplasty of lower lip, 698 upper lip and angle of mouth, 699, 700 Chelius, urethral lithotomy in women, 867 Cheloid. See Keloid. Cheselden, avulsion of arm, 147 lateral lithotomy, 848 Chest, contusions of, 355, 356 foreign bodies in, 363 injuries of, 355 tapping the. See Paracentesis thoracis. wounds of, 356, 357 Chilblain. See Pernio. Chimney-sweeper's cancer, 927 Chisolm, dislocation of semilunar bone, 286 radical cure of hernia, 751 secondary hemorrhage, 161 temporary achromatic vision, 662 Chloroform, administration of, 78 in cataract operations, 650 compared with ether, 74, 75 Chondroid tumor, 469 Chopart, amputation through tarsus, 121 cheiloplasty, 698 Chordee, 424 Chorea complicating fracture, 228 Choroid, diseases of, 659 tumors of, 660 Choroiditis, 659 syphilitic, 445 Chossat, temperature in spinal injuries, 327 Church, intra-cranial aneurism, 528 lymphoid tumors, 475 Cicatrices from burns, operations for, 300 contraction of, 48 warty tumors or ulcers of, 497, 498 Cicatrization, 48 subcrustaceous, 142 Cilia. See Eyelashes. Ciliary body, diseases of, 638 muscle, division of. See Cylicotomy. paralysis and spasm of, 664 staphyloma, 641, 643 zone, 638, 643, 644 Ciniselli, galvano-puncture for aneurism, 545 Circular amputation, 99 Circulation, collateral, 191 Circumcision, 923 Cirsocele, 935. See Varicocele. Cirsoid aneurism. See Arterial varix. Ciucci, lithotrity, 839 Civiale, lithotomy, 861, 864 lithotrity, 839, 841, 845 statistics of calculus, 833 stricture of urethra, 902, 904 vesical polypus, 875 Clamp for ovariotomy, 823 Clamp and cautery for piles, 812 prolapsus of rectum, 815 Clamp-shield for ovariotomy, 823 Clap. See Gonorrhoea. dry, 421 Clark, concussion of lung, 356 injuries of spine, 326, 327, 328, 337 pyaemia, 410 urethroplasty, 914 wounds of neck, 342 Clarke, F., atrophy of tongue, 708 Clarke, J. L., railway spine, 328 tetanus, 513 Clavicle, dislocation of, 278 excision of, 598 for dislocation, 278 fracture of, 243 Clay, ovariotomy, 823 Cleemann, fracture of spine, 332 Cleft palate, 720 scrotum, 920 Clerc, chancroid and chancre, 440 Climate, influence of, on aneurism, 528 Cline, large calculus, 833 spinal injuries, 332, 335 Clitoridectomy, 946 Clitoris, hypertrophy and excision of, 946 Cloacae in necrosis, 563 Cloquet, cleft palate, 720 extirpation of tongue, 710 fracture of spine, 332 hernia, 746, 782 multiple aneurism, 528 Closset, rhineurynter for epistaxis, 688 Clove-hitch knot, 273 Clover, apparatus for giving chloroform, 78 washing out bladder, 843, 844 Club-foot. See Talipes. Club-hand, 619 Coagulating injections in aneurism, 545 Coagulation of blood in inflammation, 36 Coagulum, external and internal, in wounds of arteries, 176 Coates, fracture-bed, 223 Coccydynia, 243 Coccyx, fracture of, 243 Cock, impermeable stricture of urethra, 908 cesophagotomy, 355 puncture of bladder through rectum, 910 Coghill, wire twister, 917, 918 Cohen, excision of laryngeal growths, 732 Cohnheim, origin of lymph corpuscle, 37 pus corpuscle, 40 Cold abscess. See Abscess. anaesthesia by use of, 79 apparent death from, 302 in cancer, 488 effects of, 302 in hemorrhage, 178 inflammation, 55 spine disease, 633 strangulated hernia, 761 Collapse. See Shock. of lung, 358 in strangulated hernia, 757 Collar for cicatrices of neck, 301 Collateral circulation, 191 Colles, fracture of radius, 254, 256 Collis, cancer in bone, 569 cheiloplasty, 699 INDEX. 965 Collis— epithelioma, 492 excision of breast, 742 harelip, 702 rodent ulcer, 498 staphyloraphy in children, 721 vaginal fistulae, 916 warty ulcers, 498 Collodion, 146 Colloid cancer, 487, 740 cysts, 462 styptic, 146 Colon, syphilitic ulceration of, 447 Color-blindness, 662 Colotomy, 793, 794 for imperforate rectum, 797 intestinal obstruction, 792, 794 recto-vesical fistula, 802 stricture of rectum, 801 Columna nasi, restoration of, 693 Coma in spinal injuries, 328 Come, Frere, lithotome cache", 854 Complaisance, operations of, 04, 109 Complex cystigerous cysts, 463 Compress, graduated, 179 Compressing bandage for eye, 647 Compression in aneurism, 540 of brain, 309 in cancer, 488 for granular lids, 637 hemorrhage, 179 in inflammation, 59 of spinal cord, 322 Compressors, arterial, 95, 96, 541, 858 Compton, excision of radius and ulna, 601 Comstock, suppression of urine in spinal injuries, 326 Concussion of auditory nerve, 686 brain, 306 cerebral irritation following, 308 lesions in, 306, 307 symptoms of, 307 treatment of, 308, 309 lung, 356 retina, 338 solar plexus, 365 spinal cord, 322 Condylomata. See Mucous patches. Confrontation in diagnosis of syphilis, 451 Congenital hernia, 771 hydrocele, 930 Congestion, 35 Congestive stricture of-urethra, 895 Conical cornea, 641, 648 stump, 105 trephine, 320, 321 Conjunctiva, diseases of, 634 dryness of. See Xerophthalmia. tumors of, 638 Conjunctivitis, 634, 635, 636 gonorrhoeal. See Gonorrhoea. Conner, excision of superior maxillary nerve, 510 Conoidal bullet, wounds by, 158 Consent of patients to operation, 69 __^ Constipation in strangulated hernia, lot Constriction, seat of, in strangulated hernia, 755 Constrictor, artery, 181 Contiguity, amputation in, 90 Continued suture, 144 Continuity, amputation in, 90 of bones, excision in, 167, 565 Contractile stricture of urethra, 898, 902, 903 Contraction of arm, 619 cicatrices, 48 forearm and hand, 619 hip, 620 knee, 621 tendons after amputation, 106 toes, 625 Contre-coup, 212 Contused wounds. See Wounds. Contusion, 137 symptoms of, 138 treatment of, 139 Contusion of arteries. See Arteries. bones. See Bones. brain. See Concussion. Convulsions after operations in children, 700 in injuries of the head, 312 spine, 325 Cooke, fistula in ano, 805 Cooper, A., animal ligatures, 182 convulsions after operations in chil- dren, 700 dislocations, 270 et seq. fractures, 231, 247 et seq. galactocele, 733 hernia, 773 et seq. hydatid testis, 938 large calculus, 833 ligation of aorta, 550 external iliac artery, 202 spinal injuries, 330, 332 Urethroplasty, 914 varicocele, 935 Cooper, B., irreducible hernia, 752 Cooper (of Bungay), excisions, 593, 602 Coote, concussion of retina, 338 harelip, 702 ice in aneurism, 547 ligation of lingual artery, 711 moist and dry gangrene, 388 separation of sloughs in gangrene, 49 Copaiba in gonorrhoea, 424 Copeland, recto-vaginal fistula, 802 Copland, erysipelas of arachnoid, 401 tetanus coexisting with hysteria, 514 Coracoid process, fracture of, 248 Corbett, lithotomy staff, 855 Cord, spermatic, haematocele of, 934 hydrocele of, 933 tumors of, 939 wounds of, 376 Corelysis, 649 Cormack, air in veins, 171 Cornea, abscess of, 639 conical, 641,648 diseases of, 638 966 INDEX. Cornea— fistula of, 640 foreign bodies on, 338 hernia of, 640 herpes of, 639 opacities of, 640 paracentesis of, 639 for glaucoma, 665 staphyloma of, 642 ulcers of, 640 Corneitis, 638 . Corns, 495, 496 Coronoid process, fracture of, 253 Corpuscles, lymph, 37 pus, 39 red and white blood, in inflammation, 36 Corpuscular lymph, 37 Corrigan, button cautery, 85 incontinence of urine in children, 879 Corrosive liquids, injuries by drinking, 345 Coryza in hereditary syphilis, 450 Costal cartilages. See Cartilages. Costiveness in spinal injuries, 326 Couching for cataract, 651 Coulson, AV., statistics of calculus, 833 Coulson, W. J., mercurial inunction in sy- philis, 455 test for success of lithotrity, 843 Counter-extension in fractures, 260, 261 Counter-irritation, 84 in arthritis, 577 hip disease, 582 inflammation, 59 spine disease, 633 Counter-stroke, fracture by, 212 Couvercle, 176 Cowell, syphilitic retinitis, 445 Coxalgia. See Hip disease. Cradle, Salter's, for fractured leg, 266, 267 Crampton, dislocation of shoulder, 282 presse-artere, 189 Craniotabes in rickets, 418 Creeping chancroid, 432 Crepitation in chronic synovitis, 572 Crepitus in fractures, 219 in spinal injuries, 331 Crico-thyrotomy, 350 Crisp, aneurism, 528, 537 ligation of femoral artery, 553 Critchett, operations on the eye, 643, 648, 653, 667 strapping ulcers, 386 Critical days in burns, 299 Croft, anchylosis of hip, 590 Crosby, dislocation of thumb, 286 excision of scapula, 598 Cross-eyes. See Strabismus. Crosse, statistics of calculus, 833 lateral lithotomy, 859 Croup, 731 Croupous lymph, 37 Cruise, endoscope, 892 phimosis, 921 Crural hernia. See Hernia, femoral. Crushing calculus. See Lithotrity. in lateral lithotomy, 856 Cryptorchids, 927 Crystalline lens. See Lens. Cubebs in gonorrhoea, 424 Cuboid bone, dislocation of, 296 Cuirass-like scirrhus of breast, 740 Cullerier, gonorrhceal rheumatism, 429 syphilis, 437, 447 Cumming, excision of scapula, 598 Cuneiform bone, dislocation of, 296 Cup of optic papilla, 661 Cupped blood in inflammation, 36 Cupping, 88 Curdy pus, 39 Curette, 651, 652 urethral, 845 Curling, colotomy, 794 diseases of anus and rectum, 800, 816 testis, 927, 936 et seq. duodenal ulcer in burns, 298 eccentric atrophy, 234 gastrostomy, 730 hydrocele of hernial sac, 748 Curvature, antero-posterior, of spine, 629 lateral, of spine, 616 Cusack, hemorrhoids, 812 Cusco's speculum, 947 Cutaneous erysipelas. See Erysipelas. proliferous cysts, 464 Cuticle, transplantation of, for ulcers, 386 Cutter, ligation of external iliac artery, 552 Cutting for stone. See Lithotomy. Cuvillier, subclavian aneurism, 546 Cuyler, excision of rib for wound of inter- costal artery, 241 Cyclitis, 643, 644 Cylicotomy for glaucoma, 665 Cyphosis, 616 Cyst or Cysts, autogenous, 461 colloid, 462 complex cystigerous, 463 compound, 463 cutaneous proliferous, 464 dentigerous, 465 endogenous and exogenous growth of, 463 multilocular, 463 mucous, 462 oily, 462 origin of, 461 parent, 463 primary and secondary, 461 proliferous, 463, 464 sanguineous, 462 sebaceous, 464, 465 seminal, 463 serous, 461 simple or barren, 461 synovial, 461, 462 Cysts, abdominal, 828 of antrum, 713 back, congenital, 629 in bone, 568 of breast, 737, 738 broad ligament, 819, 820 labia majora, 946 INDEX. 967 Cysts of— neck, 706 omentum, 747, 766 ovary. See Ovarian tumors. parotid region, 706 prostate, 888 testis, 938 tongue, 708 Cystic sarcocele, 938 tumor. See Cyst. Cystine calculus, 830 Cystitis, 872, 873, 874 complicating lithotrity, 847 in spinal injuries, 327 Cystocele, 745, 872, 948 calculus in, 868 Cystotome, 651, 652 Cystotomy. See Lithotomy. for ruptured bladder, 373 DA COSTA, wry-neck, 615 Dacryo-adenitis, 672 Dacryo-cystitis, 673 Dactylitis, syphilitic, 449 Daniels, fracture-bed, 223 Darby, silicate of potassa bandage, 84 David, abscess in bone, 559 Davies, radical cure of hernia, 751 Davis, apparatus for hip disease, 582, 583 elastic extension in dislocations, 273, 275 Dawson, clamp for ovariotomy, 823 Day-blindness. See Nyctalopia. Day-sight. See Hemeralopia. Deaderick, excision of lower jaw, 719 Deafness, nervous, 686 De Borsa, median lithotomy, 861 Debridement, 164 for protrusion of intestine, 369 Decalcification of bone, 555 Decristoforis, galvano-puncture in aneu- rism, 546 Deformities, treatment of. See Orthopaedic surgery. Deformity, amputation for, 93, 109 in fractures, 217, 218 spinal injuries, 331 Degeneration of lymph, 38 De La Peyronie, white gangrene, 396 Deligation. See Ligation. Delirium in spinal injuries, 328 traumatic, 135, 136 Delpech, club-foot, 622 fecal fistula, 372 Demarcation, line of, 49 Demarquay, extirpation of tonsil, 725 gangrene of penis, 924 hernia of testis following puncture, 426 Demeaux, development of hernial sac, 746 De Morgan, wry-neck, 616 Dentigerous cysts, 465 of antrum, 713 Depletion in inflammation, 60 Deposits, urinary, 828 Depressed fracture of skull, 314, 318 nose, 696 Depression of cataract, 651 Desault, aneurism, 536, 539 dislocated astragalus, 296 fractures, 246, 259 radical cure of hernia, 770 stricture of urethra, 902, 905, 906 tartar emetic in head injuries, 313 Deschamps, aneurism, 539 Desmoid tumor, 469 Desormeaux, endoscope, 892 Destructive changes in inflammation, 40 Detachment of retina, 660 Determination, 35 D'Etiolles, stricture of urethra, 902 Detmold, abscess of brain, 312 club-foot, 622 ununited fracture, 235 Development of lymph, 38 Dewar, cheek-compressor for harelip, 702 Dewees, leeches in mammitis, 735 Dextrine bandage, 84 Diabetes, syphilitic, 448 Diabetic cataract, 655 Diagnosis, anaesthetics to aid, 73 Diaphoretics in inflammation, 61 Diaphragm, injuries of, 364 Diaphragmatic breathing in spinal injuries, 325 hernia, 364, 768 Diastasis, 269 of pelvis, 242, 277 of sternum, 241, 277 Diatheses, urinary, 828 Diathesis, aneurismal, 528 cancerous, 487 hemorrhagic, 175 purulent or pyogenic. See Pyaemia. Diathetic diseases, 413 Dick, gonorrhoea, 423 Dickinson, tetanus, 513 Dieffenbach, anchylosis of knee, 591 depressed nose, 696 lace-suture, 913 ruptured perineum, 377 staphyloraphy, 721 tenotomy for old dislocations, 275 urethroplasty, 913, 914 Diet in inflammation, 54 after operations, 65 Dieulafoy, aspirator for tapping chest, 362 puncture of bladder, 887 Diffuse inflammation. See Inflammation. Diffused hydrocele of spermatic cord, 933 suppuration, 383 Dilatation of urethral stricture, 901, 902 Dilated oesophagus, 727 Dilator, oesophageal, 728 urethral, 866 Dip of conoidal bullet, 158 Diphtheria, 731 Diphtheritic deposit on wounds, 69 Director, grooved, 185 Disarticulation, 90. See Amputation. of lower jaw, 719, 720 968 INDEX. Dislocation, 269 articular changes produced by, 271 causes of, 270 complete, 269 complicated, 269, 274 complicating fractures, 228, 230 compound, 269. 274 amputation for, 93, 274 congenital, 269, 275, 276 diagnosis of, 270 old, 269, 274, 275 partial, 269 pathological and spontaneous, 269, 275 prognosis of, 271 reduction of, 272, 273, 275 symptoms of, 270 treatment of, 271, 274 Dislocations of ankle, 295, 296 astragalus, 296 carpal bones, 286 clavicle, 278 crystalline lens, 339 elbow, 283, 284, 285 hip, 287 et seq. in hip disease, 580 hyoid bone, 277 knee, 294, 295 lower jaw, 276, 277 metacarpus and fingers, 286 metatarsus and toes, 296 patella, 294 pelvis, 277 ribs, 277 scapula, 278 semilunar cartilages, 295 shoulder, 279 et seq. spine, 330 sternum, 241, 277 tarsus, 296 wrist, 285 Displacement in fractures, 217, 218 Dissecting aneurism, 527 Dissection wounds. See Wounds. Distichiasis, 669 Dittel, siphon apparatus for washing out bladder, 844 Diuretics in inflammation, 61 Division of tendons. See Tenotomy. Dix, filopressure, 189 Dixon, color-blindness, 662 granular lids, 637 prolapsed iris, 642 Dobson, phlegmonous erysipelas, 402 Dolbeau, ivory-like exostoses, 474 perineal lithotrity, 845 Ponders, strabismus, 666 sympathetic neurosis, 665 Donovan, old dislocation of jaw, 277 Dorsey, suppression of urine in spinal in- juries, 326 Double-lip, 697 Douche, Thudichum's, for ozaena, 689 Drainage in ovarian cysts, 820 suppurating joints, 210 Drainage-tube, Chassaignac's, 210 introduction of, in abscess, 381 Drainage-tube— after paracentesis thoracis, 362 Dressing of operation wounds, 72 Drill, burr-head, 561 for ununited fracture, 235, 236 Dropsy of antrum, 713 Druitt, needle for vesico-vaginal fistula, 917 upward dislocation of foot, 295 Dry-dressing, 104 Duchaussoy, intussusception, 791 Duchenne, paralysis from rupture of nerves, 205 Duck-billed speculum, 914, 915, 947 Duct, nasal, obstruction of, 673 Dugas, ligation of common iliac artery, 551 Duodenal ulcer in burns, 298 Dupuytren, abscess of brain, 312 amputation at hip, 130 at shoulder, 118 aneurism, 540 bilateral lithotomy, 859 classification of burns, 297 sequestra, 164 dislocation of shoulder, 282 enterotome, 371, 372 excision of upper jaw, 715 splint for injuries at ankle, 267, 296 Dura mater, fungus of, 626 Durham, anchylosis of jaw, 302 excision of laryngeal growths, 732 foreign bodies in air-passages, 346,347, 348 fractured larynx, 344 gastrostomy, 729, 730 gastrotomy for removal of foreign bodies, 372 gonorrhoea, 423 penetrating wound of neck, 342 staphyloraphy in children, 721 tracheotomy, etc., 345, 351, 352 Dysphagia from aneurism, 531 conditions which produce, 727 in spinal injuries, 326 wounds of throat, 343 Dyspnoea from aneurism, 531 in spinal injuries, 325, 326 wounds of lung, 357 • throat, 343 EAR, accumulation of wax in, 676 cancer of, 686 diseases of, 675 syphilitic, 445 foreign bodies in, 340 hemorrhage from, 315 inflammation of, fatal, 686 neuralgia of, 686 ringing in. See Tinnitus aurium. watery discharge from, 315 Ear-ache, 683 Ear-speculum, 676 Ear-trumpet, 685, 686 Earle, lithotomy staff, 855 Eau de luce, 154 Eburnation of bone, 555 INDEX. 969 Ecchymosis, 137 in fractures, 219 intra-orbital, 314, 315 lumbar, in haemothorax, 360 ' Echeverria, reflex paralysis, 206 Eck, compression in iliac aneurism, 550 Ecraseur in amputation of penis, 928 laryngeal, 731, 732 in removal of epithelioma, 493 hemorrhoids, 813 tongue, 710 Ectropion, 070 Eczema of auricle, 675 mercurial, 456 Eczematous ulcer. See Ulcer. Edwards, aortic aneurism, 546 Egyptian ophthalmia, 636 Ehrman, laryngeal growths, 732 Elbow, anchylosis of, 590 amputation at, 116 diseases and injuries of. See under Joints. dislocations of, 283 excision of, 165, 600 Election, operations of, 64 Electro-puncturation, 86 for ununited fracture, 235 Elephantiasis Arabum, 467, 500 of scrotum, 924 Elevator for depressed bone, 320 Ellis, vaginal speculum, 947 wire coil for drainage, 210, 381 Elongation of uvula, 723 Elytrorrhaphy, 948 Embolism, 172, 173 causing intra-cranial aneurism, 528 of central artery of retina, 660 death from, after operations, 68, 137 in pyaemia, 406 Emissions, seminal, 941 Emmet, ruptured perineum, 377 uterine polypus, 949 vaginal fistulae, 915, 916 lithotomy, 867 speculum, 947 Emmetropia, 663 Emphysema from fractured ribs, 240 puncture of bladder through rectum,887 ruptured intestine, 366 wounds of chest, 356, 357, 360, 364 throat, 343 Emprosthotonos, 511 Empyema, 358, 361 Encephalitis, traumatic, 311, 312 Encephalocele, 627 Encephaloid, 482 et seq. in bone, 483, 568, 569 of breast, 740 microscopic appearances of, 484 morbid anatomy of, 483 natural history of, 483 treatment of. See Cancer, treatment of. Enchondroma, 470 Encysted balls, 169 calculus, 833 haematocele, 934 Encysted— hernia, 773, 774 hydrocele, 933 rectum, 815 Endermic use of drugs, 85 Endogenous growth of cells, 37 Endoscope, 892 in gonorrhoea, 423 urethral chancroid, 433 Enemata in hernia, 754, 761, 765 Ensiform cartilage. See Cartilage. Enteritis, syphilitic, 447 Enterocele. See Hernia, intestinal. Entero-epiplocele. See Hernia, mixed. Enterotome for fecal fistula, 371, 372 Enterotomy for foreign bodies in intestines, 373 for intestinal obstruction, 792 Entero-vaginal fistula, 802 Entrance, wound of, 159 Entropion, 669, 670 Enucleation. See Excision. Eperon, division of, in fecal fistula, 371 Epicanthus, 672 Epididymitis, gonorrhoeal, 425, 426 Epigastric hernia, 768 Epiglottis, scarification of, 345 tumors of, 726 Epilepsy, syphilitic, 448 trephining for, 319 Epiphora, 673 Epiphyseal cartilages in rickets, 418 Epiphyses, separation of, 216, 222, 230. See also under Fractures. Epiplocele. See Hernia, omental. Episcleritis, 644 Episiorrhaphy, 948 Epispadias, 893 Epistaxis, 687, 688 Epithelial cancer. See Epithelioma. Epithelioma, 490 et seq. diagnosis of, 492 melanotic, 492 microscopic appearances of, 491, 492 prognosis of, 492 recurrent, 493 treatment of, 492, 493 warty or villous, 490 Epithelioma of anus, 801 larynx, 731 lip, 697, 698 penis, 925, 926 scrotum, 927 tongue, 709 uterus, 951 vulva, 946 Epitheliomatous ulcer, 491 Epulis, 712 Erectile tumors, 475, 519 Erichsen, air in veins, 171 cerebral irritation, 308 harelip, 702 hip disease, 578 naevus, 522 railway-spine, 328 sacro-iliac disease, 584 970 INDEX. Erosion, chancrous. See Syphilis. Erysipelas, 396 causes of, 397 cellular, 398, 402 cutaneous or simple, 397, 401, 402 diagnosis of, 398 erratic or wandering, 397 oedematous, 398 phlegmonous orcellulo-cutaneous, 397, 402 prognosis of, 398 symptoms of, 397 traumatic, 398, 403 treatment of, 399 et seq. Erysipelas of air-passages, 401, 403 arachnoid, 398, 399, 401, 403 auricle, 675 fauces and larynx, 398, 399 orbit, 402 pharynx, 725 mucous membranes, 398 peritoneum, 398, 399, 401, 403 scalp, 305, 402 scrotum, 402 serous membranes, 398 stumps, 106 Esmarch, anchylosis of jaw, 301, 720 use of dry cold, 55 Ether, administration of, 77, 78 compared with chloroform, 74, 75 Eulenberg, excision of hip-joint, 605 Eustachian catheter, 682 tube, dilatation of, 682 obstruction of, 681 Evans, innominate aneurism, 546 Eve, bilateral lithotomy, 859 fractured patella, 263 spinal injuries, 333, 335 Eversion of upper eyelid, 339 Evidement in caries, 561 Exarticulation, 90. See Amputation. Excision, 593 in arthritis, 577 gelatinous, 578 cancer of bone, 569 caries, 561 compound dislocation, 274 fracture, badly united, 232 compound, 229 ununited, 235 gunshot injuries, 164 history of, 593 indications and contra-indications for, 594 instruments required for, 595, 596 • in joint wounds, 211 mortality after, compared with ampu- tation, 595 for necrosis, 565 operative procedures used in, 596 repair after, 595 sub-periosteal, advantages of, 595 Excision of ankle, 167, 211, 611, 612 astragalus, 296, 612 axillary glands, 742, 743 Excision of— bones in continuity, for gunshot injury 167 breast, 741 calcaneum, 613 cancer, 489 clavicle, 278, 598 clitoris, 946 cysts of ovary and broad ligament, 820 elbow, 165, 600, 601 epithelioma, 493 eye, 643, 666 eyelashes, 669 fibula, 611 foot, bones of, 612, 613 hand, bones of, 603 hemorrhoids, 811 hernial sac, 750 hip, 165, 211, 586, 590, 603 et seq. inguinal glands, 434 iris. See Iridectomy. jaw, lower, 239, 718 et seq. upper, 691, 715 etseq. kidney, 825 knee, 166, 211, 590, 607 et seq. lachrymal gland, 672 malleus, 679 membrana tympani, 679 naevus, 521 nasal tumors,'692 nerves, 385, 616 orbital contents, 666 omentum, 370, 766 ovary. See Ovariotomy. parotid gland, 706 prepuce, 922 radius, 601 ribs, 598 scapula, 597, 598 scrotum, 925, 935 shoulder, 165, 598, 599 sphincter ani, 815 spleen, 825 testis. See Castration. undescended, 927 thyroid gland, 704 tibia, 611 tongue, 710 tonsils, 724, 725 tumors, 493 tunica vaginalis, 933 ulna, 601 uterine fibroids, 949 uterus, 824, 950 wrist, 165, 602, 603 Excurvation of eyelids, 671 Exfoliation, 562, 564 in stumps, 107 Exit, wound of, 159 Exomphalos. See Hernia, umbilical. Exostoses, cancellous, 473, 474 of ear, 678, 685 ivory-like, 474 near joints, 568 Expanding speculum, 947 INDEX. 971 Expediency, amputations of, 109. See also Election. Exstrophy of bladder, 868, 870 Extension, angular, 293 continuous, 577, 582, 587, 588 in dislocation, 273,- 275, 282 spinal injuries, 334 by weight, 259, 261 External piles, 808 urethrotomy, 904, 906 Extirpation. See Excision. Extraction of cataract. See Cataract. Extractor, screw, 163 Extravasation, 137, 174 fecal, 366, 368, 763, 765 in fractures, 219, 225 trephining for, 317 of urine, 368, 375, 910 Extroversion of bladder, 868, 870 Exudation in inflammation, 38 Eye or eyeball, contusion of, 339 diseases of, 634, 665 syphilitic, 444, 447, 450 excision of, 666 for staphyloma, 643 foreign bodies on, 338, 339 lesions of, in pyaemia, 408 wounds of, 340 Eyelashes, displacement of. See Trichiasis. double row of. See Distichiasis. excision of, 669, 670 transplantation of, 670 Eyelid, upper, eversion of, 339 falling of. See Ptosis. Eyelids, adhesion of. See Ankyloblepha- ron. diseases of, 668 eversion of. See Ectropion. excurvation of, 671 inversion of. See Entropion. tumors of, 672 wounds of, 337 FABRIZZI, excision of membrana tym- pani, 679 Face, diseases of, 687 injuries of, 337 plastic operations for deformity after wounds of, 338 Facial artery. See Artery. carbuncle. See Carbuncle. Fahnestock, rope windlass for dislocations, 273, 291 tonsillotome, 724 False aneurism, 526 joint. See Fracture, ununited. passage of urethra, 375, 901 Far-sight. See Presbyopia. Fatty degeneration in arteries, 524 matters in calculi, 830 tumors, 465. See Tumors. usure, 524 Fauces, erysipelas of. See Erysipelas. syphilitic affections of, 443, 447 Faure, phimosis, 921 Favre, electric probe, 163 Fayrer, elephantiasis of scrotum, 924, 925 heart-clot after operations, 68 osteo-myelitis, 558 radical cure of hernia, 751, 778 snake-bites, 154 Fearn, innominate aneurism, 546 Fecal abscess, 827 discharges, involuntary, in spinal inju- ries, 326 fistula. See Fistula. Feces, extravasation of. See Extravasation. impacted, 792 diagnosis of, from ovarian tumor, 818 Felon. See Paronychia. Feltz, duodenal ulcer in burns, 298 Female catheter, 910 Femoral artery. See Artery. hernia, 781. See Hernia. Femur, dislocation of, 287 excision of head of. See Excision of hip. fracture of. See Fracture. separation of epiphyses of, 262 Fenger, gastrostomy, 730 Fergus, rupture of gall-bladder, 366 Fergusson, aneurism, 544, 549 excisions, 596, 597, 607, 608 hernia, 770, 785 jaws, operations on, 713 et seq. nose, operations on, 690, 695, 696 palate, operations on, 721 et seq. parotid tumors, 705 vesical calculus, operations for, 836, 840, 845, 857 et seq. Ferrus, wound of heart, 364 Fever, hectic, 51 hemorrhagic, 175 inflammatory, 49 pyogenic or suppurative. See Pyaemia. secondary, 51 urethral, 899 Fibrillous or fibrinous lymph, 37 Fibrin in inflammation, 36 Fibrinous calculi, 831 Fibro-calcareous tumors, 469 Fibro-cartilaginous tumors, 470 Fibro-cellular tumors, 467 Fibro-cystic tumors, 469 Fibro-muscular tumors, 469 Fibro-nucleated tumors, 476 Fibro-plasfic tumors, 473 Fibroid tumors, 469 malignant, 470, 487 recurrent, 475 uterine, 948 Fibrous and fibro-cellular bodies in sac of hydrocele, 933 cancer, 470, 487 epulis, 712 tissue, syphilitic affections of, 448 tumors, 469 Fibula, dislocation of, 295 excision of, 611 fractures of, 264, 267 972 INDEX. Fiddes, excision of tongue, 710 Figure-of-8 bandage, 81 suture, 145 Filiform bougies, 889 Filkin, excision of knee, 594, 607 Filopressure, 189 Fine, umbilical colotomy, 793 Fingers, amputation of, 113 chancre of, 452 contraction of, 619 dislocation of, 286 excision of, 603 fracture of, 256 strangulation of, by ring, 139 First intention, union by, 141 Fischer, statistics of aneurism, 542, 544, 551 wounds of heart and pericardium, 363 Fissure of anus, 805, 806 lower lip and angle of mouth, 703 upper lip. See Harelip. scrotum, 920 vagina, 947 Fistula, 383 aerial, 343 in ano, 803, 804, 805 biliary, 371 blind urinary, 913 of cheek, 341 cornaa, 640 entero-vaginal, 802 fecal or intestinal, 371, 372, 756 et seq. gastric, 371 of lachrymal gland, 672 lacrymalis, 674 of nose, 693 oesophageal, 343 penile, 913 perineal, 857, 913 rectal, 801 recto-labial, 802 recto-urethral, 801 recto-vaginal, 802 recto-vesical, 801 salivary, 341, 696 urethral, 912 urethro-rectal, 914 urethro-vaginal, 914 urinary, in female, 914 et seq. in male, 912 et seq. vesico-rectal, 914 vesico-uterine, 914, 918 vesico-utero-vaginal, 914, 918 vesico-vaginal, 914 et seq. Fixed bandages, 83 Flame, inhalation of, 299 Flap amputation, 100 rectangular, 102 operation for cataract, 651 Flat foot. See Talipes valgus. Flaubert, naso-pharyngeal polypus, 691 ununited fracture, 236 Fletcher, stricture of oesophagus, 728 Flexion in aneurism, 544 hemorrhage, 179 Floating tumors, 478 Flour-paste bandage, 84 Flower, subcoracoid dislocation of hu- merus, 280 Fluctuation of abscess, 379 Flushed face in spinal injuries, 327 Fluxion, 35 Fock, excision of hip, 605 Follicular abscesses of ear, 676 Follin, epispadias, 893 Fomentations in inflammation, 57 Foot, amputations of, 119, 123 dislocations of, 295 excisions of, 612, 613 flat or splay. See Talipes valgus. fractures of, 268 Forbes, amputation at hip, 565 forward dislocation of elbow, 285 Forceps, artery, 97 for aural polypus, 677 bone, 564, 595 bullet, 163 canula, 648 entropion, 670 gouge, 561 iris, 647 knife-bladed, 596, 597 laryngeal, 731 lion-jawed, 596 lithotomy, 850, 853 oesophageal, 353, 354 polypus, 690 sequestrum, 564 Snellen's 669 tracheal, 348 urethral, 865 uterine, 950 Forceps-scissors for cutting uvula, 723, 724 Forearm, amputation of, 115 contraction of, 619 dislocations of, 284 fractures of, 253 Foreign bodies in air-passages, 345 bladder, 374 brain, 316, 319 ear, 340 eye, 338 gunshot wounds, 163 incised wounds, 143 nose, 340 oesophagus, 353 pharynx, 341, 353 rectum, 374 stomach and bowels, 372 thoracic cavity, 363 tongue, 341 urethra, 375 vagina, 376 Formative changes in inflammation, 37 Forster, acupressure, 189 aneurism, 553 gastrostomy, 729 hydrophobia, 155 torsion, 180, 181 | Four-tailed bandage, 82 INDEX. 973 Fournier, syphilis, 440, 443 wound of heart, 364 Fox, G., apparatus for fractured clavicle, 246, 247 Fox, W., complex ovarian cysts, 463 Fracture, 212 badly united, 232 button-hole and perforating, 158, 214 causes of, 212, 213 comminuted, double, and multiple, 215 complete, 214 complicated, 215, 227, 228, 230 compound, 215 amputation for, 93, 228, 229, 232 complications of, 229, 2>i0 excision for, 229, 230 treatment of, 228 et seq. from counterstroke, 212 crepitus in, 219 delayed union of, 233 diagnosis of, 219, 220, 270 directions of, 216 displacement in, 217, 218 epiphyseal. See Epiphyses, separation of. false joint after. See Fracture, un- united. fissured and grooving, 214 gangrene from tight bandaging in, 225 green-stick and partial, 214, 233 gunshot, 164, 168 impacted, 215, 233 implicating joints, 228, 229 incomplete, 214 intra-periosteal, 216 longitudinal, 216 from muscular action, 213 oblique, 216 partial, 214, 233 reduction or setting of, 223 simple, 214, 223 splints for, 224 statistics of, 213 in stumps, 228 symptoms of, 217, 218, 219 transverse, 216 treatment of, 223 et seq. union of, 221, 222 delayed, 233 ununited, 233, 234, 235 varieties of, 214 Fracture-beds, 223 Fracture-box, 266 Fractures of acetabulum, 242 acromion, 248 ankle, 267 astragalus, 268 calcaneum, 268 clavicle, 243, 245 coccyx, 243 coracoid process of scapula, 248 coronoid process of ulna, 253 costal cartilages, 241 femur, condyles of, 262 head of, 242 shaft of, 260, 262 Fractures of femur— upper extremity of, 256 et seq. fibula, 264 fingers, 256 foot, 268 forearm, 253 humerus, lower extremity of, 251 shaft of, 250 upper extremity of, 248, 249 hyoid bone, 239 jaw, lower, 238, 239 upper, 237 lachrymal bone, 237 larynx, 344 leg, 264, 265, 266 malar bone, 237 nasal bones, 237 olecranon, 252 patella, 263 pelvis, 242 radius, 254 ribs, 239, 240 sacrum, 243 scapula, 247, 248 skull, 314 spine, 330 sternum, 241 tibia, 264, 267 ulna, 253, 256 vertebrae, 330 zygoma, 237 Fragilitas ossium. See Osteomalacia. Franco, supra-pubic lithotomy, 863 Frank, concussion of spinal cord, 322 Fraser, chest wounds, 357, 359, 360, 364 Freer, compression for aneurism, 540 Fricke, epididymitis, 426 torsion, 180 Friction in inflammation, 60 Frog-face, 691 Frontal sinus, affections of, 675, 696 Frost-bite, 303 amputation for, 92 Fuller, bivalve tracheal canula, 352 Fumigation, mercurial, in syphilis, 455, 456 Functional changes in inflammation, 34, 45 Fungus of brain, 627 dura mater, 626 haematodes, 483, 485 of skull, 626 Furnari, syndectomy or peritomy, 637 Furuncle, or boil, 393 Fusible calculus, 830 Fusiform aneurism, 526 GAILLARD, ununited fracture, 235, 236 Gairdner, pilot trocar for introducing tracheal tube, 352 Galactocele, 733 Galezowski, strabismometer, 667 Gall-bladder, abscess in, 826 distended, puncture of, 828 rupture of, 366 Gall-stone, impacted, 792 974 IND EX. Galozzi, ligation of internal iliac artery 552 Gait, conical trephine, 320, 321 Galvanic cautery, 86, 691, 731 Galvano-puncture for aneurism, 545, 546 Gama, wound of spinal cord, 325 Gamgee, rupture of heart, 356 Ganglion, 504 Gangraena oris. See Stomatitis, gangrenous. Gangrene, 40, 48 amputation for, 92 from arterial occlusion, 194 of bone. See Necrosis. mephitic, 562, 563 dry, 49, 388 hospital, 389 amputation for, 92 idiopathic, 393 microscopic appearances in, 390 symptoms of, 390, 391 treatment of, 391, 392 of intestine in hernia, 756 in lacerated and contused wounds, 148 moist, 49, 388 of penis, 924 scrotum, 388 senile, 388 spontaneous, 387, 388 from tight bandaging, 225, 226 traumatic or spreading, 148 amputation for, 151 white, 396 Gangrenous diseases, 387, 396 stomatitis. See Stomatitis. Gaping of wounds, 140 Garangeot, obturator hernia, 785 Garrod, rheumatoid arthritis, 585 Garrot, 96 Gascoyen, syphilitic iritis, 444 Gastric fistula. See Pyaemia. infection. / J Pus, 39 absorption of, in abscesses, 380 pyaemia, 405 characters of, in caries, 560 cold abscesses, 382 corpuscles, origin of, 39 varieties of, 39 ' Pustular ophthalmia, 635 Pustule, malignant, 395, 396 Putrid, infection. See Pyaemia. Puzzle, Indian, for dislocations, 286 Pyaemia, 403 analogy of, with gonorrhoeal rheuma- tism and urethral fever, 411, 429, 899 arterial, 406, 407 causes of, 409 contagiousness of, 409 diagnosis of, 410, 411 frequency of, in thigh amputations, 109 idiopathic or essential, 409 materies morbi of, 409 metastatic abscesses in, 407 morbid anatomy of, 407, 408 nomenclature of, 404 pathology of, 404 etseq. prognosis of, 411 symptoms of, 410 treatment of, 411 et seq. trephining as a prophylactic against, 319. Pyaemic patches, 407, 408 Pyarthrosis, 554, 573 Pyocyanine, 39 Pyogenic diathesis or fever. See Pyaemia. Pyrexia, paralytic, 327 QUADRUPLE ligature for naevus, 522 Quain, vascular tumor of rectum, 801 Quesnay, white gangrene, 396 Quilled suture, 145 Rack for fractures of lower extremity, 267 Radcliffe, temperature in tetanus, 512 Radial artery. See Artery. Radiating incisions in ulcers, 385 Radical cure of hernia, 750 cases favorable for, 752 femoral, 783 inguinal, 777 et seq. operations for, 750, 751 objections to, 751, 752 umbilical, 770 hydrocele, 932 varicocele, 936 Radius, dislocations of, 28:? excision of, 167, 168, 601 fractures of, 254, 255 Railway spine, 328 Rainey, loose cartilages in joints, 591 Ramoneur, 354 Randall, wound of heart, 364 Randolph, multiple calculus, 832 Ranula, 709 Rarefaction of bone, 555 Rasmussen, tapping the chest, 362 Rattlesnake poisoning, 154, 155 Reaction from shock, 68, 135, 136 Reade, compression of aneurism, 541 syphilis of nervous system, 448 Ready method, Marshall Hall's, 349 R6camier, compression in cancer, 488 fissure of anus, 807 Reclination of cataract, 651 Rectangular flap amputation, 102 staff, 854, 861, 862 Rectocele, 948 Recto-labial fistula, 802 Recto-urethral fistula, 801, 914 Recto-vaginal fistula, 802 Recto-vesical fistula, 801, 914 lithotomy, 863 Rectum, abscess near, 804 bougies for, 799 cancer of, 800 encysted, 815 fistulae of, 801 foreign bodies in, 374 hemorrhage from, 809 imperforate, 796 colotomy for, 797 malformations of, 796 occlusion cf, 796 polypus of, 801 pouches of, inflamed, 815, 816 prolapsus of, 813. See Prolapsus. puncture of bladder through, 886, 887 speculum for, 803 stricture of, 798 malignant, 800, 801 simple or fibrous, 798, 799 warty, 800 syphilitic lesions of, 447 tapping through, 820 tumors of, 801 ulcers of, 807 wounds of, 374 in lithotomy, 858 RABID animals, bites of, 155 Racemose aneurism. See Aneurism by anastomosis. Rachitis. See Rickets. adultorum. See Osteomalacia. . 996 INDEX. Recurrent bandage, 82 fibroid, 475 stricture. See Contractile stricture. tumors, 475, 476 Red corpuscles in inflammation, 36 Redness in inflammation, 42 Reducible hernia. See Hernia. Reduction of dislocations, 272 spinal, 334 fractures, 223 compound, 230 impacted and partial, 233 hernia, 750 strangulated, 760. See Taxis. in mass, 762, 763 prolapsus of rectum, 814 Reef-knot, 98 Reeves, laminaria tents for stricture, 902 Reflex paralysis, 206 Refraction, 662 Regnoli, removal of tongue, 710 Reid, manipulation for hip dislocation, 289 Relaxation of membrana tympani, 679 Renal calculus, 831 nephrotomy for, 825 vessels, thrombosis of, in spinal in- juries, 322 Rendu, ivory-like exostoses, 474 Repair after excision, 595 of fractures, 221, 222 wounds, 141 et seq. in arteries, 176, 177 nerves, 206 tendons, 207, 622 veins, 170 Resection. See Excision. osteo-plastic, of upper jaw, 692 of spine. See Trephining. Resection-sound, 596 Residual abscess. See Abscess. Resolution, 52 Respiration, artificial, 348 prone and postural, 349 Rest, in concussion of brain, 309 inflammation, 53 joint affections, 209, 210, 572, 576 spinal affections, 334, 633 Results of operations, circumstances which influence, 63 et seq. Retention of urine, 877. See Urine. in gonorrhoea, 424 after lithotrity, 845 in spinal injuries, 326 Retina, concussion of, 338 diseases of, 660 tumors of, 661 Retinitis, 660 syphilitic, 445 Retraction of divided arteries, 170 muscles after amputation, 105 nipple, in cancer, 479, 740 Retractor, 98 grooved, for excisions, 596 Retro-peritoneal suppuration, 368 Retro-pharyngeal abscess, 725, 726 Reverdin, facial carbuncle, 395 Reverdin— transplantation of cuticle, 386 Reversed spiral bandage, 81 Revulsion, 84. See Counter-irritation. Reynolds, erysipelas, 401 Rhagades, 444, 806 Rheumatic iritis, 645 ophthalmia, 644 Rheumatism, gonorrhoeal. See Gonorrhoeal. Rheumatoid arthritis. See Arthritis. Rhineurynter for epistaxis, 688 Rhinolites, 692 Rhinoplasty, 693 by Indian method, 694 Syme's method, 695 Taliacotian method, 693 Wood's method, 695 Rhinorrhoea, 689 Rhinoscopy, 689 Ribbon,lead, 146 Ribs, changes in, in rickets, 418 dislocations of, 277 excision of, 598 fracture of, 239, 240 necrosis of, 564 Richard, congenital hydrocele, 930 extroversion of bladder, 870 Richardson, local anaesthesia, 79 styptic colloid, 146 tetanus, 513 Richardson (of Dublin), hernia-knife, 765 Richardson (of New Orleans), radical cure of hernia, 751 Richerand, fracture of sacrum, 243 Richet, hypodermic use of caustic, 489 primary hydrarthrosis, 572 Rickets,. 417 in bone, 566 diagnosis and prognosis of, 419 morbid anatomy of, 418 predisposing to fracture, 214 symptoms and course of, 418 treatment of, 419 Ricord, amputation of penis, 926 phagedaenic chancroid, 435 phimosis, 923 syphilis, 438, 440, 449 varicocele, 936 Rigal, India-rubber suture, 145 Rigaud, excision of scapula, 598 Rigidity of membrana tympani, 679 Ring for fracture of patella, 263 strangulation by, 139, 924 Ring-forceps for piles, 811 Ringer, temperature in pyaemia, 410 Ripley, dislocation of hyoid bone, 277 Risus sardonicus, 512 Rizet, massage in diagnosis of fracture, 220 Rizzioli, median lithotomy, 861 Rizzoli, anchylosis of jaws, 301, 720 Robert, fracture of skull, 315 Roberts, urinary calculi, 829, 831 Robertson, rupture of trachea, 344 Robin, induration of chancre, 439 Rodent ulcer, 498 IND ex. . 997 Rodgers, anchylosis of hip, 590 excision of both upper jaws, 718 ligation of left subclavian artery, 200 internal iliac artery, 552 ununited fracture, 235, 236 Rofeta, cephalic chancroid, 430 Roger, tracheal tube, 352 Rogers, excision of scapula, 598 Rognetta, fracture of astragalus, 268 Rokitansky, bony union of fractured verte- brae, 332 tubercle, 414 Roller bandages, 81 Rollet, mediate contagion of syphilis, 437 Roosa, foreign bodies in ear, 340 Rope windlass for dislocations, 273, 291 Rose, historical notions of pyaemia, 404 Rossi, amputation at knee, 126 innominate aneurism, 546 Rotation of vertebrae in lateral curvature of spine, 616, 618 Rotatory displacement in fractures, 218 Rouse, gonorrhoeal epididymitis, 426 Roux, J., disarticulation for osteo-myelitis, 558 Roux, P. J., staphyloraphy, 721 ununited fracture, 235 Rubefacients, 84 Run-around. See Onychia. Rupia, syphilitic, 446 Rupture. See Hernia. of abdominal muscles, 365 aneurism, 534, 538 arteries, 173 bladder, 373, 910 gall-bladder, 366 heart, 356 intestine, 366, 763 kidneys, 326, 366 liver, 366 lungs, 355 muscles and tendons, 207 perineum, 376 peritoneum, 366 sphincter ani, 807 vaginae, 948 stomach, 366 stricture of urethra, 902 ureter, 366 urethra, 375, 910 SABINE, subclavian aneurism, 547 Sac of hernia. See Heruia. Sacciform disease of anus, 815 Sacculated aneurism, 526 bladder, 874 oesophagus, 727 Sacro-iliac disease, 584, 585 joint, arthritis of, 584, 585 Sacrum, fracture of, 243 Salivary fistula, 341, 696 Salivation, mercurial, 45b Salleron, hernia of testis 426 tuberculous sarcocele J47 Salter, cradle for fractured leg, 266, 267 Salts of blood in inflammation, 36 Sand-bags for fractured thigh, 260 Sands, innominate aneurism, 546 laryngeal growths, 732 Sanguineous cysts, 462 Sanious pus, 39 Sanson, catoptric test for cataract, 649 recto-vesical lithotomy, 863 Santonio, lithotrity, 839 Saponaceous matter in calculi, 830 Sappey, blisters for ulcers, 385 Sarcocele, 937 cystic, 938 malignant, 939 simple, 937 syphilitic, 447, 938 tubercular, 448 tuberculous, 937 Sarcoma, 476 sero-cystic, 463, 464 of breast, 738 Sarsaparilla in inflammation, 62 Saussier, rupture of lung, 355 Savory, pyaemia, 407, 409 shock, 135 Savreux-Lachappelle, idiopathic pyaemia, 409 Saw, amputating, 97 Butcher's, 121, 596 chain, 596 Hey's, 318 Sayre, anchylosis of hip, 590 excision of hip, 605 hip disease, 582, 583 jointed probe, 560 oakum seton, 561 Scabbing, healing by, 142 Scalds. See Burns. Scalp, aneurism by anastomosis of, 519 contusions of, 304 erysipelas of, 402 naevus of, 522 tumors of, 626 sebaceous, 464 wounds of, 304, 305 Scalpel, 96 Scaphoid bone, dislocation of, 296 Scapula, dislocation of, 278 excision of, 597 fracture of, 247 Scarification, 87 Scarpa, diffused hydrocele of cord, 933 galactocele, 733 shoe for club-foot, 623 staphyloma, 642 Schell, arrow wounds, 153 Schmakhalden, fecal fistula, 372 Schneiderian membrane, inflammation and thickening of, 688, 689 Schuh, excision of scapula, 598 Schwanda, phagedaenic chancroid, 435 Schwann, repair of divided nerves, 206 Sciatic artery. See Artery. hernia, 787 Scirrhous cancer. See Scirrhus. Scirrhus, 479 998 ini Scirrhus— acute, 482, 740 atrophic, 480, 489, 740 of breast, 740 retraction of nipple in, 479, 740 treatment of, 741 cachexia in, 480 cuira'ss-like, 482, 740 infiltration of, 479 lardaceous, 479, 740 microscopic appearances of, 481 morbid anatomy of, 481, 482 natural history of, 479, 480, 481 treatment of. See Cancer, treatment of. ulceration of, 479, 480 Scissors, canula, 655, 656 for cutting uvula, 723, 724 Sclerema. See Scleroderma. Scleroderma, 467, 500 Sclerosis of bone, 555 Sclerotic, staphyloma of, 641 Sclerotitis, 643, 644 Scoop, lithotomy, 850, 854 Screw extractor, 163 Scrofula or scrofulosis, 415 in bone, 416, 567 joints, 416 lymphatic glands, 416,417 mucous membranes, 416 operations in, 417 in skin, 415, 416 treatment of, 416, 417 Scrofulous diathesis, 415 osteitis, 567 sarcocele. See Sarcocele, tuberculous. synovitis, 573 temperament, 415 ulcer, 415, 416, 417 Scrotal fistula, 913 hernia, 771, 773 diagnosis of, 776 Scrotum, contusions of, 375 diffuse inflammation of, 923 epithelioma of, 927 erysipelas of, 402 excision of, 925 for varicocele, 935 fissure or cleft of, 920 gangrene of, 388 hypertrophy or elephantiasis of, 925 wounds of, 375 Scultetus, bandage of, 82 Sealing gunshot wounds of chest, 358 Searcher for lithotomy. 850 Sebaceous tumor, 464, 465 Second intention, union by, 142 Secondary abscesses. See Pyaemia. adhesion, 142 amputation, 109 aneurism, 537 cataract, 655 deposits of encephaloid, 483 epithelioma, 490 scirrhus, 480 EX. Secondary— ■ fever, 61 hemorrhage. See Hemorrhage. syphilis, 442. See Syphilis. Secondi, sympathetic neuritis, 666 Secretion in inflammation, 34, 45 Section of bone in amputation, 100 excision, 596 Caesarean, 825 of nerves for tetanus, 515 v perineal, 906. See Urethrotomy, ex- ternal. of tendons. See Tenotomy. veins for phlebitis, 517 varicocele, 936 varix, 519 Sedatives in inflammation, 61 Sedillot, amputation of leg, 124 . volume, of about one thousand pages, with 374 wood outs, extra cloth, $4; strongly bound in leather, with raised bands, $4 75. The Compend of Drs. Neill and Smith is incompara- bly the most valuable work of its class ever published In this country. Attempts have been made in various quarters to squeeze Anatomy, Physiology, Surgery, the Practice of Medicine, Obstetrics, Materia Medica, and Chemistry into a single manual; but the opera- tion has signally failed in the hands of all up to the advent of "Neill and Smith's" volume, which is quite a miracle of success. The outlines of the whole are admirably drawn and illustrated, and the authors are eminently entitled to the grateful consideration of the student of every class.—N. 0. Med. and Surg. Journal. There are but few students or practitioners of me- dicine unacquainted with the former editions of this anassuming though highly instructive work. The whole science of medicine appears to have been sifted, as the gold-bearing sands of £1 Dorado, and the pre- cious factstreasnred up in this little volume. A com- plete portable library so condensed that the student may make it his constant pocket companion.— West- ern Lancet. In the rapid course of lectures, where work for the students is heavy, and review necessary for an exa- mination, a compend is not only valuable, but it is almost a sine qua nnn. The one before us is, in most of the divisions, the most unexceptionable of all books of the kind that we know of. Of course it is useless for us to recommend it to all last course students, but there Is a class to whom we very sincerely commend this cheap book as worth its weight in silver—that class is the graduates In medicine of more than ten years' standing, who have not studied medicine since. They will perhaps find out from it that the science is not exactly now what it was when they left It off.—The Stethoscope. TTARTSHORNE (HENRY), M. D., Professor of Hygiene in the University of Pennsylvania. A CONSPECTUS OF THE MEDICAL SCIENCES; containing Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicino, Surgery, and Obstetrics. In one large royal 12mo. volume of 1000 closely printed page.-!, with over 300 illustrations on wood, extra cloth, $4 50 ; leather, raised bands, $5 2ft. (Just Issued.) The ability of the author, and his practical skill in condensation, give assurance that this work will prove valuable not only to the student preparing for examination, but also to the prac- titioner desirous of obtaining within a moderate compass, a view of the existing condition of the various departments of science connected with medicine. less valuable to the beginner. Every medical student who desires a reliable refresher to his memory when the pressure of lectures and other college work crowds to prevent him from having an opportunity to drink deeper in the larger works, will find this one of th« greatest utility. It is thoroughly trustworthy from beginning to end; and as we have before intimated, a remarkably truthful outline sketch of the present state of medical science. We could hardly expect it should be otherwise, however, under the charge of such a thorough medical scholar as the author has already proved himself to be.—AT. York Med. Record, March 15, 1869. This work is a remarkably complete one in its way, and comes nearer to our idea of what a Conspectus should be than any we have yet eeen. Prof. Harts- horne, with a commendable forethought, intrusted the preparation of many of the chapters on special subjects to experts, reserving only anatomy, physio- logy, and practice of medicine to himself. As a result we have every department worked up to the latest date and in a refreshingly concise and lucid manner. There are an immense amount of illustrations scat- tered throughout the work, and although they have often been seen before in the various works upon gen- eral and special subjects, yet they will be none the T UDLO W (J. L.), M. D. A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmaoy, and Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised and greatly extended and enlarged. With 370 illustrations. In one handsome royal 12mo. volume of 816 large pages, extracloth, $3 25; leather, $3 75. The arrangement of this volume in the form of question and answer renders it especially suit- able for the office examination of students^ and for those preparing for graduation. WANNER (THOMAS HA WKES), M. D., §-c. A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- NOSIS. Third American from the Second London Edition. Revised and Enlarged by Tilbury Fox, M. D., Physician to the Skin Department in University College Hospital, &c In one neat volume small 12mo., of about 375 pages, extra cloth. $150. (Just Issued.) *** By reference to the " Prospectus of Journal" on page 3, it will be seen that this work is offered as a premium for procuring new subscribers to the "American Journal of the Medica* Sciences." The objections commonly, and justly, urged agaimt the general run of "compends," "conspectuses," and other aids to indolence, are not applicable to this little volume, which contains in concise phrase just those practical details that are of most use in daily diag- nosis, but which the young practitioner finds it dilf Taken as a whole, it is the most compact vade me- cum for the use of the advanced strident and jumor practitioner with which we are acquainted.—Boston Med. and Surg. Journal, Sept. 22, 1870. It contains so much that is valuable, Prelsented *n n so attractive a form, that it can hardly De spaiea j always in hie memory without some even in the presence of more full and complete works. The additions made to the volume by Mr. * °x very materially ennance n» vn,i»c, »..------——~ , ., new work Its convenient sue wakes it * jf u™e companion to the country pvac Loner and if con- stantlv carried by him, would often re/de5^m«6°i service, and relieve many a doubt and peiplexity.- quickly accessible means of reference. Altogether, tVe hook is one which we can heartily commend to those who have not opportunity for extensive read- ing, or who, having read much, still wish an occa- sional practical reminder.— N. Y. Med. Gor.'t'e,-Hoy. 10, 1870. service,-------- ,-, T , ,,-n Leavenworth Med. Herald, July, 1S-0 6 Henry C. Lea's Pu QUAY (HENRY), F.R.S., Lecturer on Anatomy at St. George's Hospital, London. ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by H. V. Carter, M. D., late Demonstrator on Anatomy at St. George's Hospital; the Dissec- tions jointly by the Author and De. Carter. A new American, from the fifth enlarged and improved London edition. In one magnificent imperial octavo volume, of nearly POO pages, with 466 large and elaborate engravings on wood. Price in extra cloth, $6 00; leather, raised bands, $7 00, (Just Issued.) The author has endeavored in this work to cover a more extended range of subjects than is cus- tomary in the ordinary text-books, by giving not only the details necessary for the student, but also the application of those details in the practice of medicine and surgery, thus rendering it both a guide for the learner, and an admirable work of reference for the active practitioner. The en ■ gravings form a special feature in the work, many of them being the size of nature, nearly all original, and having the names of the various parts printed on the body of the cut, in place of figures of reference, with descriptions at the foot. They thus form a complete and splendid series, which will greatly assist the Btudent in obtaining a clear idea of Anatomy, and will also serve to refresh the memory of those who may find in the exigencies of practice the necessity of recalling the details of the dissecting room; while combining, as it does, a complete Atlas of Anatomy, with a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of essential use to all physicians who receive students in their offices, relieving both preceptor and pupil of much labor in laying the groundwork of a thorough medical education. Notwithstanding the enlargement of this edition, it has been kept at its former very moderate price, rendering it one of the cheapest works now before the profession. The illustrations are beautifully executed, and ren- I From time to time, as successive editions have ap- der this work an indispensable adjunct to the library peared, we have bad much pleasure in expressing of the surgeon. This remark applies with great fotce to those surgeons practising at a distance from our large cities, as the opportunity of refreshing their memory by actual dissection is not always attain- able.— Canada Med Journal, Aug. 1870. The work is too well known and appreciated by the the general judgment of the wonderful excellence of Gray's Anatomy.—Cincinnati Lancet, July, 1870. Altogether, it is unquestionably the most complete and serviceable text-book in anatomy that has ever been presented to the student, and forms a striking contrast to the dry and perplexing volumes on tbe profession to need any comment. No medical man same subject through which their predecessors strug- can afford to be without it, if its only merit were to gled in days gone by.—Jf. Y. Med. Record, June 15, serve as a reminder of that which so soon becomes j 1870. forgotten, when not called into frequent use, viz., the To COWmend Gray's Anatomy to the medical pro- relations and names of the complex organism of the fes8jon js almost as much a work of supererogation human body. The present edition is much improved. a8 u would be to gi ve a favorable notice of the Bible ^-California Med. Gazette, July, 1870. | iQ the religions press To say that It is the most Gray's Anatomy has been so long the standard of j complete and conveniently arranged text book of its perfection with every student of anatomy, that we | kind, is to repeat what each generation of students need do no more than call attention to the improve- has learned as a tradition of th» elders, and verified ment in the present edition.—Detroit Review of Med. \ by personal experience.—N. Y. Med. Gazette, Deo. and Pliarm., Ang. 1870. I 17, 1870. VMITH (HENRYH.), M.D., and TJORNER ( WILLIAM E.), M.D., Prof, of Surgery in the Univ. of Pen na., Ac. Late Prof, of Anatomy in the Univ. of Penna., &e. AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, extra cloth, with about six hundred and fifty beautiful figures. $4 50. The plan of this Atlas, which renders it so pecu-1 the kind that has yet appeared; and we must add, llarly convenient for the student, and its superb ar-1 fjie very beautiful manner in which it is "got up," tistical execution, have been already pointed out. We is 60 creditable to the country as to be flattering to must congratulate the student upon th» completion I our national pride.—American Medical Journal. of this Atlas, as it is the most convenient work of I &HARPEY (WILLIAM), M.D., and Q UAIN (JONES $■ RICHARD). HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Leidv, M.D., Professor of Anatomy in the University of Pennsylvania. Complete in two large octavo volumes, of about 1300 pages, with 511 illustrations; extra cloth, $6 00. The very low price of this standard work, and its completeness in all departments of the subject, should oommand for it a place in the library of all anatomical students. R ODGES, (RICHARD M.), M.D., Late Demonstrator of Anatomy in the Medical Department of Harvard University. PRACTICAL DISSECTIONS. Second Edition, thoroughly revised. In one neat royal 12mo. volume, half-bound, $2 00. The object of this work is to present to the anatomical student a clear and concise description of that whioh he is expected to observe in an ordinary course of dissections. The author has endeavored to omit unnecessary details, and to present the subject in the form which many years' experience has shown him to be the most convenient and intelligible to the student. In the revision of the present edition, he has sedulously labored to render the volume more worthy of the favor with which it has heretofore been received. Henry C. Lea's Publications—(Anatomy). 1 TyiLSON (ERASMUS), F.R.S. A SYSTEM OF HUMAN ANATOMY, General and Special. Edited by W. H. Gobrecht, M. D., Professor of General and Surgical Anatomy in the Medical Col- lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. In one large and handsome octavo volume, of over 600 large pages; extra cloth, $4 00; lea- ther, $5 00. The publisher trusts that the well-earned reputation of this long-established favorite will be more than maintained by the present edition. Besides a very thorough revision by the author, it has been most carefully examined by the editor, and the efforts of both have been directed to in- troducing everything which increased experience in its use has suggested as desirable to render it a- complete text-book for those seeking to obtain or to renew an acquaintance with Human Ana- tomy. The amount of additions which it has thus received may be estimated from the faot that the present edition contains over one-fourth more matter than the last, rendering a smaller type and an enlarged page requisite to keep the volume within a convenient size. The author has not only thus added largely to tbe work, but he has also made alterations throughout, wherever there appeared the opportunity of improving the arrangement or style, so as to present every fact in its most appropriate manner, and to render the whole as clear and intelligible as possible. The editor has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased the number of illustrations, of which there are about one hundred and fifty more in this edition than in the last, thus bringing distinctly before the eye of the student everything of interest or importance. JJEATH (CHRISTOPHER), F. R. C. S., ■*■-*- Teaclier of Operative Surgery in University College, London. PRACTICAL ANATOMY: A Manual of Dissections. From the Second revised and improved London edition. Edited, with additions, by W. W. Kees; M. D., Lecturer on Pathological Anatomy in the Jefferson Medical College, Philadelphia. In one handsome royal 12mo. volume of 578 pages, with 247 illustrations. Extra cloth, $3 50; leather, $4 00. (Just Issued.) Dr. Keen, the American editor of this work, in his | Such manuals of anatomy are always favorite works preface, says: "In presenting this American edition I with medical students. We would earnestly recoin- of ' Heath's Practical Anatomy,' I feel that I have ! mend this one to their attention ; it has excellences been instrumental in supplying a want long felt for I which make it valuable as a guidq in dissecting, as a real dissector's manual," and thi* assertion of its ! well as in studying anatomy.—Buffalo Medical and editor we deem is fully justified, after an examina- j Surgical Journal, Jan. 1871. tion of its coutents, for it is really an excellent work. | Tne nrgt English edition was issued about six years Indeed, we do not hesitate to »ay, the best of its class ag0> an(j wag favorably received not only on account with which we are acquainted ; resembling Wilson ' oi t'ne great reputation of its author, but also from in terse and clear description, excelling most of the jts greac value and excellence as a guide-book to the so-called practical anatomical dissectors in the scope ! practical anatomist. The American edition has uu- of the subject and practical selected matter. . . . j dergone some alterations and additions which will In reading this work, one is forcibly impressed with n0 doubt enhance Us value materially. The conve- the great pains the author takes to impress the sub- | nience 0f the student has been carefully consulted in ject upon the mind of the student. He is full of rare the arrangement of the text, and the directions given and pleasing little devices to aid memory in main- fol. tue prosecution of certain dissections will be duly tainingits hold upon the slippery slopes of anatomy. ■ appreciated.—Canada Lancet, Feb. 1871. -St. Louis Med. and Surg. Journal, Mar. 10, 1871. This .s aQ excellent Director's Manual; one which It appears to us certain that, as a guide in dissec- is not merely a descriptive manual of anatomy, but tion, and as a work containing facts of anatomy in a guide to the student at the dissecting table, euabhnS brief and easily understood form, this manual is him, though a beginner, to prosecute his work mtel- complete This work contains, also, very perfect | ligently, and without assistance, fhe American edi- illustrations of parts which can thus be more easily \ tor has made many valuable alterations and addi- nnderstood and studied; in this respect it compares I tions to the original work— Am. Journ. of Obstetrics, favorably with works of much greater pretension. Feb. 1871. MACLISE (JOSEPH). SURGICAL ANATOMY. By Joseph Maclise, Surgeon. In one volume very large imperial quarto; with 68 large and splendid plates, drawn in the be?t style and beautifully colored, containing 190 figures, many of them the size of life: together with copious explanatory letter-press. Strongly and handsomely bound in extra cloth. Price $14 00. ,,. . , . it_ _ ,. , , ,, As no complete work of the kind has heretofore been published in the English language, the present volume will supply a want long felt in this country of an accurate and comprehensive Atlas of Surgical Anatomy, to which the student and practitioner can at all times refer to ascer- tain the exact relative positions of the various portions of the human frame towards each> other and to the surface, as well as their abnormal deviations. Notwithstanding the large size, beauty and finish of the very numerous illustrations, it will be observed that the price u so low as to place it within the reach of all members of the profession. ■or i «• m^t „„ anroiral anatomy which . refreshed by those clear and distinct dissections, We know of no work on surgical anatomy w ^ich ever/one must appreciate who has a particle can compete with it.—Lancet. - j 0f enthusiasm. The English medical press has quite Tbe work of Maclise on surgical anatomy Is ol tne exnausted tne word8 0f praise, in recommending thjs highest value. In some respects it is the best PUDl1- a(imirable treatise. Those Who have any curiosity cation of its kind we have seen, and is woifny oi a | ^ gratifVi in reference to the perfectibility of t he place in the libiary of any medical man, wnue iue . ,ltll0graphic art in delineating the complex mecljan student could scarcely make a be«7\,nves"n(?^„° „ ism of the human body, are Invited to examine out this.-ZVie Western Journal of Medicine cmd Surgery. No such lithographic iUustrations oJT wrgica^re- specimen copy. If anything will induce surgeons and students to patronize a book of such rare value and everyday importance to them, it will be a survey glons have hitherto, we think, been 8iv«n_ where ' of tne artlstical skill exhibited in'these fac-similee ol the operator is shown every vessel ana "°r . ; aature._£0«t0n Med. and Surg. Journal. *n operation is contemplated, the exact anaijui______________ , *,. »mrv i vn HT9T0LOGY I In 2 vols. 8vo., of over 1000 pages, with more than t^^SJS?™™^^^' 30°wood'cuts:extraclotb'*"w- 8 Henry C. Lea's Publications—(Physiology). 1KTARSHALL (JOHN), F. R. S., JJJ. Professor of Surgery in University College, London, &e. OUTLINES OF PHYSIOLOGY, HUMAN AND COMPARATIVE. With Additions by Francis Gurney Smith, M. D., Professor of the Institutes of Medi- cine in the University of Pennsylvania, Ac. With numerous illustrations. In one large and handsome octavo volume, of 1026 pages, extra cloth, $6 50; leather, raised bands. $7 50. In fact, in every respe'ct, Mr. Marshall has present- ed us with a most complete, reliable, and scientific work, and we feel that it is worthy our warthest commendation.—St. Louts Med. Reporter, Jan. 1869. This is' an elaborate and carefully prepared digest of human and comparative physiology, designed for the use of general readers, but more especially ser- viceable to the student of medicine. Its style is con- cise, clear, and scholarly; its order perspicuous and exact, and its range of topics extended. The author and his American editor have been careful to bring to the illustration of the subject the important disco- veries of modern science in the various cognate de- partments of investigation. This is especially visible in the variety of interesting information derived from the departments of chemistry and physics. The great amount and variety of matter contained in the work is strikingly illustrated by turning over the copious index, covering twenty-four closely printed pages in double columns.—Silliman's Journal, Jan. 1869. We doubt If there is in the English language any compend of physiology more useful to the student than this work.—St. Louis Med. and Surg. Journal, Jan. 1869. It quite fulfils, in our opinion, the author's design of making it truly educational in its character—which is, perhaps, the highest commendation that can be asked.—Am. Journ. Med. Sciences, Jan. 1869. We may now congratulate him on having com- pleted the latest as well as the best summary of mod- ern physiological science, both human and compara- tive, with which we are acquainted. To speak ot this work in the terms ordinarily used on such occa- sions would not be agreeable to ourselves, and would fail to do justice to its author. To write such a book requires a varied and wide range of knowledge, con- siderable power of analysis, correct judgment, skill in arrangement, and conscientious spirit. It must have entailed great labor, but now that the task has been fulfilled, the book will prove not only invaluable to the student of medicine'and surgery, but service- able to all candidates in natural science examinations, to teachers in schools, and to the lover of nature gene- rally. In conclusion, we can only express the con- viction that the merits of the work will command for It that success which the ability and vast labor dis- played in its production so well deserve.—London Lancet, Feb. 22, 1868. If the possession of knowledge, and peculiar apti- tude and skill in expounding it, qualify a man to write an educational work, Mr. Marshall's treatise might be reviewed favorably without even opening the covers. There are few, if any, more accomplished anatomists and physiologists than the distinguished professor of surgery at University College ; and he has long enjoyed the highest reputation as a teacher of physiology, possessing remarkable powers of clear exposition and graphic illustration. We.have rarely the pleasure of being able to recommend a text-book so unreservedly as this.—British Med. Journal, Jan. 25, 1868. flARPENTER (WILLIAM B.), M.D., F.R.S., v Examiner in Physiology and Comparative Anatomy in the University of London. PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief appli- cations to Psychology, Pathology, Therapeutics, Hygiene and Forensic Medicine. A new American from the last and revised London edition. With nearly three hundred illustrations. Edited, with additions, by Francis Gurnet Smith, M. D., Professor of the Institutes of Medicine in the University of Pennsylvania, Ac. In one very large and beautiful octavo volume, of about 900 large pages, handsomely printed; extra cloth, $5 50 ; leather, raised bands, $6 50. We doubt not it is destined to retain a strong hold on public favor, and remain the favorite text-book in our colleges.—Virginia Medical Journal. With Dr. Smith, we confidently believe "that the present will more than sustain the enviable reputa- tion already attained by former editions, of being one of the fullest and most complete treatises on the subject in the English language." We know of none from the pages of which a satisfactory knowledge of the physiology of the human organism can be as well obtained, none better adapted for the use of such as take up the study of physiology in its reference tof the institutes and practice of medicine.—Am. Jour. Med. Sciences. The above is the title of what is emphatically the great work on physiology; and we are conscious that it would be a useless effort to attempt to add any- thing to the reputation of this invaluable work, and can only say to all with whom our opinion has any influence, that It Is our authority.—Atlanta Med. Journal. T>Y THE SAME AUTHOR. PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New Ameri- can, from the Fourth and Revised London Edition. In one large and handsome octavo volume, with over three hundred beautiful illustrations Pp. 752. Extra cloth, $5 00. As a complete and condensed treatise on its extended and important subject, this work becomes a necessity to students of natural science, while the very low price at which it is offered places it within the reach of all. JflRKES (WILLIAM SENHOUSE), M.D. A MANUAL OF PHYSIOLOGY. A new American from the third and improved London edition. With two hundred illustrations. In one large and hand- some royal 12mo. volume. Pp. 686. Extra cloth, $2 25; leather, $2 75. It is at once convenient in size, comprehensive in design, and concise in statement, and altogether well adapted for the purpose designed.—St. Louis Med. and, Surg. Journal. The physiological reader will find It a most excel- lent guide in the study of physiology in its most ad- vanced and perfect form. The author has shown himself capable of giving details sufficiently ample in a condensed and concentrated shape, on a science in which it is necessary at once to be correct and not lengthened.—Edinburgh Med. and Surg. Journal, Henry C. Lea's Publications—(Physiology). 9 J1ALTON (J. C), M. D., •*S Professor of Physiology in the College of Physicians and Surgeons, New York, &c. A TREATISE ON HUMAN PHYSIOLOGY. Designed for the use of Students and Practitioners of Medicine. Fourth edition, revised, with nearly three hun- dred illustrations on wood. In one very beautiful octavo volume, of about 700 pages, extia cloth, $5 25; leather, $6 25. From the Preface to the New Edition. "The progress made by Physiology and the kindred Sciences during the last few years has re- quired, for the present edition of this work, a thorough and extensive revision. This progress has not consisted in any very striking single discoveries, nor in a decided revolution in any of the departments of Physiology; but it has been marked by great activity of investigation in a multitude of different directions, the combined results of which have not failed to impress a new character on many of the features of physiological knowledge. ... In the revision a.nd correction of the present edition, the author has endeavored to incorporate all such improve- ments in physiological knowledge with the mass of the text in such a manner as not essentially to alter the structure and plan of the work, so far as they have been found adapted to the wants and convenience of the reader. . . . Several new illustrations are introduced, some of them as additions, others as improvements or corrections of the old. Although all parts of the book have received more or less complete revision, the greatest number of additions and changes were required in the Second Section, on the Physiology of the Nervous System." The advent of the first edition of Prof. Dalton's merits of clearness and condensation, and being fully Physiology, about eight year.s ago, marked a new era '' Ja the study of physiology to the American student. Under Dalton's skilful management, physiological science threw off the long, loose, ungainly garments of probability and surmise, in which it had been ar- rayed by most artists, and came among us smiling and attractive, in the beautifully tinted and closely fitting dress of a demonstrated science. It was a stroke of genius, as well as a result of erndition and talent, that led Prof. Dalton to present to the world a work on physiology at once brief, pointed, and com- prehensive, and which exhibited plainly in letter and drawings the basis upon which the conclusions ar- rived at rested. It is no disparagement of the many brought up to the present level of Physiology, it is undoubtedly one of the most reliable text-books upon this science that could be placed in the hands of the medical student.—Am. Journal Med. Sciences, Oct. 1867. Prof. Dalton's work has such a well-established reputation that it does not stand in need of any re- commendation. Ever since its first appearance it has become the highest authority in the English language; and that it is able to maintain the enviable position which it has taken, the rapid exhaustion of the dif- ferent successive editions is sufficient evidence. The present edition, which is the fourth, has been tho- excellent works on physiology, published prior to I roughly revised, and enlarged by the incorporation that of Dalton, to say that none of them, either in ! of a11 the many important advances which have plan of arrangement or clearness of execution, could I lately beeu raade in this rapidly progressing science. be compared with his for the use of students or gene- ral practitioners of medicine. For this purpose his book has no equal in the English language.— Western Journal of Medicine, Not. 1867. A capital text-book In every way. We are, there- w£> !l!LdJ?«8J? 5f l*,1,*? fon£* 6duti0n- ," haS alreldy The present edition of this now standard work fully ™^n^«L*Kf"^ stains the high reputation of its accomplished an- —N. Y. Med. Record, Oct. 15, 1867. As it stands, we esteem it the very best of the phy- siological text-books for the student, and the most concise reference and guide-book for the practitioner. —N. Y. Med. Journal, Oct. 1867. we need not now further advert to it beyond remark Ing that both revision and enlargement have been most judicious.— London Med. Times and Gazette, Oct. 19, 1867. No better proof of the value of this admirable work could be produced than the fact that it has al- ready reached a fourth edition in the Bhort space of eight years. Possessing in an eminent degree the thor. It is not merely a reprint, but has been faith- fully revised, and enriched by such additions as the progress of physiology has rendered desirable. Taken as a whole, it is unquestionably the most reliable and useful treatise on the subject that has been issued from the American press.—Chicago Med. Journal, Sept. 1867. J}UNGLISON (ROBLEY), M.D., •U Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and extensively modified and enlarged, with five hundred and thirty-two illustrations. In two large and handsomely printed octavo volumes of about 1500 pages, extra cloth. $7 00. TEHMANN (C. G.). PHYSIOLOGICAL CHEMISTRY. Translated from the second edi- tion by George E. Dat, M. D., F. R. S., 4c, edited by R. E. Rogers, M. D., Professor of Chemistry in the Medical Department of the University of Pennsylvania, with illustrations selected from Funke's Atlas of Physiological Chemistry, and an Appendix of plates. Com- plete in two large and handsome octavo volumes, containing 1200 pages, with nearly two hundred illustrations, extra cloth. $6 00. VY THE SAME AUTHOR. MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the Germati, with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory Essay on Vital Force, by Professor Samuel Jackson, M. D., of the University of Pennsyl- vania. With illustrations on wood. In one very handsome octavo volume of 336 pages. extra cloth. $2 25. __________________ WODD (ROBERT B.), M.D. F.R.S., and JfiOWMAN (W.), F.R.S. THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN With about three hundred large and beautiful illustrations on wood. Complete in one large octavo volume of 950 pages, extra cloth. Price $4 75. 10 Henry C. Lea's Publications—(Chemistry). ATTFIELD (JOHN), Ph.D., Professor of Practical Chemistry to the. Pharmaceutical Society of Great Britain, *c. CHEMISTRY, GENERAL, MEDICAL, AND PHARMACEUTICAL; including the Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, and their Application to Medicine and Pharmacy. From the Second and Enlarged English Edition, revised by the author. In one handsome royal 12mo. volume of about 550 pages ; extra cloth, $2 75 : leather, $3 25. (Just Issued.) It contains a most admirable digest of what is spe-1 required at his examinations.—The Pharmaceutical cially needed by the medical student in all that re- j Journal. lates to practical chemistry, and constitutes for him | At page 3go of the cnrrent T0lume of this journal, a sound and useful text-book on the subject. . . . . , we remarked that " there is a sad dearth of [medical] We commend it to the notice of every medical, as well | stu(ients> text-books in chemistry." Dr. Attfield's 8> pharmaceutical, student. We only regret that we . vohiine, just published, is rather a new book than a had not the hook to depend upon in working up the I second edition of his previous work, and more nearly subject of practical and pharmaceutical chemistry for , reftnzes our ideal than any book we have before seen the University of London, for which it seems to ns that it is exactly adapted. This is paying the book a high compliment.—The Lancet. Dr. Attfield's book is written in a clear and able manner; it is a work sui generis and without a rival; it will be welcomed, we think, by every reader of the 'Pharmacopoeia,' and is quite aR well suited for the medical student as for the pharmacist.—The Chemi- cal News. A valuable guide to practical medical chemistry, and an admirable companion to the "British Phar- macopoeia. " It Is rare to find so many qualities com- bined, and quite curious to note how much valuable information finds a mutual interdependence.—Medi- cal Times and Gazette. It is almost the only book from which the medical student can work up the phannacopoeial chemistry on the subject. — The British Medical Journal. The introduction of new matter has not destroyed the original character of the work, as a treatise on pharmaceutical and medical chemistry, but has sim- ply extended the foundations of these special depart- ments of the science.—The Chemist and Druggist. We believe that this mannal has been already adopted as the class-book by many of the professors in the public schools throughout the United Kingdom. ... In pharmaceutical chemistry applied to the phar- macopoeia, we know of no rival. It is, therefore, par- ticularly suited to the medical student.—The Medical Press and Circular. It in every way fulfils the intention of the author. We can strongly recommend it as a most complete manual of chemistry, alike useful to the physician and pharmaceutist.—Canada Med. Journ., Nov.'70. fiDLING (WILLIAM), ^s Lecturer on Chemistry, at St. Bartholomew's Ho/>pitil, &c. A COURSE OF PRACTICAL CHEMISTRY, arranged for the Use of Medical Students. With Illustrations. From the Fourth and Revised London Edition. In one neat royal 12mo. volume, extra cloth. $2. (Lately Issued.) As a work for the practitioner it cannot be excelled. I ganio chemistry, etc. The portions devoted to a dis- It is written plainly and concisely, and gives in a very I cussion of these subjects are very excellent. In no small compass the information required by the busy I work can the physician find more that is valuable practitioner. It is essentially a work for thephysi- and reliable in regard to urine, bile, milk, bone, uri- cian, and no one who purchasesit will ever regret the | nary calculi, tissue composition, etc. The work is outlay. In addition to all that is usually given in | small, reasonable in price, and well published.— connection with inorganic chemistry, there are most | Richmond and Louisville Med. Journal, Dec. 1869. valuable contributions to toxicology, animal and or-1 JDO WMAN (JOHN E.), M. D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited by C. L. Bloxam, Professor of Practical Chemistry in King's College, London. Fifth American, from the fourth and revised English Edition. In one neat volume, royal 12mo., pp. 351, with numerous illustrations, extra cloth. S2 25. (Just Issued.) The fourth edition of this invaluable text.book of Medical Chemistry was published in England in Octo- ber of the last year. The Editor has brought down the Handbook to that date, introducing, as far as was compatible with the necessary conciseness of such a work, all the valuable discoveries in the science which have come to light since the previous edition was printed. The work is indispensable to every student of medicine or enlightened practitioner. It is printed in clear type, and the illustrations are numerous and intelligible.—Boston Med. and Surg. Journal. JDY THE SAME AUTHOR. ---- INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANALYSIS. Fifth American, from the fifth and revised London edition. With numer- ous illustrations. In One neat vol., royal 12mo., extra cloth. $2 25. (Just Issued.) One of the most complete manuals that has for a long time been, given to the medical student.— Athenawm. We regard it as realizing almost everything to be desired in an introduction to Practical Chemistry. It is by far the best adapted for the Chemical student of any that has yet fallen in our way.—British and Foreign Medieo-Chirurgical Review. The best introductory work on the subject with which we are acquainted.—Edinburgh Monthly Jour. pRAHAM (THOMAS), F.R.S. ^THE ELEMENTS OF INORGANIC CHEMISTRY, including the Applications of the Science in the Arts. New and much enlarged edition, by Henrt Watts and Robert Bridges, M. D. Complete in one large and handsome octavo volume, of over 800 very large pages, with two hundred and thirty-two wood-cuts, extra cloth. $5 50. _____________ KNAPP'S TECHNOLOGT; or Chemistry Applied to very handsome octavo volumes, with 500 wood the Arts, and to Manufactures. With American engravings, extra cloth, $6 00. additions, by Prof. Walter K. Johnson; In two Henry C. Lea's Publications—( Chemistry, Pharmacy, &c). 11 pro WNES (GEORGE), Ph. D. A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. With one hundred and ninety-seven illustrations. A new American, from the tenth and revised London edition. Edited by Robert Bridges, M. D. In one large royal 12mo. volume, of about 850 pp., extra cloth, $2 75 ; leather, $3 25. (Just Issued.) Some years having elapsed sinoe the appearance of the last American edition, and several revisions having been made of the work in England during the interval, it will be found very greatly altered, ami enlarged by about two hundred and fifty pages, containing nearly one half more matter than before. The editors, Mr. Watts and Dr. Bence Jones, have labored sedulously to render it worthy in all respects of the very remarkable favor which it has thus far enjoyed, by incorporating in it all the most recent investigations and discoveries, in so far as is compatible with its design as an elementary text-book. While its distinguishing characteristics have been pre- served, various portions have been rewritten, and especial pains have been takeu with the department of Organic Chemistry in which late researches have accumulated so many new facts and have enabled the subject to be systematized and rendered intelligible in a manner formerly impossible. As only a few months have elapsed since the work thus passed through the hands of Mr. Watts and Dr. Bence Jones, but little has remained to be done by the American editor. Such additions as seemed advisable have however been made, and especial care has been taken to secure, by the closest scrutiny, the accuracy so essential in a work of this nature. Thus fully brought up to a level with the latest advances of science, and presented at a price within the reach of all, it is hoped that the work will maintain its position as the favorite text- book of the medical student. This work is so well known that it seems almost i the General Principles of Chemical Philosophy, and superfluous for us to speak about it. It has been a favorite text-book with medical students for years, and its popularity has in no respect diminished. Whenever we have been consulted by medical stu- dents, as has frequently occurred, what treatise on chemistry they should procure, we have always re- commended Fownes', for we regarded it as the best. There is no work that combines so many excellen- ces. It is of convenient size, not prolix, of plain perspicuous diction, contains all the most recent discoveries, and is of moderate price.—Cincinnati Med. Repertory, Aug. 1669. Large additions have been made, especially in the department of organic chemistry, and we know of no other work that has greater claims on the physician, pharmaceutist, or student, than this. We cheerfully recommend it as the best text-book on elementary chemistry, and bespeak for it the careful attention of students of pharmacy.—Chicago Pharmacist, Aug. 1869. The American reprint of the tenth revised and cor- rected English edition is now issued, and represents the present condition of the science. No comments are necessary to insure it a favorable reception at the hands of practitioners and students. — Boston Med. and Surg. Journal, Aug. 12, 1869. It will continue, as heretofore, to hold the first rank as a text-book for students of medicine.—Chicago Med. Examiner, Aug. 1869. This work, long the recognized Manual of Chemistry, appears as a tenth edition, under the able editorship of Bence Jones and Henry Watts. The chapter on the greater part of the organic chemistry, have been rewritten, and. the whole work revised in accordance with the recent advances in chemical knowledge. It remains the standard text-book of chemistry.—Dub- lin Quarterly Journal, Feb. 1869. There is probably not a student of chemietry in this country to whom the admirable manual of the late Professor Fownes is unknown. It has achieved a success which we believe is entirely without a paral- lel among scientific text-books in our language. This success has arisen from the fact that there is no En- glish work on chemistry which combines so many excellences. Of convenient size, of attractive form, clear and concise in diction, well Illustrated, and of moderate price, it would seem that every requisite for a student's hand-book has been attained. The ninth edition was published under the joint editor- ship of Dr. Bence Jones and Dr. Hofmann; the new one has been superintended through the press by Dr. Bence Jones and Mr. Henry Watts. It is not too much to say that it could not possibly have been in better hands. There is no one in England who can compare with Mr. Watts in experience as a compiler in chemical literature, and we have much pleasure in recording the fact that his reputation is well sus- tained by this, his last undertaking.—The Chemical News, Feb. 1869. Here is a new edition which has been long watched for by eager teachers of chemistry. In its new garb, and under the editorship of Mr. Watts, it has resumed its old place as the most successful of text-books.— Indian Medical Gazette, Jan. 1, 1869. -DRANDE (WM. T.), D. C.L., and r^AYLOR (ALFRED S.), M.D., F.R.S. CHEMISTRY. Second American edition, thoroughly revised by Dr. Taylor. In one handsome 8vo. volume of 764 pages, extra cloth, $5 00; leather, $6 00. From Dr. Taylor's Preface. "The revision of the second edition, in consequence of the death of my lamented colleague, has devolved entirely upon myself. Every chapter, and indeed every page, has been revised »nd numerous additions made in all parts of the volume. These additions have been restricted chiefly to subjects having some practical interest, and they have beer, made as concise as P«"^l«, in order to keep the bool within those limits which may retain for it the character of a Student a Manual "—London, June 29, 1867. . A book that has already so established a reputa- | of information.with the most sparing^ose of technical tion, as has Brande and Taylor's Chemistry, can erms and[ ^^^y^^nl^ ^n'lt^ hardly need a notice, save to -ef on the add t10n8 ^he he a ^£™^*X\& spence and' "VTCM.1 aVvS'texWok^n f. practice of.chemistry.''-Journal of Applied Che„, wwia win luujj remain n> .«.»*.. *«~----- - - . •cuools, as well as a convenient book of reference lor tll—N. Y. Medical Gazette, Oct. 12, 1867. For this reason we hail with delight the republica- tion, in a form which will meet with general approval and command public attention, of this really ™lua" ble standard work on chemistry-more V^^L is it has been adapted with such care to the wants of have been careful to give the largest possible amount ] istry, Oct. 1867. This second Amerioan edition of an excellent trea- tise on chemical science is not a mere republication from the English press, but is a revision and en- largement of the original, under the supervision of the surviving author, Dr. Taylor. The favorable opinion expressed on the publication of the former edition of this work is fully sustained by the pres-ut revision, in which Dr. T. has increased the size of the volume, bv"an addition of sixty-eight pages.—Am. 12 Henry C. Lea's Publications—(Mat. Med. and Therapeutics). JDARRISH (ED WARD), Professor of Materia Medica in the Philadelphia College of Pharmacy. A TREATISE ON PHARMACY. Designed as a Text-Book for the Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. Third Edition, greatly improved. In one handsome octavo volume, of 850 pages, with several hundred illustrations, extra cloth. $5 00. The immense amount of practical information oondensed in this volume may be estimated from the fact that the Index contains about 4700 items. Under the head of Acids there are 312 refer- ences ; under Emplastrum, 36; Extracts, 159; Lozenges, 25; Mixtures, 55 ; Pills, 56; Syrups, 181; Tinctures, 138; Unguentum, 57, &o. We have examined this large volume with a good .not wish it to be understood as very extravagant deal of care, and find that the author has completely | praise. In truth, it is not so much the best as the exhausted the subject upon which he treats ; a more i only book.—The London Chemical News. complete work, we think, it would be impossible to . _ . . . , , ... ... , , find To the student of pharmacy the work is indis- _ An attempt to furnish anything like an analysis of pensable; indeed, so far as we know, it is the only one £arr'8,h 8, *iryj;a,nable "d el^r^ Treatise on of its kind in existence, and even to the physician or Practical Pharmacy would require more space than medical student who can spare five dollars to pur- we ha™ at °nr disposal This, however. Is not so chase It, we feel sure the practical information he rouch a matter of regret, inasmuch as it would be will obtain will more than compensate him. for the difficult to think of any point, however minute and out,ay.-C«««rf« Med. Journal, Nov. 1864. | ^^^^Zl^JSS^^&^Z The medical student and the practising physician j not ^BU clearly and carefully discussed in this vol. will find the volume of inestimable worth for study j nme Want of space prevents our enlarging further and reference.— San Francisco Med. Press, July, on tnis valuable work, and we must conclude by a 1864. simple expression of our hearty appreciation of its When we say that this book is in some respects | merits.—Ditblin Quarterly Jour, of Medical Science, the best Which has been published on the subject in August, 1S64. the English language for a great many years, we do I SfTILLE (ALFRED), M.D., U Professor of Theory and Practice of Medicine in the University of Penna. THERAPEUTICS AND MATERIA MEDICA; a Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and History. Third edition, revised and enlarged. In two large and handsome octavo volumes of about 1700 pages, extra cloth, $10 ; leather, $12. Dr. Stille's splendid work on therapeutics and ma-1 abroad its reputation as a standard treatise on Materia teria medica.—London Med. Times, April 8, 1865. i Medica is securely established. It is second to no Dr. Stille' stands to-day one of the best and most j work on the SUDJect in the English tongue, and, in- honored representatives at home and abroad, of Ame- \ de?d'i8 decidedly superior in some respects, to any rican medicine; and these volumes, a library in them- other.— Pacific Med. and Surg. Journal, July, 1868. selves, a treasure-house for every studious physician, Still6's Therapeutics is incomparably the best work assure his fame even had he done nothing more.—The on the subject.—N. Y. Med. Gazette, Sept. 26, 1868. Western Journal of Medicine, Dec. 1868. Dr stul6>8 work is becoming the best known of any We regard this work as the best one on Materia of our treatises on Materia Medica. . . . One of the Medica in the English language, and as such it de- i most valuable works in the language on the subjects serves the favor It has received.—Am. Journ. Medi cal Sciences, July 1868. We need not dwell on the merits of the third edition of this magnificently conceived work. It is the work of which it treats.—N. Y. Med. Journal, Oct. 1S6S. The rapid exhaustion of two editions of Prof. Stille's scholarly work, and the consequent necessity for a third edition, is sufficient evidence of the high esti- on Materia Medica, in which Therapeutics are prima- j mate placed upon it by the profession. It is no exag- rily considered—the mere natural history of drugs ! geration to say that there is no superior work upon being briefly disposed of. To medical practitioners j the 'subject in the English language. The present this is a very valuable conception. It is wonderful edition is fully up to the most recent advance in the how much of the riches of tbe literature of Materia Medica has been condensed into this book. The refer- ences alone would make it worth possessing. But it is not a mere compilation. The writer exercises a good judgment of his own on the great doctrines and points of Therapeutics. For purposes of practice, science and art of therapeutics.—Leavenworth Medi- cal Herald, Aug. 1868. The work of Prof. Stille has rapidly taken a high place in professional esteem, and to say that a third edition is demanded and now appears before as, suffi- ciently attests the firm position this treatise has made ^.^3^ tft fef o Tr^ °f iD; *' *&" A« a ™rtTof grekt^re";arch7and scholar «.. «V mI Zl Vw, ?« ' TrLh»e 5?t\°,55,a,ui »Wr it is safe to say we have nothing superior. It is uses of meiicm^.-London Lancet, Oct. SI, 1868. 1 exc* d,ngly full- a*d the busy practitioner will flnd • Through theformer editions, the professional world ' ample suggestions upon almost every important point is well'acquainted with this work. At home and | of therapeutics.—Cincinnati Lancet, Aug. 1868. QRIFFTTH (ROBERT E.)t M.D. A UNIVERSAL FORMULARY, Containing the Methods of Pre- paring and Administering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceutists. Second edition, thoroughly revised, with numerous additions, by Robert P. Thomas, M.D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large and handsome octavo volume of 650 pages, double-columns. Extra cloth, $4 00; leather, $5 00. Three complete and extended Indexes render the work especially adapted for immediate consul- tation. 0ne, of Diseases and their Remedies, presents under the head of each disease the remedial agents whieh haVe, been usefully exhibited in it, with reference to the formulae containing them—while* another of Pharmaceutical and Botanical Names, and a very thorough General Index afford the means of-obtaining at once any information desired. The Formulary itself ia arranged alphabetically, under the heads of the leading constituents of the prescriptions. We know of none in oar language, or any other, so comprehensive in its details.—London Lancet. One of the most complete/works of the kind in any language.—Edinburgh Med. Journal. We are not cognizant of the existence of a parallel work.— London Med. Gazette. Henry C. Lea's Publications—(-Ma*. Med. and Therapeutics). 13 pEREIRA (JONATHAN), M.D., F.R.S. and L.S. MATERIA MEDICA AND THERAPEUTICS; being an Abridg- ment of the late Dr. Pereira's Elements of Materia Medica, arranged in conformity with the British Pharmacopoeia, and adapted to the use of Medical Practitioners, Chemists and Druggists, Medical and Pharmaceutical Students, empiricism. We must conclude by again express- There is no work in medical literature which can i in« onr hi8h sense of the immense benefit which ail the place of this one. It is the Primer of the Dr- Williams has conferred on medicine by the pub- young practitioner, the Koran of the scientific one.— j Nation of this work. We are certain that in the Stethoscope. present state of our knowledge his Principles of Medi- ....,.,., ., , . I cine could not possibly be surpassed.—London Jour A text-book to which no other in our language is j of Medicine *««•«*«•« <*• comparable.—Charleston Med. Journal. HARRISON'S ESSAY TOWARDS A CORRECT THEORY OF THE NERVOUS SYSTEM. In one octavo volume of 232 pp. $1 50. SOLLY ON THE HUMAN BRAIN : Its Structure,Phy- siology, and Diseases. From the Second and much enlarged London edition. In one octavo volume of 500pages. witb 120wood-cuts: extra cloth. 4(2 50. LA ROCHE ON YELLOW FEVER, considered in Its Historical, Pathological, Etiological, and Therapeu- tical Relations. In two large and handsome octavo volumes, of nearly 1500 pages, extra cloth, $7 00. LA ROCHE ON PNEUMONIA ; its Supposed Connec- tion, Pathological, and Etiological, with Autumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria. In one handsome oc- tavo volume, extra cloth, of 500 pages Price iSfln. BUCKLER ON FIBRO-BRONCHITIS AND RHEU- MATIC PNEUMONIA. In one octavo vol., extra cloth, pp. 150. $1 25. FISKE FUND PRIZE ESSAYS.—LEE ON THE EF- FECTS OF CLIMATE ON TUBERCULOUS DIS- EASE. AND WARREN ON THE INFLUENCE OF PREGNANCY ON THE DEVELOPMENT OF TU- BERCLES. Together in one neat octavo volume extra cloth, $1 00. T>ARCLAY (A. W.), M. D. "A MANUAL OF MEDICAL DIAGNOSIS; being an Analysis of the Signs and Symptoms of Disease. Third American from the second and revised London edition. In one neat octavo volume of 451 pages, extra cloth. $3 50. A work of immense practical utility.—London I The book should be in the hands of every practical Med. Times and Gazette. man.—Dublin Med. Press. Henry C. Lea's Publications—(Practice of Medicine). TjlLINT (AUSTIN), M.D., „ „,„„ „ T ■L Professor of the Principles and Practice of Medicine in Bellevue Med. College, N. Y. A TREATISE ON THE PRINCIPLES AND PRACTICE OF MEDICINE; designed for the use of Students and Practitioners of Medicine. Third edition, revised and enlarged. In one large and closely printed octavo volume of 1002 pages; handsome extra cloth, $6 00; or strongly bound in leather, with raised bands, $< 00. (Lately Published.) By common consent of the English and American medical press, this work has been assigned to the highest position as a complete and compendious text-book on the most advanced condition of medical science. At the very moderate price at which it is offered it will be found one of the cheapest volumes now before the profession. Admirable and unequalled. — Western Journal of Medicine, Nov. 1869. Dr. Flint's work, though claiming no higher title than that of a text-book, is really more. He is a man uf large clinical experience, and his book ia full of kucu masterly descriptions of disease as can only be drawn by a man intimately acquainted with their various forms. It is not so long since we had the pleasure of reviewing his first edition, and we recog- nize a great improvement, especially in the general part of the work. It is a work which we can cordially recommend to our readers as fully abreast of the sci- ence of the day.—Edinburgh Med. Journal, Oct. '69. One of the best works of the kind for the practi- tioner, and the most convenient of all for the student. —Am. Journ. Med. Sciences, Jan. 1S69. This work, which stands pre-eminently as the ad- vance standard of medical science up to the present time in the practice of medicine, has for its author one who is well and widely known as one of the leading practitioners of this continent. In fact, it is neldom that any work is ever issued from the press more deserving of universal recommendation.—Do- minion Med Journal, May, 1869. The third edition of this most excellent book scarce- ly needs any commendation from us. The volume, as it stands now, is really a marvel: flri-t of all, it is excellently printed and bound—and we encounter that luxury of America, the ready-cut pages, which the Yankees are 'cute enough to insist upon—nor are these by any means trifles ; but the contents of the book are astonishing. Not only is it wonderful that anyone man can have grasped in his mind the whole Bcope of medicine with that vigor which Dr. Flint ■hows, but the condensed yet clear way in which this is done is a perfect literary triumph. Dr. Flint is pre-eminently one of the strong men, whose right to do this kind of thing is well admitted ; and we say do more than the truth when we affirm that he is very nearly the only living man that could do it with such results as the volume before us.—The London Practitioner, March, 1869. This is in some respects the best text-book of medi- cine in our language, and it is highly appreciated on the other side of the Atlantic, inasmuch as the first edition was exhausted in a few months. The second edition was little more than a reprint, but the present has, as the author says, been thoroughly revised. Much valuable matter has been added, and by mak- ing the type smaller, the bulk of the volume is not much increased. The weak point in many American works is pathology, but Dr. Flint has taken peculiar pains on this point, greatly to the value of the book. —London Med. Times and Gazette, Feb. 6, 1869. Published in 1866, this valuable book of Dr. Flint's has in two years exhausted two editions, and now we gladly announce a third. We say we gladly an- nounce it, because we are proud of it as a national representative work of not only American, but of cosmopolitan medicine. In it the practice of medicine is young and philosophical, based on reason and com- mon sense, and as such, we hope it will be at the right hand of every practitioner of this vast continent. —California Medical Gazette, March, 1869. Considering the large number of valuable works in the practice of medicine, already before the profes- sion, the marked favor with which this has been re- ceived, necessitating a third edition in the short space of two years, indicates unmistakably that it is a work of more than ordinary excellence, and must be accept- ed as evidence that it has largely fulfilled the object for which the author intended it. A marked feature in the work, and one which particularly adapts it for the use of students as a text-book, and certainly ren- ders it none the less valuable to the busy practitioner as a work of reference, is brevity and simplicity. The present editiou has been thoroughly revised, and much new matter incorporated, derived, as the author informs us, both from his own clinical studies, and from tbe latest contributions to medical literature, thus bringing it fully up with the most recent ad- vances of the science, and greatly enhancing its prac- tical utility; while, by a slight modification of its typographical arrangement, the additions have been accommodated without materially increasing its bulk.—St. Louis Med. Archives, Feb. 1869. If there be among our readers any who are not fa- miliar with the treatise before us, we shall do them a service in persuading them to repair their omission forthwith. Combining to a rare degree the highest scientific attainments with the most practical com- mon sense, and the closest habits of observation, the author has given us a volume which not only sets forth the results of the latest investigations of other laborers, but contains more original views than any other single work upon this well-worn theme within our knowledge.—N. Y. Med. Gazette, Feb. 27, 1869. Practical medicine was at sea when this book ap- peared above the horizon as a safe and capacious har- bor. It came opportunely aud vra* greeted with pleasurable emotions throughout the land.—Nash- ville Med. and Surg. Journal, May, 1869. D UNGLISON, FORBES, TWEEDIE, AND CONOLLY. THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, &c. Y THE SAME A UTHOR. A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE RESPIRATORY ORGANS. Second and revised edition. In one handsome octnvo volume of 595 pages, extra cloth, $4 50. Premising this observation of the necessity of each student and practitioner making himself acquainted with auscultation and percussion, we may state our honest opinion that Dr. Flint's treatise is one of the most trustworthy guides which he can consult. The style is clear and distinct, and is also concise, being free from that tendency to over-reflnement and unne- cessary minateness which characterizes many works on the same subject.—Dublin Medical Press, Feb. 6, 1867. The chapter on Phthisis is replete with interest; and his remarks on the diagnosis, especially in the early stages, are remarkable for their acumen and great practical value. Dr. Flint's 6tyle is clear and elegant, and the tone of freshness and originality which pervades his whole work lend an additional force to its thoroughly practical character, which cannot fail to obtain for it a place as a standard work on diseases of the respiratory system.—London Lancet, Jan. 19, 1867. This is an admirable book. Excellent in detail and execution, nothing better could be desired* by the practitioner. Dr. Flint enriches his subject with much solid and not a little original observation.— Ranking's Abstract, Jan. 1867. p\YY{F. W.),M.D.,F.R.S., ■*- Senior Asst. Physician to and Lecturer on Physiology, at Guy's Hospital, &c. A TREATISE ON THE FUNCTION OF DIGESTION; its Disor- ders and their Treatment. From the second London edition. In one handsome volume, small octavo, extra cloth, $2 00. (Lately Published.) The work before us is one which deserves a wide treatise, and sufficiently exhaustive for all practical circulation. We know of no better guide to the study purposes.—Leavenworth Med. Herald, July, 1869. of digestion and its disorders.—St. Louis Med. and A verv valuable work on the subject of which it Surg. Journal, July 10, 1869. treats. Small, yet it is full of valuable information. A thoroughly good book, being a careful systematic —Cincinnati Med. Repertory, June, 1869. (1HAMBERS (T. K.), M.D., ^ Consulting Physician to St. Mary's Hospital, London, &c. THE INDIGESTIONS; or, Diseases of the Digestive Organs Functionally Treated. Third and revised Edition. In one handsome octavo volume of 333 pages, extra cloth. $3 00. (Lately Published.) thoroughly clinical treatise in the language.— N. Y. Medical Gazette, Jan. 28, 1871. Like other works proceeding from the pen of Dr. King Chambers, this present one is characterized by its essentially practical character. The treatise pre- sents throughout most valuable hints and suggestions to those called upon to deal with disease as witnessed in everyday medical experience. Many such might be collected and put before the profession as a volume of medical aphorisms that should have a place in each professional head. The lengthened review writ- ten of this treatise, and the observations made in the course of it, sufficiently attest our high opinion of its value to the practitioner. —Brit, and For. Medico- Chirurg. Review, Jan. 1871. So very large a proportion of the patients applying to every general practitioner suffer frorn some form of indigestion, that whatever aids him in their man- agement directly "puts money in his purse," and in- directly does more than anything else to advance his reputation with the public. From this purely mate- rial point of view, setting aside its higher claims to merit, we know of no more desirable acquisition to a physician's library than the book before us. He who should commit its contents to his memory would nnd its price an investment of capital that returned him a most usurious rate of interest. As compared with the second edition, the arrangement of the illus- trative cases has been changed in many instances, numerous new ones added, and the entire volume carefully revised; being in its present form the most T>Y THE SAME AUTHOR. (Just Ready.) TfT?«TnTJ ATTVF MEDICINE. An Harveian Annual Oration, deliv- ered at the Royal CoUege of Physicians, London, on June 24,1871. With Two Sequels. In one very handsome volume, small 12mo., extra cloth, $1 00. 18 Henry C. Lea's Publications—(Practice of Meaicint). DOBERTS (WILLIAM), M.D.. ■*■*' Lecturer on Medicine in the Manchester School of Medicine, &c. A PRACTICAL TREATISE ON URINARY AND RENAL DIS- EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. Sec- ond Edition, Revised. In one very handsome octavo volume. (Preparing.) TQASHAM (W.R.), M.D., J-* Senior Physician to the Westminster Hospital, A-c. RENAL DISEASES: a Clinical Guide to their Diagnosis and Treat- ment. With illustrations. In one neat royal 12mo. volume of 304 pages. $2 00. (Just Issued.) The chapters on diagnosis and treatment are very I ment render the book pleasing and convenient.—Am. good, and the student and young practitioner will | Journ. Med. Sciences, July, 1870. find them full of valuable practical hints. The third A took that we believe will be found a valuable part, on the urine, is excellent, and we cordially | assistant to the practitioner and guide to the student. recommend its perusal. The author has arranged his matter in a somewhat novel, and, we think, use- ful form. Here everything can be easily found, and, what is more important, easily read, for all the dry details of larger books here acquire a new interest from the author's arrangement. This part of the book is full of good work.—Brit, and For. Medico- Chirurgical Review, July, 1870. The easy descriptions and compact modes of state- —Baltimore Med. Journal, July, 1870. The treatise of Dr. Basham differs from the rest in \ its special adaptation to clinical study, and its con- densed and almost aphorismal style, which makes it easily read and easily understood. Besides, the author expresses some new views, which are well I worthy of consideration. The volume is a valuable addition to this department of knowledge.—Pacific Med. and Surg. Journal, July, 1870. MORLAND ON RETENTION IN THE BLOOD OF THE ELEMENTS OF THE URINARY SECRETION. 1 vol. 8vo., extra cloth. 75 cents. TONES (C. HANDFIELD), M. D., t/ Physician to St. Mary's Hospital, witn illustrations. In one large and handsome octavo volume of over 700 over iu» pages, extra cloth, $5 00 ; leather, $6 00. (Just Issued.) °pT'n.8 this standard work again for the press, the author has subje rOUgO revision. ManV DOrtions hnvahaan ranrition ond mnnli now in£ " XBy 8eem aImost ^Perflu- j anything practical connected with the diagnosis, bis- pus to say more of it than that a new edition has been toy, or treatment of these affections.—N. Y. Medical issued. Hut the author s industry has reudered this | Journal, March 1671 new edition virtually a new work, and so merits as fjULLERTER (A.), and ^ Surgeon to the Hdpital du Midi. T^UMSTEAD (FREEMAN J), -LJ Professor of Venerea I Diseases in the College of Physicians and Surgeons, N. Y AN ATLAS OP VENEREAL DISEASES. Translated and Edited by Freeman J. Bpmstead. In one large imperial 4to. volume of 328 pages, double-columns, with 26 plates, containing about 150 figures, beautifully colored, many of them the size of We; strongly bound in extra cloth, $17 00; also, in five parts, stout wrappers for mailing, at S3 per part. (Lately Published.) ° Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- lars a Fart, thus placing it within the reach of all who are interested in this department of prac- tice, trentlemen desiring early impressions of the plates would do well to order it without delay. A specimen of the plates and text sent free by mail, on receipt of 25 cents. We wish for once that our province was not restrict- ed to methods of treatment, that we might say some- thing of the exquisite colored plates in this volume —London Practitioner, May, 1869. As a whole, it teaches all that can be taught by ?,eV/J{ pIates and P'in-t.— London Lancet, March Superior to anything of the kind ever before issued on this continent.—Canada Med. Journal, March, '69. The practitioner who desires to understand this Branch of medicine thoroughly should obtain this the most complete and best work ever published — Dominion Med. Journal, May, 1869. This ig a work of ma8ter handg on both gideg> M cullerier is scarcely second to, we think we may truly say is a peer of the illustrious and venerable Ricord, while in this country we do not hesitate to say that ur. Bumstead, as an authority, is without a rival Assuring our readers that these illustrations tell the whole history of venereal disease, from its inception to its end, we do not know a single medical work, wnich for its kind is more necessary for them to have. —California Med. Gazette, March, 1869. The most splendidly illustrated work in the lan- guage and in our opinion far more useful than the French original.—Am. Journ. Med. Sciences, Jan.'69. The fifth and concluding number of this magnificent work has reached us, and we have no hesitation in saying that its illustrations surpass those of previous numbers.—Boston Med. and Surg. Journal, Jan. 14. 1869. Other writers besides M. Cullerier have given us a good account of the diseases of which he treats, but no one has furnished us with such a complete series of illustrations of the venereal diseases. There is, however, an additional interest and vstlue possessed by the volume before us; for it is an American reprint and translation of M. Cullerier's work, with inci- dental remarks by one of the most eminent American syphilographers, Mr. Bumstead. The letter-press is chiefly M. Cullerier's, but every here and there a few lines or sentences are introduced by Mr. Bumstead ; and, as M. Cullerier is a unicist, while Mr. Bumstead is a dualist, this method of treating the subject adds very much to its interest. By this means a liveliness is imparted to the volume which many other treatises sorely lack. It is like reading the report of a conver- sation or debate ; for Mr. Bumstead often finds occa- sion toquestion M.Cullerier's statements or inferences, and this he does in a short and forcible way which helps to keep up the attention, and to make the book a very readable one.—Brit, and For. Medico-Chir. Review, July, 1869. JJLLL (BERKELEY), Surgeon to the Lock Hospital, London. ON SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. one handsome octavo volume ; extra cloth, $3 25. (Lately Published.) Bringing, as it does, the entire literature of the dis- ease down to the present day, and giving with great ability the results of modern research, it is in every respect a most desirable work, and one which should find a place in the library of every surgeon.—Cali- fornia Med. Gazette, June, 1869. Considering the scope of tbe book and the careful attention to the manifold aspects and details of its subject, it is wonderfully concise All these qualities render it an especially valuable book to the beginner, In to whom we would most earnestly recommend ita study; while it Is no less useful to the practitioner.— St. Louis Med. and Surg. Journal, May, 1869. The most convenient and ready book of reference we have met with.— N. Y. Med. Record, May 1,1869. Most admirably arranged for both student and prac- titioner, no other work on the subject equals it; it is more simple, more easily studied.—Buffalo Med. and Surg. Journal, March, 1869. •LALLEMAND AND WILSON ON THE CAUSES, Sl'MPTOMS, AND TREATMENT OF SPERMA- TORRHCE clotb, $2 7; In one vol. 8vo., of about 400 pp., 20 Henry C. Lea's Publications—(Diseases of the Skin). TyiLSON (ERASMUS), F.R.S. ON DISEASES OF THE SKIN. With Illustrations on wood. Sev- enth American, from the sixth and enlarged English edition. In one large octavo volume of over 800 pages, $b. (Lately Publislied.) A SERIES OF PLATES ILLUSTRATING "WILSON ON DIS- EASES OF THE SKIN;" consisting of twenty beautifully executed plates, of which thir- teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, and embracing accurate representations of about one hundred varieties of disease, most of them the size of nature. Price, in extra cloth, $5 50. Also, the Text and Plates, bound in one handsome volume. Extra cloth, $10. The industry and care with which the author has revised the present edition are shown by the fact that the volume has been enlarged by more than a hundred pages. In its present improved form it will therefore doubtless retain the position which it has acquired as a standard and classical authority, while at the same time it has additional claims on the attention of the profession as the latest and most complete work on the subject in the English language. Such a work as the one before us is a most capital and acceptable help. Mr. Wilson has long been held as high authority in this department of medicine, and his book on diseases of the skin has long been re- garded as one of the best text-books extant on the subject. The present edition is carefully prepared, and brought up in its revision to the present time. In this edition we have also included the beautiful series of plates illustrative of the text, and in the last edi- tiou published separately. There are twenty of these plates, nearly all of them colored to nature, and ex- hibiting with great fidelity the various groups of diseases treated of in the body of the work.—Cin- cinnati Lancet, June, 1863. No one treating skin diseases should be without a copy of this standard work.— Canada Lancet. August, 1863. JOY THE SAME AUTHOR. We can safely recommend it to the profession as the best work on the subject now In existence In the English language.—Medical Times and Gazette. Mr. Wilson's volume is an excellent digest of the actual amount of knowledge of cutaneous diseases; it includes almost every fact or opinion of importance connected with the anatomy and pathology of the skin.—British and Foreign Medical Review. These plates are very accurate, and are exeouted with an elega nee and taste which are highly creditable to the artistic skill of the American artist whoexecuted them.—St. Louis Med. Journal. The drawings are very perfect, and the finish and coloring artistic and correct; the volume is an indis- pensable companion to the book it illustrates and completes.—Charleston Medical Journal. THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Dis- eases of the skin. In one very handsome royal 12mo. volume. $3 50. (Lately Issued.) JSTELIGAN (J.MOORE), M.D.,M.R.I.A. A PRACTICAL TREATISE ON DISEASES OF THE SKIN. Fifth American, from the second and enlarged Dublin edition by T. W. Belcher, M.D. In one neat royal 12mo. volume of 462 pages, extra cloth. $2 25. Fully equal to all the requirements of students and young practitioners. It is a work that h,as stood its ground, that was worthy the reputation of the au- thor, and the high position of which has been main- tained by its learned editor.—Dublin Med. Press and Circular, Nov. 17,1869. Of the remainder of the work we have nothing be- yond unqualified commendation to offer. It is so far the most complete one of its size that has appeared, and for the student there can be none which can corn- fully up to the times, and is thoroughly stocked with most valuable information.—New York Med. Record, Jan. 15, 1867. This instructive little volume appears once more. Since the death of its distinguished author, the study of skin diseases has been considerably advanced, and the results of these investigations have been added by the present editor to the original work of Dr. Neli- gan. This, however, has not so far increased its bulk as to destroy its reputation as the most convenient pare with it in practical value. All the late disco- ] manual of diseases of the skin that can be procured veries in Dermatology have been duly noticed, and j by the student.—Chicago Med. Journal, Dec. 1866. their value justly estimated; in a word, the work is JDY THE SAME AUTHOR. ---- ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, with exquisitely colored plates, Ac, presenting about one hundred varieties of disease. Extra cloth, $5 50 The diagnosis of eruptive disease, however, under all circumstances, is very difficult. Nevertheless, Dr. Neligan has certainly, "as far as possible," given a faithful and accurate representation of this class of diseases, and there can be no doubt that these plates will be of great use to the student and practitioner in drawing a diagnosis as to the class, order, and species to which the particular case may belong. While looking over the "Atlas" we have been induced to examine also the "Practical Treatise," and we are Inclined to consider it a very superior work, com- bining accurate verbal description with sound views of the pathology and treatment of eruptive diseases. —Glasgow Med. Journal. A compend which will very much aid the practi- tioner in this difficult branch of diagnosis Taken with the beautiful plates of the Atlas, which are. re- markable for their accuracy and beauty of coloring, It constitutes a very valuable addition to the library of a practical man.—Buffalo Med. Journal. TJILLIER (THOMAS), M.D., -*•-*- Physician to the Skin Department of University College Hospital, &c. HAND-BOOK OF SKIN DISEASES, for Students and Practitioners. Second American Edition. In one royal 12mo. volume of 358 pp. With Illustrations. Extra cloth, $2 25. (Just Issued.) We can conscientiously recommend it to the Btu- i It in a concise, plain, practical treatise on the vari- dent; the style is clear and pleasant to read, the ous diseases of the skin; just such a work, indeed, matter is good, and the descriptions of disease, with as was much needed, both by medical students and the modes of treatment recommended, are frequently I practitioners. — Chicago Medical Examiner, May, illustrated with well-recorded cases.—London Med. I 1865. Times and Gazette, April J, 1865. I _____Henry C. Lea's Publications—(Diseases of Children). 21 gMITHiJ.LEmS^MLxT ~~ A nn\T°f'ii'i0r °f Morhid Anat°™y in the Bellevue Hospital Med. College, N. Y. oimivR%ETE PRACTICAL TREATISE ON THE DISEASES OF $5 75 In °ne handsome octavo volume of 620 pages, extra cloth, $4 75 ; leather, ^^Feb'^l.^1^"16 ^*-««W Med The excellence of this book is one explanation of our not having reviewed it sooner. Taking it up from work is an illustration, and pervading every chapter of it is a spirit of sound judgment and common sense, without which any work on any department of the [t , practice of medicine is, to use the mildest word, de- tirae to time, we have been freshly interested in its ' fr011*6- We are sorry that we cannot give further illustrations of the excellence of this book.—London Lancet, Sept. i, 1869. various chapters and so been led to defer writing our opinion or it. It is one of those works with which we are happily becoming familiar, as coming tons from time to time from across the Atlantic, which contain all that is good in European works of the Bitine kind, together with much that is original both in reflection and observation. It is astonishing how well the American writers succeed in gleaning and yet giving a^fresh character to their books. This We have no work upon the Diseases of Infancy and Childhood which can compare with it.—Buffalo Med. and Surg. Journal, March, 1869. Tbe description of the pathology, symptoms, and treatment of the different diseases is excellent.—Am. Med. Journal, April, 1869. QjONDIE (D. FRANCIS), M. D. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Sixth edition, revised and augmented. In one large octavo volume of nearly 800 closely- printed pages, extra cloth, $5 25 ; leather, $6 25. (Lately Issued.) The present edition, which is the sixth, is fully up . in this department of medicine. His work has been to the times in the discussion of all those points in the so long a standard for practitioners and medical stu- pathology and treatment of infantile diseases which \ dents that we do no more now than refer to the fact have been brought forward by the German and French teachers. As a wholt', however, the work is the best American one that we have, and in its special adapta- tion to American practitioners it certainly has no equal.— New York Med. Record, March 2, 1868. Ko other treatise on this subject is better adapted to the American physician. Dr. Condie has long stood I Reporter, Feb. 15, 186S. before his countrymen as one peculiarly pre-eminent 1 that it has reached its sixth edition. We are glad once more to refresh the impressions of our earlier days by wandering through its pages, and at the same time to be able to recommend it to the youngest mem- bers of the profession, as well as to those who have the older editions on their shelves.—St. Louis Med. WEST (CHARLES), M.D., ' ' Physician to the Hospital for Sick Children, <6e. LECTURES ONSTHE DISEASES OF INFANCY AND CHILD- HOOD. Fourth American from the fifth revised and enlarged English edition. In one large and handsome octavo volume of 656 closely-printed pages. Extra cloth, $4 50; leather, $5 50. Of all the English writers on the diseases of chil- I living authorities in the difficult department of medi- dren, there is no one so entirely satisfactory to us as | cal science in which he is most widely known.— Dr. We6t. For years we have held his opinion as I Boston Med. and Surg. Journal, April 26, 1866. judicial, and have regarded him as one of the highest | flY THE SAME AUTHOR. (Just Ready.) ON SOME DISORDERS OF THE NERYOUS SYSTEM IN CHILD- HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians of Lon- don, in March, 1871. In one volume, small 12mo., extra cloth, $1 00. gMITH(EUSTACE), M. D., Physician to the Northwest London Free Dispensary for Sick Children. A PRACTICAL TREATISE ON THE WASTING DISEASES OP INFANCY AND CHILDHOOD. Second American, from the second revised and enlarged English edition. In one handsome octavo volume, extra cloth, $2 50. (Now Ready.) This is in every way an admirable book. modest title which the author has chosen for it scarce- ly conveys an adequate idea of the many subjects upon which it treats. Wasting is so constant an at- tendant upon the. maladies of childhood, that a trea- tise upon I he wasting diseases of children must neces sarily embrace the consideration of many affections Of which it is a symptom; and this is excellently well done By Dr. Smith* The book might fairly be de- scribed as a practical handbook of the common dis- eases of children, 60 numerous are the affections con- sidered either collaterally or directly. We are acquainted with no safer guide to the treatment of children's diseases, and few works give rue insight into the physiological and other peculiarities of chil- dren that Dr. Smith's book does.—Brit. Med. Journ., April 8, 1871. rtUERSANT (P.), M. D., ™ Honorary Surgeon to the Hospita I for Sick Children, Paris. SURGICAL DISEASES OF INFANTS AND CHILDREN. Trans- lated by R. J. Dunglison, M. D. (Publishing in the Medical News and Library.) As this work embodies the experience of twenty years' service in the great Children's Hospital of P„i« it ran hardlv fail to maintain the reputation of the valuable practical series of volumes which^ have been laid^efore the subscribers of the " American Journal of the Medical Sci- EVCKS." For terms, see p. 3. _----------------- DEWEES ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILDREN. Eleventh edition. 1 vol. Svo. of 518 pages. $2 80. 22 Henry C. Lea's Publications—(Diseases of Women). rTHOMA& (T. GAILLARD), M.D., ■*- Professor of Obstetrics, &c in the College of Physicians and Surgeons, N. Y., Ac. A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Se- cond edition, revised and improved In one large and handsome octavo volume of 650 pages, with 225 illustrations, extra cloth, $5; leather, $6. From the Preface to the Second Edition. In a science so rapidly progressive as that of medicine, the profession has a rignt to expect that, when its approbation of a work is manifested by a call for a new edition, the author should re- spond by giving to his book whatever of additional value may be derivable from more extended experience, maturer thought, and the opportunity for correction. Fully sensible of this, the author of the present volume has sought by a careful revision of the whole, and by the addition of a chapter on Chlorosis, to render his work more worthy of the favor with which it has been received.—New York, March, 1869. If the excellence of a work is to be judged by its rapid sale, this one must take precedence of all others upoo the same, or kindred subjects, as evidenced in the short time from its first appearance, in which a ne w edition is called for, resulting, as we are informed, from the exhaustion of the previous large edition. We deem it scarcely necessery to recommend this work to physicians as it is now widely known, and most of them already possess it, or will certainly do so. To students we unhesitatingly recommend it as the best text-book on diseases of females extant.—St.Louis Med. Reporter, June, 1869. Of all the army of books that have appeared of late years, on the diseases of the uterus and its appendages, we know of none that is so clear, comprehensive, and practical as this of Dr. Thomas', or one that we should more emphatically recommend to the young practi- tioner, as his guide.—California Med. Gazette, June, 1869. If not the best work extant on the subject of which it treats, it is certainly second to none other. So short a time has elapsed since the medical press teemed with commendatory notices of the first edition, that it would be superfluous to give an extended re- view of what is now firmly established as the American text-book of Gynaecology.—N. Y. Med. Gazette, July 17, 1869. This is a new and revised edition of a work which we recently noticed at some length, and earnestly commended to the favorable attention of our readers. The fact that, in the short space of one year, this second edition makes its appearance, shows that the general judgment of the profession has largely con- firmed the opinion we gave at that time.— Cincinnati Lancet, Aug. 1869. It is so short a time since we gave a full review of the first edition of this book, that we deem it only necessary now to call attention to the second appear- ance of the work. Its success has been remarkable, and we can only congratulate the author on the brilliant reception his book has received.—N. Y. Med. Journal, April, 1869. We regard this treatise as the one best adapted to serve as a text-book on gynaecology.—St. Louis Med. and Surg. Journal, May 10, 1869. * The whole work as it now stands is an absolute indispensable to any physician aspiring to treat the diseases of females with success, and according to the most fully accepted views of their aetiology and pa- thology.—Leavenworth Medical Herald, May, 1869. We have seldom read a medical book In which we found so much to praise, and so little—we can hardly say to object to—to mention with qualified commen- dation. We had proposed a somewhat extended review with copious extracts, but we hardly know where we should have space for it. We therefore content ourselves with expressing the belief that every practitioner of medicine would do well to pos- sess himself of the work.—Boston Med. and Surg. Journal, April 29, 1869. The number of works published on diseases of women is large, not a few of which are very valuable. But of those which are the most valuable we do not regard the work of Dr. Thomas as second to any. Without being prolix, it treats of the disorders to which it is devoted fully, perspicuously, and satisfac- torily. It will be founi a treasury of knowledge to every physician who turns to its pages. We would like to make a number of quotations from the work of a practical bearing, but our space will not permit. The work should find a place in the libraries of all physicians.—Cincinnati Med. Repertory, May, 1S69. No one will be surprised to learn that the valuable, readable, and thoroughly practical book of Professor Thomas has so soon advanced to a second edition. Although very little time has necessarily been allowed our author for revision and improvement of the work, he has performed it exceedingly well. Aside from the numerous corrections which he has found neces- sary to make, he has added an admirable chapter on chlorosis, which of itself is worth the cost of the volume.—N. Y. Med. Record, May 15, 1869. QHURCHILL (FLEETWOOD), M. D., M. R. I. A. ESSAYS ON THE PUERPERAL FEYER, AND OTHER DIS- EASES PECULIAR TO WOMEN. Selected from the writings of British Authors previ- ous to the close of the Eighteenth Century. In one neat octavo volume of about 450 pages, extra cloth. $2 50. A \ SHWELL (SAMUEL), M. D., J,ate Obstetric Physician and Lecturer at Guy's Hospital. PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. Illustrated by Cases derived from Hospital and Private Practice. Third Ame- rican, from the Third and revised London edition. In one ootavo volume, extra cloth, of 528 pages. $3 50. RIGBY ON THE CONSTITUTIONAL TREATMENT I MALES. With illustrations. Eleventh Edition, OF FEMALE DISEASES. In one neat royal 12mo | with the Author's last improvements and corree. volume, extra cloth, of about 250 pages. $1 00. tions. In one octavo volume of 536 pages, with DEWEES'S TREATISE ON THE DISEASES OF FE-1 plates, extra cloth, $3 00. T>ARNES (ROBERT), M.D., F.R.C.P., •*-" Obstetric Physician to St. Thomas' Hospital, &c. A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. In one handsome ootavo volume with illustrations. (Preparing.) Henry C. Lea's Publications—(Diseases of Women). 23 uterus, to take strong ground against many of the highest authorities in this branch of medicine, and the arguments which he offers in support of his posi- tion are, to say the least, well put. Numerous wood- cuts adorn this portion of the work, and add incalcu- lably to the proper appreciation of the variously shaped instruments referred to by our author. As a contribution to the study of women's diseases, it is of great value, and is abundantly able to stand on its own merits.—N. Y. Medical Record, Sept. 15, 1868. In this point of view, the treatise of Professor Hodge will be indispensable to every student in its department. The large, fair type and general perfec- tion of workmanship will render it doubly welcome. —Pacific Med. and Surg. Journal, Oct. 1868. TTODGE (HUGH L.), M.D., , o . . -" Emeritus Professor of Obstetrics, d-c, in the University of Pennsylvania. ON DISEASES PECULIAR TO WOMEN; including Displacements of the Uterus. With original illustrations. Second edition revised and enlarg ed..In one beautifully printed octavo volume of 531 pages, extra cloth. $4 50. (Lately Issued.) In the preparation of this edition the author has spared no pains to improve it with the results of his observation and study during the interval which has elapsed since the first appearance ot the work. Considerable additions have thus been made to it, which have been partially ncoom. modated by an enlargement in the size of the page, to avoid increasing unduly the bulk ot tne volume. From Prof. W. H. Btford, of the Rush Medical College, Chicago. The book bears the impress of a master hand, and must, as its predecessor, prove acceptable to the pro- fession. In diseases of women Dr. Hodge has estab- lished a school of treatment that has become world- wide in fame. Professor Hodge's work is truly an original one from beginning to end, consequently no one can pe- ruse its pages without learning something new. The book, which is by no means a large one, is divided into two grand sections, so to speak: first, that treating of the nervous sympathies of the uterus, and, secondly, that which speaks of the mechanical treatmeut of dis- placements of that organ. He is disposed, as a non- believer in the frequency of inflammations of the TXTEST (CHARLES), M.D. LECTURES ON THE DISEASES OF WOMEN. Third American, from the Third London edition. In one neat octavo volume of about 550 pages, extra cloth. $3 75; leather, $4 75. The reputation which this volume has acquired as a standard book of reference in its depart- ment, renders it only necessary to say that the present edition has received a careful revision at the hands of the author, resulting in a considerable increase of size. A few notices of previous editions are subjoined. The manner of tbe author is excellent, his descrip-1 As a writer, Dr. West stands, in our opinion, se- tions graphic and perspicuous, and his treatment up ' cond only to Watson, the "Macaulay of Medicine;" to the level of the time—clear, precise, definite, and j he possesses that happy faculty of clothing instruc- tion in easy garments; combining pleasure with profit, he leads his pupils, in spite of the ancient pro- verb, along a royal road to learning. His work is one which will not satisfy the extreme on either side, but it is one that will please the great majority who are seeking truth, and one that will convince the student that he has committed himself to a candid, safe, and valuable guide.—N. A. Med.-Chirurg Review. We must now conclude this hastily written sketch with the confident assurance to our readers that the work will well repay perusal. The conscientious, painstaking, practical physician is apparent on every page.—N. Y. Journal of Medicine. We have to say of it, briefly and decidedly, that It is the best work on the subject in any language, and that It stamps Dr. West as the facile prince.ps of British obstetric authors.—Edinburgh Med. Journal. We gladly recommend his lectures as in the highest degree instructive to all who are interested in ob- marked by strong common sense. — Chicago Med, Journal, Dec. 1861. We cannot too highly recommend this, the second edition of Dr. West s excellent lectures on the dis- eases of females. We know of no other book on this subject from which we have derived as much pleasure and instruction. Every page gives evidence of the honest, earnest, and diligent searcher after truth. He U not the mere compiler of other men's ideas, but his lectures are the result often years' patient investiga- tion in one of the widest fields for women's diseases— St. Bartholomew's Hospital. As a teacher, Dr. West Is simple and earnest in his language, clear and com- prehensive in his perceptions, and logical in his de- ductions.—Cincinnati Lancet, Jan. 1862. We return the author our gTateful thanks for the Vast amount of instruction he has afforded us. His valuable treatise needs no eulogy on our part. His graphic diction and truthful pictures of disease all speak for themselves.—Medieo-Chirurg. Review. Mo6t justly esteemed a standard work.....It j gtetric practice.—London. Lancet. bears evidence of having been carefully revised, and | . ____m_i«». Is well worthy of the fame it has already obtained. We know of no treatise of the kind so complete, -Dub. Med. Quar. Jour. I and yet so compact.-C/«caj?o Med. Journal. TOY THE SAME AUTHOR. ----- AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE TTT.f!F.H.ATTON C\V THE OS UTERI. In one neat octavo volume, extra cloth. $1 OF 25. M LeProf^sSrofSstSrils, &c. in Jefferson Medical College, Philadelphia. WOMAN- HER DISEASES AND THEIR REMEDIES. A Series o/Lectures to his Class. Fourth and Improved edition In one.large.and beautifully printed octavo volume of over 700 pages, extra cloth, $5 00; leather, »b 00. Z}Y THE SAME AUTHOR. ____^ ON THE NATURE, SIGNS, AND TREATMENT OF CHILDBED FEVER In a Series of Letters addressed to the Students of his Class. In one handsome octavo volume of 365 pages, extra cloth. $2 00. VIMPSON (SIR JAMES Y.), M.D. PT TNTCAL LECTURES ON THE DISEASES OF WOMEN. With BumerouTillustrations. In one octavo volume of over 500 pages. Second edition, preparing. 24 Henry C. Lea's Publications—(Midwifery). JJODGE (HUGH L.), M.D., Emeritus Professor of Midwifery, Ac. in the University of Pennsylvania Ac THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illus- trated with large lithographic plates containing one hundred and fifty-nine figures from original photographs, and with numerous wood-cuts. In one large and beautifully printed quarto volume of 550 double-columned pages, strongly bound in extra cloth, $14. The work of Dr. Hodge is something more than a simple presentation of his particular views in the de- partment of obstetrics; it is something more than an ordinary treatise on midwifery; it is, in fact, a cyclo- paedia of midwifery. He has aimed to embody in a single volume the whole science and art of Obstetrics. An elaborate text is combined with accurate and va- ried pictorial illustrations, so that no fact or principle is left unstated or unexplained.—Am. Med. Times, Sept. 3,1S64. We should like to analyze the remainder of this excellent work, but already has this review extended beyond our limited space. We cannot conclude this notice without referring to the excellent finish of the work. In typography it is not to be excelled; the paper is superior to what is usually afforded by our American cousins, quite equal to the best of English books. The engravings and lithographs are most beautifully executed. The work recommends itself for its originality, and is in every way a most valu- able addition to those on the subject of obstetrics.— Canada Med. Journal, Oct. 1864. It is very large, profusely and elegantly illustrated, and is fitted to take its place near the works of great obstetricians. Of the American works on the subject It is decidedly the best.—Edinb. Med. Jour., Dec. '64. **# Specimens of the plates and letter-press will be forwarded to any address, free by mail, en receipt of six cents in postage stamps. We have examined Professor Hodge's work with great satisfaction; every topic is elaborated most fully. The views of the author are comprehensive, and concisely stated. The rules of practice are judi- cious, and will enable the practitioner to meet every emergency of obstetric complication with confidence. — Chicago Med. Journal, Aug. 1864. More time than we have had at our disposal since we received the great work of Dr. Hodge is necessai y to do it justice. It is undoubtedly by far the most original, complete, and carefully composed treatise on the principles and practice of Obstetrics which has ever been issued from the American press.—Pacific Med. and Surg. Journal, July, 1864. We have read Dr. Hodge's book with great plea- sure, and have much satisfaction in expressing our commendation of it as a whole. It Is certainly highly Instructive, and in the main, we believe, correct. The great attention which the author has devoted to the mechanism of parturition, taken along with the con- clusions at which he has arrived, point, we thjak, conclusively to the fact that, in Britain at least, the doctrines of Naegele have beeu too blindly received. —Glasgow Med. Journal, Oct. 1864. JIANNER (THOMAS H.), M.D. ON THE SIGNS AND DISEASES OF PREGNANCY. First American from the Second and Enlarged English Edition. With four colored plates and illustrations on wood. In one handsome octavo volume of about 500 pages, extra cloth, $4 25. The very thorough revision the work has undergone has added greatly to its practical value, and increased materially its efficiency as a guide to the student and to the young practitioner.—Am. Journ. Med. Sci., April, 1863. With the immense variety of subjects treated of and the ground which they are made to cover, the im- possibility of giving an extended review of this truly remarkable work must be apparent. We have not a single fault to find with it, and most heartily com- mend it to the careful study of every physician who would not only always be sure of his diagnosis of pregnancy, but always ready to treat all the nume- rous ailments that are, unfortunately for the civilized women of to-day, so commonly associated with the function.—N. Y. Med. Record, March 16, 1868. We have much pleasure in calling the attention of our readers to the volume produced by Dr. Tanner, the second edition of a work that was, in its original state even, acceptable to the profession. We recom- mend obstetrical students, young and old, to have this volume in their collections. It contains not only a fair statement of the signs, symptoms, and diseases of pregnancy, but comprises in addition much inter- esting relative matter that is not to be found in any other work that we can name.—Edinburgh Med. Journal, Jan. 1868. In its treatment of the signs and diseases of preg- nancy it is the most complete book we know of, abounding on every page with matter valuable to the general practitioner.—Cincinnati Med. Repertory, March, 1868. This Is a most excellent work, and should be on the table or in the library of every practitioner.—Hum- boldt Med. Archives, Feb. 1868. A valuable compendium, enriched by his own la- bors, of all that is known on the signs and diseases of pregnancy.—St. Louis Med. Reporter, Feb. 15,1868. s WAYNE (JOSEPH GRIFFITHS), M.D., Physician-Accoucheur to the British General Hospital, &c. OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- MENCING MIDWIFERY PRACTICE. From the Fourth and Revised London Edition, with Additions by E. R. Hutchiss, M. D. With Illustrations. In one neat 12mo. vol- ume. Extra cloth, $1 25. (Lately Published.) It is really a capital little compendium of the sub- ject, and we recommend young practitioners to buy it and carry it with them when called to attend cases of labor. They cau while away the otherwise tedious hours of waiting, and thoroughly fix in their memo- ries the most important practical suggestions it con- tains. The American editor has materially added by his notes and the concluding chapters to the com- pleteness and general value of the book.—Chicago Med. Journal, Feb. 1870. The manual before us contains in exceedingly small compass—small enough to carry in the pocket—about all there is of obstetrics, condensed into a nutshell of Aphorisms. The illustrations are well selected, and serve as excelleut reminders of the conduct of labor— regular and difficult.—Cinainhatt Lancet, April, '70. 1 his is a nioitadmirable little work, and completely answers the purpose. It is not only valuable for young beginners, but no one who is not a proficient in the art of obstetrics should be without it, because It condenses all that is necessary to know for ordi- nary midwifery practice. We commend the book most favorably.—St. Louis Med. and Surg. Journal, Sept. 10, 1870. A studied perusal of this little book has satisfied us of its eminently practical value. The objector the work, the author says, In his prefaee, is to give tbe student a few brief and practical directions respect- ing the management of ordinary cases of labor ; and also to point out to him in extraordinary oases when and how he may act upon his own responsibility, and when he ought to send-for assistance.—N. Y. Medical Journal, May, 1870. Henry C. Lea's Publications—(Midwifery). 25 TlfEIGS (CHARLES D.), M.D., •*■'-*- Lately Professor of Obstetrics, A-c, in the Jefferson Medical College, Philadelphia OBSTETRICS: THE SCIENCE AND THE ART. Fifth edition revised. With one hundred and thirty illustrations. In one beautifully printed octavo volume of 760 large pages. Extra cloth, $5 50; leather, $6 50. It is to the student that our author has more par- ticularly addressed himself; but to the practitioner we believe it would be equally serviceable as a book of reference. No work that we have met with so thoroughly details everything that falls to the lot of the accoucheur to perform. Every detail, no matter how minute or how trivial, has found a place.— Canada Medical Journal, July, 1867. The original edition is already so extensively and favorably known to the profession that no recom- mendation is necessary; it is sufficient to say, the present edition is very much extended, improved, and perfected. Whilst the great practical talents and unlimited experience of the author render it a most valuable acquisition to the practitioner, it Is so con- densed as to constitute a most eligible and excellent text-book for the student.— Southern Med. and Surg. Journal, July, 1867. T>AMSBOTHAM (FRANCIS H.), M.D. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- CINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the author. With additions by W. V. Keating M D Professor of Obstetrics, Ac, in the Jefferson Medical College, Philadelphia. In one large and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised bands; with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in all nearly 200 large and beautiful figures. $7 00. We will only add that the student will learn from It all he need to know, and the practitioner will find It, as a book of reference, surpassed by none other.— Stethoscope. The character and merits of Dr. Ramsbotham's work are so well known and thoroughly established, that comment is unnecessary and praise superfluous. The illustrations, which are numerous and accurate, are executed in the highest style of art. We cannot too highly recommend the work to our readers.—St. Louis Med. and Surg. Journal. To the physician's library it is indispensable, while to the student, as a text-book, from which to extract the material for laying the foundation of an education on obstetrical science, it has no superior.—Ohio Med. and Surg. Journal. When we call to mind the toil we underwent in acquiring a knowledge of this subject, we cannot but envy the student of the present day the aid which this work will afford him.—Am. Jour, of the Med. Sciences. fjHURCHILL (FLEETWOOD), M.D., M.R.I. A. ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American from the fourth revised and enlarged London edition. With notes and additions by D. Francis Condib, M. D., author of a "Practical Treatise on the Diseases of Chil- dren," 50. A SHHURST (JOHN, Jr.), M. D.. ■**- Surgeon to the Episcopal Hospital, Philadelphia. THE PRINCIPLES AND PRACTICE OF SURGERY. For the use of Students and Practitioners. In one very handsome octavo volume, with about 550 illustrations. (I/t Press.) Henry C. Lea's Publications—(Surgery). 27 fiJRICHSEN (JOHN), -*-' Senior Surgeon to University College Hospital. THE SCIENCE AND ART OF SURGERY; being a Treatise on Stir- gical Injuries, Diseases, and Operations. From the Fifth enlarged and carefully revised London Edition. With Additions by John Ashhurst, Jr., M. D., Surgeon to the Episcopal Hospital, Ac. Illustrated by over six hundred Engravings on wood. In one very large and beautifully printed imperial octavo volume, containing over twelve hundred closely printed pages: cloth, $7 50; leather, raised bands, $8 50. (Lately Published.) This volume having enjoyed repeated revisions at the hands of the author has been greatly enlarged, and the present edition will thus be found to contain at least one-half more matter than the last American impression. On the latest London edition, just issued, especial care has been bestowed. Besides the most minute attention on the part of the author to bring every portion of it thoroughly on a level with the existing condition of science, he called to his aid gentlemen of distinction in special departments. Thus a chapter on the Surgery of the Eye and its Appendages has been contributed by Mr. Streatfeild ; the section devoted to Syphilis has been rearranged under the supervision of Mr. Berkeley Hill; the subjects of General Surgical Diseases, including Pyemia, Scrofula, and Tumors, have been revised by Mr. Alexander Bruce; and other professional men of eminence have assisted in other branches. The work may thus bo regarded as embodying a complete and comprehensive view of the most advanced condition of British surgery; while Buch omissions of practical details in American surgery as were found have been supplied by the editor, Dr. Ashhurst. Thus complete in every respect, thoroughly illustrated, and containing in one beautifully printed volume the matter of two or three ordinary octavos, it is presented at a price which renders it one of the cheapest works now accessible to the profession. A continuance of the very remarkable favor which it has thus far enjoyed is therefore confidently expected. Erichsen'a Surgery needs no review at the present A noble volume, to review which would require an day. Long ago it took and has since maintained a analysis of the whole domain of modern surgery. leading position in surgical literature, and this posi- Within its comprehensive compass will be found every detail of information which is needed by the practical surgeon.—N. Y. Med. Gazette, Oct. 23, 1869. If there are two books which are more familiar aud more generally known to the medical stndeut, they are those of Watson's Practice and Erichsen's Sur- gery. And few will deny that their distinguished authors are deserving of this and all honor which has been paid them. Watson's Practice but a t'eiv years since might have been called the Kible of Phy- sicians, and Erichsen's volume now before us is not undeserving of a similar compliment from the sur- geon. The original English edition is too well known to need any recommendation on our part, but this American edition has so much in it that has been added by the American editor, Dr. Ashhurst, as to call forth the highest praise and most siucere admi- ration of the completeness with which he has done his part in rendering the book the best on general surgery which is offered to tbe surgeon in this coun- try —The Am. Journ. of Obstetrics, Nov. 1869. tion is so firmly held, that no efforts on the part of a reriewer would serve to weaken the estimate which has beeu placed upon the book—nor, indeed, could they materially strengthen It. The duty, then, de- volving upon us is simply to note the appearance of this new edition, and to point out the improvements therein made.—N. Y. Med. Journal, Jan. 1870. In the recent republication in this country of the last London edition of 'Erichsen's Snrgery" the practitioner and student are supplied with a guide aud text-book which apparently leaves nothing to be desired. Full and complete in every essential par- ticular, and inculcating the most advanced and cor- rect modes of practice, it is certain to come into very general use. The additions of Dr. Ashhurst, though not extensive, are to the point; they relate chiefly to items of American practice.—The Journal, of Psy- ehnlogical Medicine, Jan. 1870. Whether we regard it as a text-book forthe-medical student, or as a guide for the practitioner, it deserves oar highest praise.—Am. Journ. Med. Sci., Jan. 1670. TjY THE SAME AUTHOR. (JustIssued.) ON RAILWAY, AND OTHER INJURIES OF THE NERYOUS SYSTEM. In small octavo volume. Extra cloth, $1 00. ILLER (JAMES), M •*■ -*■ Late Professor of Surgery in the University of Edinburgh, Ac. PRINCIPLES OF SURGERY. Fourth American, from the third and revised Edinburgh edition. In one large and very beautiful volume of 700 pages with two hundred and forty illustrations on wood, extra cloth. $3 75. flY THE SAME AUTHOR. ---- THE PRACTICE OF SURGERY. Fourth American, from the last Edinburgh edition. Revised by the American editor. Illustrated by three hundred and sixty-four engravings on wood. In one large octavo volume of nearly 700 pages, extra cloth. $3 75. piRRIE ( WILLIAM), F. R. S. E., ■ Professor of Surgery in the University of Aberdeen. THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by John Neill, M. D., Professor of Surgery in the Penna. Medica] College, Surgeon to the Pennsylvania Hospital, Ac. In one very handsome octavo volume of 780 pages, with 316 illustrations, extra cloth. $3 75. KjARGENT (F. W.), M.D. ON BANDAGING AND OTHER OPERATIONS OF MINOR SUR- GERY. New edition, with an additional chapter on Military Surgery. One handsome royal 12mo. volume, of nearly 400 pages, with 184 wood-cuts. Extra cloth, $1 76. 28 Henry C. Lea's Publications—(Surgery). J\RUITT (ROBERT), M.R. C.S., frc. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY A new and revised Amerioan, from the eighth enlarged and improved London edition. Illun- trated with four hundred and thirty-two wood-engravings. In one very handsome octavo volume, of nearly 700 large and closely printed pages. Extra cloth, $4 00; leather, $5 00. All that the surgical student or practitioner could i theoretical surgical opinions, no work that we are i.t desire.—Dublin Quarterly Journal. ' present acquainted with can at all compare'with il. It is a most admirable book. We do not know i " i» » compendium of surgical theory (if we may me when we have examined one with more pleasure.- j Jh« word) and practice in itself, and well deserve Boston Med. and Surg. Journal. ' the estimate placed upon It.-Bnt. Am. Journal. In Mr. Drum's book, though containing only some Thus enlarged and Improved, it will continue to eeven hundred pages, both the principles and the I ™nk among our best text-books on elementary sur- practice of surgery are treated, and so clearly and [ S^Y—Columbus Rev. of Med. and Surg. perspicuously, as to elucidate every important topic. | We must close this brief notice of an admirable The fact that twelve editions have already been called ' work by recommending it to the earnest attention of for, in these days of active competition, would of every medical student.—Charleston Medical Journal itself show it to possess marked superiority. We , and Review. have examined the book most thoroughly, and can , A text-book which the general voice of the profes- say that this success is well merited. His book, , pion in Dotu England and America has commended as moreover, possesses the inestimable advantages of one 0f tke most admirable "manuals," or, "vadt having the subjects perfectly well arranged and clas-1 mecum» as nB English title runs, which can be sified, and of being written in a style at once clear piaced in the hands of the student. The merits of and succinct.— Am. Journal of Med. Sciences. j DruUt's Surgery are too well known to every one to Whether we view Druitt's Surgery as a guide to ■ need any farther eulogium from us.—Nashville Med. operative procedures, or as representing the latest Journal. fJAMILTON (FRANK K), M.D., ""- Professor of Fractures and Dislocations, Ac. in Bellevue Hosp. Med. College, New York. A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- TIONS. Fourth edition, thoroughly revised. In one large and handsome octavo volume of nearly 800 pages, with several hundred illustrations. Extra cloth, $5 75; leather, $6 75. (Just Ready.) The credit of giving to the profession the only com- plete practical treatise on fractures and dislocations in our language during the present century, belongs to the author of the work before Jus, a distinguished American professor of surgery; and his book adda one more to the list of excellent practical works which have emanated from his country, notices of which have appeared fi*6ra time to time in our columns du- ring the last few months.—London Lancet, Dec. lo, 1866. In fulness of detail, simplicity of arrangement, and accuracy of description, this work stands unrivalled. So far as we know, no other work on the subject in the English language ca n be compared with it. While congratulating our trans-Atlantic brethren on the European reputation which Dr. Hamilton, along with many other American surgeons, has attained, we also may be proud that, in the mother tongue, a classical work has been produced which need not fear compa- rison with the standard treatises of any other nation. —Edinburgh Med. Journal, Dec. 1866. ASHTON (T. J.). ON THE DISEASES, INJURIES, AND MALFORMATIONS OF THE RECTUM AND ANUS; with remarks on Habitual Constipation. Second American, from the fourth and enlarged London edition. With handsome illustrations. In one very beautifully printed octavo volume of about 300 pages. $3 25. We can recommend this volume of Mr. Ashton's in the strongest terms, as containing all the latest details of the pathology and treatment of diseases connected with the rectum.—Canada Med. Journ., March, 1866. One of the most valuable special treatises that the physician and surgeon can have in his library.— Chicago Medical Examiner, Jan. 1866. The short period which has elapsed since the ap- pearance of the former American reprint, and the numerous editions published in England, are the best arguments we can offer of the merits, and of the use- lessness of any commendation oa our part of a book already so favorably known to our readers.—Boston Med. and Surg. Journal, Jan. 25, 1866. TD1GELO W (HENRY J), M. D., -D Professor of Surgery in the Massachusetts Med. College. ON THE MECHANISM OF DISLOCATION AND FRACTURE OF THE HIP. With the Reduction of the Dislocation by the Flexion Method. With numerous original illustrations. In one very handsome octavo volume. Cloth. $2 50. (Lately Issued.) graph Is largely Illustrated with exquisitely executed woodcuts, after photographs, which help to elucidate the admirable subject-matter pf the text. We /:i^r- dially commend the " Hip," by Dr. Bigelow, to the attentioa of surgeons.—Dublin Quarterly Journal of Medical Science, Feb. 1870. We cannot too highly praise this book as the work of an accomplished and scientific surgeon. We do not hesitate to say that he has done much to clear up the obscurities connected with the mechanism of dis- location of the hip-joint, and he has laid down most valuable practical rules for the easy and most suc- cessful management of these injuries. The mono- AJORLAND (W. W.), M.D. DISEASES OF THE URINARY ORGANS; a Compendium of their Diagnosis, Pathology, and Treatment. With illustrations In one large and handsome octavo volume of about 600 pages, extra cloth. $3 50. ~DRYANT (THOMAS), P.P.C.S. THE PRACTICE OF SURGERY. A Manual, with numerous engravings on wood. In one very handsome volume. (Preparing.) Henry C. Lea's Publications—(Surgery). 29 VjTELLS (J. SOELBERG), ' ' Professor of Ophthalmology in King's College Hospital, Ac. A TREATISE ON DISEASES OF THE EYE. First American Edition, with additions; illustrated with 216 engravings on wood, and six colored plates. Together with selections from the Test-types of Jaeger and Snellen. In one large and very handsome octavo volume of about 750 pages: extra cloth, $5 00; leather, $6 00. (Lately Issued.) A work has long been wanting which should represent adequately and completely the present aspect of British Ophthalmology, and this want it has been the aim of Mr. Wells to supply. The favorable reception of his volume by the medical press is a guarantee that he has succeeded in his undertaking, and in reproducing the work in this country every effort has been made to render it in every way suited to the wants of the American practitioner. Such additions as seemed desirable have been introduced by the editor, Dr. I. Minis Hays, and the number of illustrations has been more than doubled. The importance of test-types as an aid to diagnosis is so universally acknowledged at the present day that it seemed essential to the completeness of the work that they should be added, and as the author recommends the use of those both of Jaeger and of Snellen for different purposes, selections have been made from each, so that the practitioner may have at command all the assistance necessary. The work is thus presented as in every way fitted to merit the confidence of the American profession. mend It to all who desire to consult a really good work on ophthalmic science. The American edition of Mr. Wells' treatise was superintended in its passage through the press by Dr. I. Minis Hays, who has added some notes of his own where it seemed desira- ble. He has also introduced more than one hundred new additional wood-cuts, and added selections from In this respect the work before us is of much more service to the general practitioner than those heavy compilations which, in giving every person's views, too often neglect to specify those which are most in accordance with the author's opinions, or in general acceptance. We have no hesitation in recommending this treatise, as, on the whole, of all English works on the subject, the one best adapted to the wants of the test-types of Jaeger and of Snellen.—Leavenworth the general practitioner. — Edinburgh Med. Journal, j Med. Herald, Jan. 1S70. March, 1870. A treatise of rare merit. It is practical, compre- hensive, and yet concise. Upon those subjects usually found difficult to the student, he has dwelt at length and entered into full explanation. After a careful perusal of its contents, we can unhesitatingly com- Without doubt, one of the best works upon the sub- ject which has ever been published; it is complete on the subject of which it treats, and is a necessary work for every physician who attempts to treat di-^'ases of the eye.—Dominion Med. Journal, Sept. 18b:). rrOYNBEE (JOSEPH), F.R.S., ■*■ Aural Surgeon to and Lecturer on Surgery at St. Mary's Hospital. THE DISEASES OF THE EAR: their Nature, Diagnosis, and Treat- ment. With one hundred engravings on wood. Second American edition. In one very handsomely printed octavo volume of 440 pages; extra cloth, $4. The work, as was stated at the outset orour notice, is a model of its kind, and every page and paragraph of it are worthy of the most thorough study. Con sidered all in all—as an original work, well written, philosophically elaborated, and happily illustrated with cases and drawings—it is by far the ablest mo- nograph that has ever appeared on the anatomy and diseases of the ear, and one of the most valuable con- tributions to the art and science of surgeiy in the nineteenth century.—N. Am. Med.-Chirurg. Review. r A URENCE (JOHN Z.), F. R. C. S., Editor of the Ophthalmic Review, Ac. A HANDY-BOOK OF OPHTHALMIC SURGERY, for the use of Practitioners. Second Edition, revised and enlarged. With numerous illustrations. In one very handsome octavo volume, extra cloth, $3 00. (Lately Issued.) This is, as its name suggests, a book for convenient i the subject, or those recently published by Stellwag - Wells, Bader, and others, Mr. Laurence will prove a safe and trustworthy guide. He has described in this edition those novelties which have secured the confi- dence of the profession since the appearance of his last. To the portion of the book devoted to a descrip- tion of the optical defects of the eye, the publisher has given increased value by the addition of several pages of Snellen's test-types, so generally nsed to test the acuteness of vision, and which are difficult to ob- tain in this country. The volume has been conside- rably enlarged and improved by the revision and ad- ditions of its author, expressly for the American edition —Am. Journ. Med. Sciences, Jan. 1870. J A WSON (GEORGE), F. R. C. S., Engl., ■*-* Assistant Surgeon to the Royal London Ophthalmic Hospital, Moorfields,^tc. INJURIES OF THE EYE, ORBIT, AND EYELIDS: their Imme- diate and Remote Effects. With about one hundred illustrations. In one very hand- some octavo volume, extra cloth, $3 50 This work will be found eminently fitted for the general practitioner. In cases of functional or structural diseases of the eye, the physician who has not made ophthalmic surgery a special study can, in most instances, refer a patient to some competent practitioner. Cases of injury, however, supervene suddenly and usually require prompt assistance, and a work devoted espe- cially to them cannot but prove essentially useful to those who may at any moment be called upon to treat such accidents. The present volume, as the work of a gentleman of large experience, may be considered as eminently worthy of confidence for reference in all such emergencies. It is an admirable practical book in the highest and beet sense of the phrase.—London Medical Times and Gazette, May 18, 1867. reference rather than an exhaustive treatise, and as such it will be found very valuable to tbe general physician. It gives in very brief terms the symp- toms and history of the various diseases of the eye, with just enough cases detailed to elucidate the text without confusing the reader. His chapter on exami- nation of the eye is particularly good, and, it seems to us, better calculated to enlighten a novice than aoy similar instructions we have read.—California Med. Gazette, Jan. 1870. For those, however, who must assume the care of diseases and injuries of the eye, and who are too much pressed for time to study the classic works on 30 Henry C. Lea's Publications—(ovrgery). WALES (PHILIP S.), M.D., Surgeon U.S.N. MECHANICAL THERAPEUTICS: a Practical Treatise on Surgical Apparatus, Appliances, and Elementary Operations: embracing Minor Surgery, Band aging, Orthopraxy, and the Treatment of Fractures and Dislocations. With six hundred and forty-two illustrations on wood. In one large and handsome octavo volume of about 700 pages: extra cloth, $5 75; leather, $6 75. A Naval Medical Board directed to examine and report upon the merits of this volume, officially states that " it should in our opinion become a standard work in the hands of every naval sur- geon;" and its adoption for use in both the Army and Navy of the United States is sufficient guarantee of its adaptation to the needs of every-day practice. It is a unique specimen of literature in its way, in | It will prove especially useful to inexperienced conn- that, treating upon such a variety of subjects, it is as a i try practitioners, who are continually required to whole so completely up to the wants of the student , take charge of surgical cases, under circumstances and the general practitioner. We have never seen ! precluding them from the aid of experienced surgeons. any work of its kind that can compete with it in real , —Pacific Med. and Surg. Journal, Feb 1868. utility and extensive adaptability In conclusion, | , . f h aboye wofk 8ufflcieutl indica. we would state, at the risk ofeite,at on that his , contents. We have not seen for a long ib the most comprehensive.book.onJ.he-subjecit thatwe , ( g language) a treatise equal to thi! haveseen; is the best that can be placed in the hands ^ nor one which is better adapted to the of the student fn need of a first book on surgei y and ; practitioner. It is the most useful that can be named for such general g v belongs; the practitioners who, without any specialpretensions , has frequent opportunities to fill an e ner- to surgery, are occasionally liable to treat surgical . VJ knowledge as is here given. Every cases.-JV. Y. Med. Record, March 2, 1608. | *raetyitloier 8nouid mak| purchase of !uch a booki It is certainly the most complete and thorough work | it wil[ iaKt him his lifetime.----St. Louis Med. Re- of its kind in the English language. Students and i porter, Feb. 1868. young practitioners of surgery will find it invaluable. ' T With 'HO MP SON (SIR HENRY), Surgeon and Professor of Clinical Surgery to University College Hospital. LECTURES ON DISEASES OF THE URINARY ORGANS. illustrations on wood. In one neat octavo volume, extra cloth. $2 25. on which Sir Henry Thompson speaks with more au- thority than that in which he has specially gnthered his laurels; in addition to this, the conversational style of instruction, which is retained in these printed lectures, gives them an attractiveness which a sys- tematic treatise can never possess.—London Medical Times and Gazette, April 24,1S69. These lectures stand the severe test. They are in- structive without being tedious, and simple without being diffuse ; and they include many of those prac- tical hints so useful for the student, and even more valuable to the young practitioner.—Edinburgh Med. Journal, April, 1869. Very few words of ours are necessary to recommend these lectures to the profession. There is no subject J)Y THE SAME AUTHOR. ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF THE URETHUA AND URINARY FISTULA. With plates and wood-cuts. From the third and revised English edition. In one very handsome octavo volume, extra cloth, $3 50. (Just Issued.) This classical work has so long been recognized as a standard authority on its perplexing sub- jects that it should be rendered accessible to the American profession. Having enjoyed the advantage of a revision at the hands of the author within a few months, it will be found to present his latest views and to be on a level with the most recent advances of surgical science. With a work accepted as the authority upon the I ably known by the profession as this before us, must subjects of which it treats, an extended notice would | create a demand for it from those who would keep be a work of supererogation. The simple announce- I themselves well up in this department of surgery.— ment of another edition of a work so well and favor- | St. Louis Med. Archives, Feb. 1870. rfAYLOR (ALFRED S.), M.D., -*• Lecturer on Med. Jurisp. and Chemistry in Guy's Hospital. MEDICAL JURISPRUDENCE. Sixth American, from the eighth and revised London edition. With Notes and References to American Decisions, by Cle- ment B. Penrose, of the Philadelphia Bar. In one large octavo volume of 776 pages, extra cloth, $4 #0 ; leather, $5 50. The sixth edition of this popular work cornea to us i know but that his next case may create for him an In charge of a new editor, Mr. Penrose, of the Phila- emergency for its use. To those who are not the for- delphia bar, who has done much to render It useful, ' tunate possessors of a reliable, readable, interesting, not only to the medical practitioners of this country, but to those of his own profession Wisely retaining the references of the former American editor, Dr. Hartshorne, he has added many valuable notes of his own. The reputation of Dr. Taylor's work is so well established, that it needs no recommendation. He is now the highest living authority on all matters con- nected with forensic medicine, and every successive edition of his valuable work gives fresh assurance to his many admirers that he will continue to maintain his well-earned position. No one should, in fact, be without a text-book on the subject, as he does not and thoroughly practical work upon the subject, we would earnestly recommend this, as forming the best groundwork for all their future studies of the more elaborate treatises.—New York Medical Record, Feb. 16, 1867. The present edition of this valuable manual is a great improvement on those which have preceded it. It makes thus by far the best guide-book in this de- partment of medicine for students and the general practitioner in our language.—Boston Med. and Surg. Journal, Dec. 27, 1666. Henry C. Lea's Publications—(Medical Jurisprudence, &c). 31 T?LAXDFORD (G. FIELDING), M. D., F. R. C P., -*-' Lecturer on Psychological Medicine at the School of St. George's Hospital, Ac. INSANITY AND ITS TREATMENT: Lectures on the Treatment, Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the United States on the Confinement of the Insane. By Isaac Ray, M. D. In one very handsome octavo volume of 471 pages: extra cloth, $3 25. (Just Issued.) This volume is presented to meet the want, so frequently expressed, of a comprehensive trea- tise, in moderate compass, on the pathology, diagnosis, and treatment of insanity. lo render it of more value to the practitioner in this country, Dr. Kay has added an appendix which affords in- formation, not elsewhere to be foundin so accessible aform, to physicians who may ataiiy moment be called upon to take action in relation to patients. It satisfies a want which must have been sorely as our own reading extends) in any other.—London Practitioner, Feb. 1871. Dr. Blandford's book well meets the prevailing de- ficiency, and is one of that class, unhappily too small, which prove a real blessing to the busy practitioner who has no other time for reading but those odd mo- ments which he cau catch in his brief intervals of felt by the busy general practitioners of this country. It takes the form of a manual of cliuical description of the various forms of insanity, with a description of the mode of examining persons suspected of ia- sanity. We call particular attention to this feature of the book, as giving it a unique value to the gene- ral practitioner. If we pass from theoretical conside- rations to descriptions of the varieties of insanity as j leisure. It is so free from detects and is so lair a re- act ually seen in practice and the appropriate treat- I presentation of the most approved views respecting ment for them, we find in Dr. Blandford's work a insanity, that we find in it small occasion for cnti- considerable advance over previous writings on the I cism, and can do little more than commend it as an subject His pictures of the various forms of mental admirable manual for practical use. \»'o end as we disease are so clear and good that no reader can fall I began, in heartily recommending it as a most useful to be struck with their superiority to those given in ; and reliable guide to the general practitioner.— Am. ordinary manuals in the English language or (so far i Journal Med. Sciences, April, 1871. TtTINSLOW (FORBES), M.D., D.C.L., $-c. ON OBSCURE DISEASES OF THE BRAIN AND DISORDERS OF THE MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Pro- phylaxis. Second American, from the third and revised English edition. In one handsome octavo volume of nearly 600 pages, extra cloth. $4 25. (Lately Issued.) A work which, like the present, will largely aid the practitioner in recognizing and arresting the first Insidious advance* of cerebral and mental disease, is one of immense practical value, and demands earnest atteution and diligent study on the part of all who have embraced the medical profession, and have thereby undertaken responsibilities in which the welfare and happiness of individuals and families are largely involved. We shall therefore close this brief and necessarily very imperfect notice of Dr. Winslow's great and classical work by expres>ing our conviction that it is long since so important and beautifully written a volume has issued from the British medical press.—Dublin Medical Press. It is the most interesting as well as valuable book that we have seen for a long time. It is truly fasci- nating.—Am. Jour. Med. Sciences. TEA (HENRY C). SUPERSTITION AND FORCE: ESSAYS ON THE WAGER OF LAW, THE WAGER OF BATTLE, THE ORDEAL, AND TORTURE. Second Edition, Enlarged. In one handsome volume royal 12mo. of nearly 500 pages; extra oloth, $2 75. (Just Issued.) We know of no single work which contains, in so | interesting phases of human society and progress. . , small a compass, so much illustrative of the strangest ; The fulness and breadth with which he hasyarried operations of the human mind. Foot-notes give the { out his comparative survey of this repulsive field of authority for each statement, showing vast research , history [Torture], are such as to preclude our doing and wonderful industry. We advise our confreres (justice to the work within our present limits. But to read this book and ponder its teachings.—Chicago here, as throughout the volume, there will be found Med. Journal, Aug. 1870. a wealth of illustration and a critical grasp of the As a work of curious inquiry on certain outlying ! philosophical import of facts which will render Mi. points of obsolete law, '-Superstition and Force" is I ^ea« labors, of *le/lln« vaiue t0 l'le l'«to"cjr Lea nag done great honor to himself and this Examiner, Dec. 1870. [ country by the admirable works he has written on ecclesiologicaland cognate subjects. We have already had occasion to commend his "Superstition n i.d Force" aud his " History of Sacerdotal Celibacy/' 'J>he present volume is fully as admirable in its me- Mr. Lea's latest work, " Studies in Church History," fully sustaius the promise of the first. It deals with three subjects—the Temporal Power, Benefit of Clergy, and txcommuuication, the record of which has a peculiar importance for the English student, and , thodot dealing vvith topic, aud in the thoroughness- Is a chapter on Aucieut Law likely to be regarded as ! a quality so frequently acting in American a ithors— final We can hardly pass from our mention of such j with which tliey are investigated.—N. Y. Journal of works as these—with which that on "Sacerdotal! Psychol. Medicine, July, 1S70. Celibacy" should be iuciuded—without noting the | 32 Henry C. Lea's Publications. INDEX TO CATALOGUE American Journal of the Medical Sciences Abstract, Half-Yearly, of the Med Sciences Anatomical Atlas, by Smith and Horner Ashton on the Kectum and Anus . Attfield's Chemistry .... Ashwell on Diseases of Females . Ashhurst's Surgery .... Barnes on Diseases of Women Bryant's Practical Surgery . Blandford on Insanity .... Basham on Renal Diseases . Brinton on the Stomach . . . Bigelow on the Hip .... Barclay s Medical Diagnosis . Barlow's Practice of Medicine Bowman's (John E.) Practical Chemistry Bowman's (John E.) Medical Chemistry Brande & Taylor's Chemistry Buckler on Bronchitis .... Bucknill and Tuke on Insanity . Bumstead on Venereal .... Bumstead and Cullerier's Atlas of Venereal Carpenter's Human Physiology . Carpenter's Comparative Physiology . Carpenter on the Use and Abuse of Alcohol Carson'8 Synopsis of Materia Medica . Chambers on the Indigestions Chambers's Restorative Medicine Christison and Griffith's Dispensatory Churchill's System of Midwifery . Churchill on Puerperal Fever Condie on Diseases of Children . Cooper's (B. B ) Lectures on Surgery . Cullerier's Atlas of Venereal Diseases Cyclopedia of Practical Medicine . Dalton's Human Physiology . De Jongh on Cod-Liver Oil . Dewees's System of Midwifery Dewees on Diseases of Females . De wees on Diseases of Children . Dickson's Practice of Medicine Druitt's Modern Surgery Dunglison's Medical Dictionary . Dunglison's Human Physiology . Dunglison on New Remedies Ellis's Medical Formulary, by Smith . Erichsen's System of Surgery Erichsen on Nervous Injuries Flint on Respiratory Organs . Flint on the Heart..... Flint's^ractice of Medicine . Fownes's Elementary Chemistry . fuller on the Lungs, &c. Gibson's Surgery . . . • • G luge's Pathological Histology, by Leidy Graham's Elements of Chemistry . Gray's Anatomy..... Grifilth's (R. E.) Universal Formulary Gross on Foreign Bodies in Air-Passages Gross's Principles and Practice of Surgery Gross's Pathological Anatomy • • Guersant on Surgical Diseases of Children Hartshorne's Essentials of Medicine . Hartshorne's Conspectus of the Medical Scienoee Hamilton on Dislocations and Fractures Harrison on the Nervous System Heath's Practical Anatomy . Boblyn's Medical Dictionary Hodg'e on Women . Hodge'8 Obstetrics . Hodge's Practical Dissections Holland's Medical Notes and Reflections Horner's Anatomy and Histology Hudson on Fevers, .... Hill on Venereal Diseases . Hillier's Handbook of Skin Diseases Jones and Sieveking's Pathological Anatomy Jones (C. Handfield) on Nervous Disorders Kirkes' Physiology . . Knapp's Chemical Technology . PASS 1 13 13 17 17 13 25 22 21 26 I 19 15 9 , 13 25 22 | 21 | 16 28 i 9I 13 13 . 27 27 17 I 17 15 11 16 26 14 10 6 12 26 26 14 21 16 6 28 14 7 4 23 24 fi 15 7 18 19 20 14 IS i! Science Lea's Superstition and Force Lea's Studies in Church History . Lallemand and Wilson on Spermatorrhoea La Roche on Yellow Fever . La Roche on Pneumonia, &c. Laurence and Moon's Ophthalmic Surgery Lawson on the Eye .... Laycock on Medical Observation . Lehmann's Physiological Chemistry, 2 vols Lehmann'6 Chemical Physiology . Ludlow's Manual of Examinations Lyons on Fever..... Maclise's Surgical Anatomy . Marshall's Physiology .... Medical News and Library . Meigs's Obstetrics, the Science and the Art Meigs's Lectures on Diseases of Women Meigs on Puerperal Fever Miller's Practice of Surgery . Miller's Principles of Surgery Montgomery on Pregnancy . Morland on Urinary Organs . Morland on Uraemia Neil I and Smith's Compendium of Med Neligan's Atlas of Diseases of the Skin Neligan on Diseases of the Skin Odling's Practical Chemistry Pavy on Digestion Prize Essays on Consumption Parrish's Practical Pharmacy Pirrie's System of Surgery . Pereira's Mat. Medica and Therapeutics, abridged Quain and Sharpey's Anatomy, by Leidy Ranking's Abstract .... Radcliff aad others on the Nerves, &c. Roberts on Urinary Diseases . Ramsbotham on Parturition . Rigby on Female Diseases . Rigby's Midwifery..... Rokitansky's Pathological Anatomy . Royle's Materia Medica and Therapeutics Salter on Asthma..... Swayne's Obstetric Aphorisms Sargent's Minor Surgery Sharpey and Quain's Anatomy, by Leidy Simon's General Pathology . Simpson on Females .... Skey's Operative Surgery Slade on Diphtheria .... Smith (J. L.) on Children Smith (H. H.) and Horner's Anatomical Atlas Smith (Edward) on Consumption . Smith on Wasting Diseases of Children Solly on Anatomy and Diseases of the Brain Stlll6's Therapeutics Tanner's Manual of Clinical Medicine Tanner on Pregnancy Taylor's Medical Jurisprudence . Thomas on Diseases of Females . Thompson on Urinary Organs Thompson on Stricture . Todd and Bowman's Physiological Anatomy Todd on Acute Diseases .... Toynbee on the Ear .... Wales on Surgical Operations Walshe on the Heart .... Watson's Practice of Physic . Wells on the Eye..... West on Diseases of Females West on Diseases of Children West on Ulceration of Os Uteri . What to Observe in Medical Cases Williams's Principles of Medicine Wilson's Human Anatomy . Wilson on Diseases of the Skin . Wilson's Plates on Diseases of the Skin Wilson's Handbook of Cutaneous Medicine Wilson on Spermatorrhoea . Wlnslow on Brain and Mind pass 31 A » o MAY 2 01960 +1$ NL n oosbifiii o NLM005618110