THE 
PRINCIPLES AND PRACTICE 
OP 
SURGERY, 
BEING 
A TREATISE ON SURGICAL DISEASES AND INJURIES. 
BY 
I). HAYES AGNEW, M.D., LL.D., 
PROFESSOR OF SURGERY IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF PENNSYLVANIA. 
PROFUSELY ILLUSTRATED. 
SECOND EDITION—THOROUGHLY REVISED, WITH ADDITIONS. 
IN THREE VOLUMES, 
v VOL. III. 
PHILADELPHIA: 
J. B. LIPPINCOTT COMPANY. 
LONDON: 10 HENRIETTA STREET, COVENT GARDEN. 
1 88 9. Copyright, 1883, by J. B. Lippincott & Co. 
Copyright, 1889, by J. B. Lippincott Company. CONTENTS OF VOLUME III. 
CHAPTER XXVII. 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
PAGE 
Laryngoscope—History—Mode of Using—Auto-Laryngoscopy—Image obtained— 
Acute or Catarrhal Laryngitis—(Edema of the Larynx—Subglottic (Edema— 
Chronic Laryngitis—Common or Simple Chronic Laryngitis—Glandular Hyper- 
trophy of the Larynx—Tuberculous Laryngitis—Syphilitic Laryngitis—Lupus— 
Lepra—Perichondritis—Laryngo-Tracheitis, or Croup—Relations to Diphtheria— 
Tracheotomy—Results—Causes influencing the Success of Tracheotomy in Croup 
—Indications for Operation—Subjects connected with the Operation—Fatal Ter- 
mination—Stricture of the Larynx and of the Trachea—Fistulte—Foreign Bodies 
in the Air-Passages—Place of Arrest—Change which the Foreign Body under- 
goes—Morbid Effects of Retained Foreign Body—Treatment—Results—Neurosis 
of the Larynx—Anaesthesia—Hyperesthesia—Spasm, Spasmodic Croup, or Laryn- 
gismus Stridulus—Paralysis of the Muscles of the Larynx—Anatomical Consider- 
ations—Suspension of the Functions of Laryngeal Occlusion—Suspension of the 
Functions regulating the Tension of the Cords and the Form of the Glottis—Pa- 
ralysis of the Crico-Thyroid and Thyro-Arytenoid Muscles—Paralysis of the 
Lateral Crico-Arytenoid Muscles—Unilateral Paralysis of the Crico-Arytenoideus 
Lateralis—Paralysis of the Posterior Crico-Arytenoid Muscles—Anchylosis of the 
Crico-Arytenoid Articulation—Electrization of the Larynx—Tumors of the 
Larynx—Causes—Symptoms—Diagnosis—Prognosis — Fibromata—Papillomata— 
Myxomata—Angeiomata—Cystomata —Lipomata —Adenomata—Enchondromata 
—Treatment—Caustics—Evulsion—Crushing—Cutting —False Bands — Circum- 
stances which forbid Intra-Laryngeal Operations—External Incisions—Laryngot- 
omy—Cautions in Operating—Pharyngotomy—Tumors of the Trachea—Malig- 
nant Growths of the Larynx—Carcinoma—Treatment—Thyrotomv—Tracheotomy 
— Extirpation of the Larynx—Operation—Statistics—Partial Excisions of the 
Larynx—Opening the Windpipe—Bronchotomy—Laryngotomy—Surgical Rela- 
tions of the Larynx and Trachea—Thyrotomv, or Median Laryngotomy—Infe- 
rior Laryngotomy—Superior Laryngotomy—Tracheotomy—Stages of Operation— 
Form of the Opening—Complications and Difficulties—Hemorrhage—Misplaced 
Canula—Enlarged Isthmus of the Thyroid Gland—Suffocation—Displacement of 
the Thymus Gland—Emphysema—Cellulitis—Erysipelas and Diphtheria—Pneu- 
monia — Granulations — Stenosis—Fistula—After-Treatment—Laryngo-Tracheot- 
omy—Bronchotomy by Electro- and Thermo-Cautery—Suspended Animation— 
Asphyxia—Apncea—Post-Mortem Appearances—Treatment—Mouth-Inflation of 
the Lungs—Bellows-Inflation—Manual Pressure—Marshall Hall’s Method—Sil- 
vester’s Method—Howard’s Method—Precautions—Medico-Legal Aspects—After- 
Effects of Toxic Gases—Mechanical Explanation of Resulting Suffocation . . 17 
CHAPTER XXVIII. 
DISEASES AND INJURIES OF THE NOSE. THE NASO-PHARYNGEAL REGION, AND 
THE ASSOCIATED PARTS. 
Nose in Respiration—Congenital Absence—Congenital Closure—Acquired Contrac- 
tion—Stenosis from Paralysis of Levatores Alse Nasi Muscles—Congenital Clefts 
—Flattening—Affections of the Soft Parts—Acne Rosacea—Hypertrophy of the 
Nasal Integument—Follicular Inflammation, or Furuncle—Abscess—Steatoma— 
Gangrene—Lupus—Lupus Exedens, or Noli me Tangere—Differential Diagnosis 
—Epithelioma—Rodent Ulcer—Lupus Erythematosus—Treatment—Syphilitic 4 
CONTENTS OF VOLUME III. 
PAGE 
Ulceration—Wounds—Affections of the Cavities of the Nose—Epistaxis—Tam- 
poning—Rhineurynters—Examination of the Nasal Passages—Rhinoscope—Image 
—Foreign Bodies in the Nasal Passages—Nasal Calculi, or Rhinoliths—Foreign 
Bodies which enter the Nasal Passages from without—Parasites—Animal—Vege- 
table—Nasal Catarrh—Rhinitis—Simple Chronic Catarrh—Strumous Catarrh of 
Children—Hypertrophic Catarrh—Complications—Pathology—Treatment—Atro- 
phic or Dry Nasal Catarrh—Catarrh of the Accessory Cavities communicating 
with the Nasal Fossae—Inflammation of the Frontal Sinuses—Foreign Bodies in 
the Frontal Sinuses—Wounds of the Frontal Sinus—Tumors of the Frontal 
Sinus—Affections involving the Septum—Deviations—Inflammation of the Sep- 
tum—Blood-Extravasations—Abscess of the Septum—Perforating Ulcer of the 
Cartilaginous Septum—Morbid Growths in the Nasal Passages—Soft or Gelatinous 
Polypi —Avulsion —Snaring—Galvano-Cautery —Incision —Fibrous Polypi, or 
Nasal Fibromata—Frog-Face—Pathology—Symptoms—Differential Diagnosis— 
Treatment — Osteoplastic Operations —Strangulation— Injections —Electrolysis— 
Enchondromata—Osseous Tumors—Papillomata—Neuromata—Malignant Growths 
—Sarcomata—Carcinoma—Neuroses of the Nasal Passages—Anosmia—Sneezing 
—Sudden Swelling of the Mucous Membrane—Screatus—Rhinoplasty—Rules for 
Success—Indian Plan—Taliacotian or Italian Method—French Method—Partial 
Loss of Nose—Operation 92 
CHAPTER XXIX. 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
Advance of Ophthalmic Surgery—General Observations bearing on the Examination 
and Diagnosis of Diseases of the Eye—Blood-Vessel Supply—Central Retinal Ar- 
tery—Posterior and Anterior Ciliary Arteries—Palpebral Arteries—Deportment 
of Patient—Examination of Patient—Tension—Acuity of Vision—Field of Vision 
—Examination of the Interior of the Eye—Ophthalmoscopes—Examination of 
Fundus of Eye—Upright Method—Indirect or Inverted Image—Normal Ap- 
pearances of the Fundus—The Optic Nerve or Disk—Surgical Affections of the 
Appendages of the Eye—Eyebrows—Wounds and Contusions—Loss of Hair— 
Eyelids — Contusions — (Edema — Emphysema — Wounds—Burns or Scalds — 
Stings—Hordeolum, or Stye—Acne Tarsi—Palpebral Abscess—Blepharitis Ciliaris 
—Malposition or Maldirection of the Cilia—Pediculus Pubis—Fissure of Lids— 
Entropion— Ectropion— Adhesions of Lids —Ankyloblepharon —Symblepharon 
— Conjunctival Approximation— Transplantation — Reduplication — Mechanical 
Means—Exeurvation—Muscular Defects of the Eyelids—Lagophthalmus, or Hare- 
eye—Blepharospasm—Choreic or Nictitating Movements—Ptosis—Coloboma—Ep- 
icanthus—Tumors of the Eyelids—Chalazion—Sebaceous—Millet-Grains—Pilif- 
erous Cysts— Molluscum— Fibroma—Warts —Horns— Lipoma — Naevus —Ade- 
noma—Elephantiasis Graecorum, or Lepra—Cysticerci—Amyloid Disease—Epi- 
thelioma—Diseases of the Lachrymal Apparatus—Lachrymal Gland—Functional 
Dacryoadenitis—Fistula—Morbid Growths in the Lachrymal Gland—Carcinoma 
—Dacryops, or Cyst—Hydatid or Dermoid Cysts—Removal of the Lachrymal 
Gland—Affections of the" Lachrymal Passages—Overflow of Tears—Deviations of 
the Punctum Lachrymale—Directions for Passing Probes—Obstructions of the 
Canaliculi—Dacryoliths—Obliteration of the Punctum—Inflammation of the Lach- 
rymal Sac—Mucocele—Stricture—Dilatation—Introduction of Style—Intractable 
(jases—Leptotbrix—Surgical Affections of the Muscles of the Eye—Strabismus— 
Convergent—Divergent—Operation—Tenotomy—Affections of the Conjunctiva— 
Congestion—Turning of Eyelids—Catarrhal Conjunctivitis—Purulent Ophthal- 
mia—Ophthalmia Neonatorum—Gonorrhoeal Ophthalmia—Secondary or Meta- 
static—Phlyctenular Conjunctivitis—Pannus Herpeticus—Exanthematous Oph- 
thalmia—Granular Conjunctivitis—Trachoma—Pterygium Tenue et Crassum— 
Excision— Strangulation—Transplantation— Xerophthalmia—Xerosis— Encanthis 
—Tumors of the Conjunctiva—Pinguicula—Lipomata—Membranous Lipomata— 
Polypi—Cystomata—Warts—Dermoid Tumors—Cvsticercus—Epithelioma—En- 
cephaloid—Cancer—Sarcoma—Fibromata—Angeiomatous or Vascular Growths— 
Glandular Concretions—Ecchvmosis—(Edema, or Chemosis—Emphysema—Amy- 
loid Disease—Stains of the Conjunctiva—Diseases of the Tunics of the Eye— 
Keratitis—Pannus—Suppuration or Abscess of the Cornea—Interstitial Keratitis 
—Ulcers of the Cornea—Hypopyon—Keratitis, or Ulceration—Fistula of the 
Cornea—Opacities of the Cornea—Nebula—Albugo, or Leucoma—Arcus Senilis— 
Staphyloma— Keratoglobus— Amputation — Strangulation — Seton —Wounds of 
the Cornea—Contusions of the Eye—'Tumors of the Cornea—Diseases and In- CONTENTS OF VOLUME III. 
5 
PAGE 
juries of the Sclerotic Coat of the Eye—Wounds—Staphyloma—Sclerotitis— 
Tumors of the Sclerotic—Diseases and Injuries of the Iris—Congenital Imperfec- 
tions—Irideremia—Coloboma—Membrana Pupillaris Remaining—Albinism—My- 
driasis—Myosis—Iridodonesis, or Tremulous Iris—Iritis—Traumatic—Rheumatic 
—Syphilitic—Treatment—Sequels of Iritis—Posterior Synechia—Tumors of the 
Iris—Carcinoma — Sarcoma—Lepra — Nsevus—Cysts—Operations on the Iris— 
Iridectomy—Instruments—Operation — Iridodesis—Iridodialysis—Affections of 
the Chambers of the Eye—Hydrophthalmos—Blood—Foreign Bodies—Hydatids— 
Irido-Choroiditis and Irido-Cyclitis—Choroiditis—Serous—Plastic—Suppurative 
—Tuberculosis of the Choroid—Coloboma—Detachment—Rupture—Blood-Ex- 
travasations—Colloid Disease—Ossification—Tumors of the Choroid—Sarcomata 
—Carcinomatous Sarcoma—Diseases of the Retina—Congestion—Arterial—Ve- 
nous—Ischaemia—Retinitis—Hemorrhages in Retinitis—Retinitis Nephritica or 
Albuminurica—Diabetic Retinitis—Syphilitic Retinitis—Retinitis Leucaemica— 
Retinitis Pigmentosa—Detachment of the Retina—Tumors of the Retina—Gli- 
oma—Sarcoma—Cysts—Vascular Growths—Tubercular Disease—Diseases of the 
Optic Nerve—Optic Neuritis—Peri-Neuritis—Atrophy of the Optic Nerve—Pa- 
renchymatous—Interstitial—Hemiopia—Homonymous—Amblyopic Affections— 
Amblyopia—Amaurosis—Traumatic Amblyopia—Pathological — Toxic—Modifi- 
cations of Retinal Sensibility—Retinal Anaesthesia—Hemeralopia—Nyctalopia— 
Hysterical Amblyopia—Color-Blindness, or Achromatopsia—Simulated Blindness 
—Embolism of the Central Artery of the Retina—Glaucoma—Acute—Chronic 
—Non-Inflammatory—Fulminans — Secondary — Hemorrhagicum Absolutum — 
Sclerotomy—Diseases of the Crystalline Lens and its Capsule—Position of Lens 
—Congenital Absence—Dislocation—Cataract—Causes—Senility—Traumatism— 
Forms and Symptoms—Cortical—Nuclear—Lamellar — Traumatic—Capsular — 
Catoptric Test—Treatment—Conditions contra-indicating Operation—Operations 
—Extraction—History—Linear—Modified Linear—Conditions for and against 
Operations—Flap Extraction—Instruments—Preparation of the Patient—Steps of 
the Operation—Dressing—After-Treatment—Diet —Complications — Iritis—Pro- 
lapse of the Iris—Suppuration—Extraction by the Lower Flap—Linear—Modi- 
fied Linear—Steps in the Operation—Waldau’s Operation—Mooren’s Method— 
Liebreich’s Method—Wolfe’s Method—Secondary Cataract—Treatment—Divis- 
ion, or Discission—Discission through the Sclerotic, or Scleronyxis—Discission 
through the Cornea, or Keratonyxis—Reclination, or Couching—Suction, or As- 
piration—Treatment of Lamellar, Zonular, or Congenital Cataract—Treatment 
of Traumatic Cataract—General Results of Cataract-Operations—Comparison of 
Methods—Results of Linear Extraction and its Modifications—All Methods com- 
bined—Graefe Method by Seven Operators—Diseases of the Vitreous Body—Hya- 
litis—Hemorrhage—Opacities—Cysticercus—Muscse Volitantes, or Myodesopia— 
Anomalies of Accommodation—Paresis—Paralysis—Spasm—Presbyopia—Refrac- 
tion—Myopia—Hypermetropia—Astigmatism—Meridians of the Eye—Tests— 
Treatment—Enucleation of the Eyeball—Operation—Hemorrhage—Use of Arti- 
ficial Eyes—Introduction—Removal ......... 141 
CHAPTER XXX. 
DISEASES AND INJURIES OF THE EAR. 
General Rules to be observed in examining the Ear—Method—Acuity of Hearing 
—Voice-Test—Defect of Particular Sounds — The Tuning-Fork — Interference 
Otoscope—Pain—Syringing or Washing the External Auditory Canal—Examina- 
tion of the External Auditory Canal and Membrane of the Tympanum—Use of 
Otoscope—Forms of Otoscope—Appearance of the Membrana Tympani—Inflating 
the Membrana Tympani—Politzer Bag—Eustachian Catheter—Catheterization— 
Bougies—Faucial and Post-Palatine Regions examined—Affections of the Auricle 
—Malformations—Absence — Supernumerary—Acquired Deformities—Pathologi- 
cal Malformations—Eczema—Calcareous Formations—Tumors of the Auricle— 
Othaematoma—Progress—Fibroma—Sebaceous Tumors—Papillomata, or Warts— 
Epithelioma—Sarcoma—Angioma, or Naevus—Affections of the External Auditory 
Canal—Impacted Cerumen—Foreign Bodies in the Ear—Insects—Larvae—Other 
Foreign Bodies—Parasitic Growths—Inflammation of the External Ear—Furun- 
culus, or Abscess—Tumors of the External Auditory Cunal—Benign—Polypi — 
Fibromata—Cystomata—Angiomata—Myxomata —Malignant—Carcinoma — Sar- 
coma—Exostosis—Hyperostosis—Affections of the Membrana Tympani—Diseases 
of the Middle Ear—Catarrhal Inflammation—Acute Non-Suppurative Inflamma- 
tion—Chronic Non-Suppurative Inflammation—Eustachian Tube invaded—Mu- 
cous Accumulations in the Cavity of the Tympanum—Naso-Pharyngeal and CONTENTS OF VOLUME III. 
6 
PAGE 
Post-Palatine Regions involved—Treatment—Acute Suppurative Inflammation— 
Chronic Suppurative Inflammation—Necrosis of Petrous Portion of Temporal 
Bone—Mastoid Disease—Trephining the Mastoid—Affections of the Internal Ear 
—Labyrinthic Dealness — Nervous Deafness—Diagnosis—Causes — Traumatic— 
Concussions—Inflammatory Transudations—Basal Meningitis—Catarrhs—Quinia 
—Syphilis—Diphtheria—Exanthemata—Parturition —Cerebro-Spinal Meningitis 
—Central Lesions—Hysterical Deafness—Treatment—Tinnitus Aurium and Aural 
Vertigo—External Ear—Membrana Tympani—Middle Ear—Internal Ear—Gas- 
tric Tinnitus—Toxic Tinnitus—Otalgia—Ear-Cough and Ear-Vomiting—Instru- 
mental Aids for Deafness—Ear-Trumpets—Deaf-Mutism—Dactylology . . 287 
CHAPTER XXXI. 
MALFORMATIONS AND DEFORMITIES—TENOTOMY IN THE TREATMENT OF 
ORTHOILEDIA. 
Beauty of Form—Tenotomy—History — Principle of Healing of Subcutaneous 
Wounds, and the Results following—Operation—Instruments — Malformations 
and Deformities—Etiology—Position—Fractures—Dislocations—Rickets—Articu- 
lar Disease—Burns—Paralysis—Spasmodic, Tonic, or Spastic Conditions of the 
Muscles—Hereditary Influences—Intra-Uterine Pressure—Maternal Impressions 
—Talipes, or Club-Foot—Causes—Varieties—Statistics—Pathological Changes— 
Atrophy—Treatment—Means employed—Bathing — Manipulation—Faradization 
—Apparatus — Operation—Tenotomy— Excision—Time required to restore the 
Limb to its Proper Position—Period to Operate—Cases for Operation—Talipes 
Equinus—Talipes Calcaneus—Talipes Varus—Equino-Varus—Talipes Valgus— 
Calcaneo-Valgus—Equino-Valgus—Mixed Varieties—Treatment — Adduction of 
the Thighs—Flexion of the Thigh—Genu Valgum, or Knock-Knee—Causes— 
Hereditary—Rachitis—Yielding Bones—Rheumatism—Paralysis—Muscular Ri- 
gidity—Articular Disease—Fractures—Condyloid Development—Independency— 
Views of Causation—Author’s View—Treatment—Forcible Straightening with 
and without Division of the External Lateral Ligament—Straightening by Appa- 
ratus—Operations—Redressement Brusque—Osteotomy—Reeves’s Plan—Ogston’s 
—Macewen’s—Genu Extrorsum Curvatum, or Bow-Leg, or Out-Knee—Treat- 
ment—Anterior and Posterior Curvature of the Leg—Weak Ankle—Deformities 
of the Foot—Flat-Foot or Splay-Foot—Podelcoma—Perforating Ulcer of Foot— 
Deformities of Toes—Entire Absence—Polydactylisrft—Webbed Toes—Overlap- 
ping of the Toes—Flexed, Hammer, or Talon Toes—Hypertrophy—Deformities of 
the Upper Extremity—Congenital Absence—Rachitic Curvatures—Paralysis and 
Spasm of the Muscles—Club-IIand—Deformities from Burns and Scalds—Manual 
and Digital Irregularities—Polydactylism—Absence—Supernumerary—Webbed 
—Hypertrophy—Contraction or Flexion—Varieties—Diagnosis from Muscular 
Contraction — Treatment — Lock-Finger — Torticollis, or Wry-Neck—Causes— 
Treatment—Apparatus—Paralytic—Muscular Atony—Choreic—Caries of Cervi- 
cal Vertebrae—Posterior Torticollis, or Spasmodic Extension of the Head—Tenot- 
omy of the Sterno-Mastoid Muscle—Dividing or Stretching the Spinal Accessory 
Nerve 333 
CHAPTER XXXII. 
AFFECTIONS OF THE MUSCLES, TENDONS, BURSAE. AND APONEUROSES. 
Muscles—Wounds—Incised—Contused—Rupture and Laceration—Gunshot Wounds 
—Paresis—Luxation—Inflammation of Muscles, or Myositis—Myalgia, or Mus- 
cular Neuralgia—Degeneration of Muscles—Simple Atrophy—Granular and Fatty 
Atrophy—Waxy Atrophy—Progressive Atrophy—Hypertrophic Muscular Paral- 
ysis—Parasitic Cysts in Muscles—Tumors—Non-Parasitic Cysts—Fibromata— 
Angeiomata—Myxomata — Sarcomata — Carcinomata — Enchondromata—Osteo- 
mata—Affections of the Tendons and their Sheaths—Repair—Wounds of Ten- 
dons—Rupture—Rupture of Long Tendon of Biceps—Rupture of the Tendon of 
the Rectus Femoris or of the Tendo Patellae—Dislocation—Dislocation of Mus- 
cles of the Back—Inflammation of Tendons—Thecitis—Affections of the Bursae 
Mucosae—Ganglions—Subcutaneous Bursae—Bursitis—Tendinous Bursae—Inflam- 
mation of Bursae—Contents of Bursae—Fluid Contents—Diagnosis—Treatment— 
House-Maid’s Knee—Posterior Carpal Bursa or Ganglion—Anterior Carpal Bursa CONTENTS OF VOLUME III. 
7 
PAGE 
—Bursae of the Extensor Muscles of the Thumb—Subdeltoid Bursa—Anterior 
Femoral Bursa—Bursa Tendinis Patellae—Trochanteric Bursa—Bursa beneath 
Tuberosities of the Ischii—Popliteal Bursa—Bursae beneath the Sartorius, Gra- 
cilis, and Semi-Tendinosus Muscles—Bursa of the Tendon of the Peroneus Longus 
Muscle—Calcaneal Bursa—Affections of the Aponeuroses—Wounds—Kupture— 
Inflammation .............. 381 
CHAPTER XXXIII. 
SURGICAL AFFECTIONS OF THE NERVES. 
Neuritis —Wounds —Contused —Contused by Ligature — Laceration — Punctured 
Wounds—Incised Wounds—Injuries to Nerves of Special Sense—Healing of 
Nerves—Treatment—Evil Effects following Injuries of the Nerves—Loss of Tem- 
perature—Nutrition of Paralyzed Part—Swelling of Joints—Condition after 
Puncture or Partial Division—Neuralgia—Symptoms—Pathology—Diagnosis— 
Treatment—Excision— Nerve-Stretching—Statistics for Sciatica—Traumatic Neu- 
ralgia—Traumatic Tetanus—Neuralgia of Different Branches of Fifth Pair of 
Cranial Nerves—Mimic Spasm—Miscellaneous Neuralgic Affections—Central 
Disease—Torticollis—Paralysis—Epilepsy—Diseases of the Optic Nerve—Contrac- 
ture and Spasm—Operation—Force necessary to rupture Nerves—Central Affec- 
tions induced by Irritation of Peripheral Nerves—Epilepsy—Chorea—Contrac- 
ture of Muscles—Hypertrophy—Scrivener’s Palsy—Tetanus—Symptoms—Causes 
—Diagnosis— Pathology— Treatment— Nerve-Atrophy— Hypertrophy —Pseudo- 
Hypertrophic Muscular Paralysis—Infantile Paralysis—Tumors of Nerves—Neu- 
romata— Fibromata— Sarcomata— Myxomata —Carcinomata —Cystomata —Glio- 
Sarcomata—Gummata ............ 405 
CHAPTER XXXIY. 
SURGICAL AFFECTIONS OF THE LYMPHATIC SYSTEM, SKIN, AND SUBCUTANEOUS 
CONNECTIVE TISSUE. 
Congenital Absence and Irregularities of Formation—Lymphangitis—Angeioleu- 
citis—Wounds and Kupture of the Thoracic Duct and of the Lymph-Vessels— 
Dilatation and Rupture of the Thoracic Duct—Wounds of the Lymph-Vessels— 
(Edema— Superficial Varicose Enlargement — Deep Varices — Chyloderm, or 
Lymph-Scrotum— Lymphangiectasis— Lymphorrhagia—Chylocele—Lymphangi- 
oma— Lymph-Glands—Adenitis—Amyloid Degeneration—Surgical Affections of 
the Skin and Subcutaneous Tissue—Erysipelas—Causes—Local Signs—Diagnosis 
—Prognosis—Treatment—Local Rhus Dermatitis—Dermoid and Subdermoid Con- 
nective Tissue— Hypertrophies—Callosities—Clavus—Corns—Verruca—Warts— 
Cornua—Horns—Moles—Cutaneous Redundancy—Keloid—Molluscum Fibrosum 
—Neuroma Cutis—Elephantiasis Arabum—Boucnemia Tropica—Barbadoes Leg 
—Scleroderma—Eiloid—Framboesia—Yaws—Tumors of the Skin—Malignant 
Neoplasms—Sarcoma— Melanosis—Scirrhus—Encephaloma— Benign Neoplasms 
—Cystoma—Myoma—Cutaneous Parasites—Tinea Circinata—Ringworm—Chigoe 
—Sand-Flea—Guinea-Worm—Affections of the Hair—Redundancy of Hair—Alo- 
pecia, or Baldness—Localized Baldness, or Alopecia Areata—Vitiligo—Pityriasis 
Capitis—Plica Polonica—Affections of the Nails—Wounds—Matrixitis—Onychia 
—Inflammation of the Ungual Matrix—Corneous Growths—Exostosis—Incurvated 
Toe-Nail—Whitlow—Paronychia—Felon—Delhi Boil of India—Mycetoma of 
India—Bronchocele, or Goitre—Abscess—Vascular Enlargement—Graves’s or Base- 
dow’s Disease—Cy9tic Hypertrophy—Fibrous Hypertrophy—Calcareous Hyper- 
trophy—Aneurismal Hypertrophy—Causes — Diagnosis—Prognosis—Treatment— 
Operative Measures—Extirpation—Retropharyngeal Goitre—Carcinoma . . 444 
CHAPTER XXXV. 
SYPHILIS. 
History—Stages or Order of Syphilis—Acquired Syphilis—Chancres—Two Doc- 
trines—Syphilitic Virus—Manner of entering the System—Chancroid, or Soft 
Chancre — Seat — Number — Development— Bubo — Prophylaxis— Treatment of 8 
PAGE 
Chancroid—Complications—Phagedena—Local Syphilis—Chancre—Seat—Num- 
ber—Inoculability—Diagnosis—Indurated Bubo—Prognosis—Treatment of Chan- 
cre—Complications—Constitutional Syphilis—Cutaneous Eruptions—Erythema- 
tous—Papular—Vesicular—Pustular—Syphilitic Impetigo—Syphilitic Ecthyma— 
Bullous Syphiloderm—Bupia—Syphilitic Pemphigus—Gummatous Syphiloderm 
—Tubercular Syphiloderm—Syphilitic Affections of the Cutaneous Appendages— 
Onychia—Alopecia—Epidermic Accumulations—Syphilis of the Mucous Mem- 
branes—Exanthemata and Mucous Patches—Erythema, or Angina—Mucous 
Patches—Treatment of Early Syphilis—Syphilization—Constitutional Treatment 
of Early Syphilis—Mercurial Vapor-Baths—Hypodermic Use of Mercury—Local 
Treatment of Early Syphilis—Late Syphilis and Syphilis of Special Organs— 
Gummata—Glossitis—Larynx—Trachea and Bronchi—Lungs—Organs of Special 
Sense—Eye—Iritis—Choroiditis—Retinitis—Organ of Hearing—Olfactory Appa- 
ratus—Syphilis of the Alimentary Tract—(Esophagus—Stomach—Intestines— 
Syphilis of the Periosteum, Bones, and Articulations—Osteo-Periostitis—Tuber- 
cular Lesions—Syphilis of Hard Palate and Nasal Bones—of Muscles and Ten- 
dons—of Articulations—Dactylitis—Syphilis of the Nervous System—Cerebral— 
Meningeal—Encephalon—Spinal Cord—Syphilis of the Genito-Urinary Organs— 
Testes—Spermatic Cord—Uterus and Ovai'ies—Fallopian Tubes—Bladder—Kid- 
ney—Suprarenal Capsule—Syphilis of the Vascular System—Pericardium and 
Heart—Blood-Vessels—Syphilis of Racemose Glands—Mammary—Salivary—Pan- 
creas—Syphilis of Lymph-Glands—Syphilis of the Liver—Spleen—Treatment of 
Late Syphilis—Local—Infantile or Hereditary Syphilis—Signs of Infantile Syph- 
ilis—Appendages of the Skin—Locomotor System—Teeth—Liver—Spleen—Supra- 
renal Capsule—Thymus Gland—Lungs—Nervous System—Eye—Ear—Treatment 
of Hereditary Syphilis—Mineral Waters—Syphilis in its Social Relations—Mar- 
riage—Legal Regulation of Prostitution 504 
CHAPTER XXXYI. 
TUMORS. 
General Considerations—Classification—Origin—Tabulated Classification—Benign 
Tumors—Cysts—Etiology—Sebaceous Cysts—Millet-Grains—Comedones, or Acne 
—Steatomata, or Wens—Mucous Cysts—Salivary Cysts—Seminal Cysts—Oil Cysts 
—Lactiferous Cysts—Synovial Cysts—Blood or Venous Cysts—Exudation Cysts 
—Extravasation or Sanguineous Cysts—Hydatid or Parasitic Cysts—Dentigerous 
Cysts—Cutaneous or Dermoid Cysts—Proliferous Cysts—Typical Tumors, or Be- 
nign Neoplasms which conform in their Histological Elements to Connective 
Tissue—Lipoma—Fibromata—Hard Fibroma—Soft Fibroma—Cavernous Fibroma 
—Myomata — Enchondromata — Osteomata —Exostoses— Osteoma Eburnatum — 
Osteoma Dura — Osteoma Spongiosum — Lymphoma — Soft Lymphoma—Hard 
Lymphoma— Lymphangiomata— Myxomata— Angeiomata— Neuromata— Plexi- 
form Cylindrical Neuroma—Papilloma—Hard—Soft—Adenoma—Tubular or Fol- 
licular—Sarcomata—Round-Celled or Granulation Sarcoma—Alveolar Sarcoma— 
Lymphadenoid Sarcoma—Large Round-Celled Sarcoma—Spindle-Celled Sarcoma— 
Large Spindle-Celled Sarcoma—Giant-Celled Sarcoma—Myeloid—Melanotic Sar- 
coma— Myxo-Sarcoma— Lipomatous Sarcoma— Osteoid Sarcoma —Angeiolithic 
Sarcoma — Endothelial Sarcoma — Diagnosis — Glioma — Inflammatory Fungoid 
Neoplasm — Carcinomata — Extension— Causes— Heredity— Epithelioma —Squa- 
mous—Cylindrical—Scirrhus —Pathology—Encephaloid, or Soft Carcinoma—Fun- 
gus Hematodes—Fatty Carcinoma—Colloid Carcinoma—Melanotic Carcinoma— 
Diagnosis—Treatment—Local Treatment—Compression—Cold—Caustics—Injec- 
tions—Electricity—Cauteries—Eeraseur—Ligature—Excision—Conditions forbid- 
ding Operations 579 
CHAPTER XXXVII. 
DISEASES OF THE MAMMARY GLAND. 
Anatomy—Abnormalities—Affections of the Nipple—Congenital Abnormalities— 
Retracted Nipple—Ulceration—Eczema and Psoriasis—Abscess of the Areola— 
Neoplasms—Syphilis—Affections of the Mammary Gland in the Female—Hyper- 
trophy—Atrophy—Neuralgia—Hyperesthesia—Mastitis, or Inflammation of the 
Mamma—Abscess—Subcutaneous Abscess—Interlobular Abscess—Post-Mammary 
Abscess—Cold Abscess—Tumors of the Mamma—Cysts—Retention-Cysts—Lac- 
teal Cysts—Galactocele—Non-Lacteal Cysts—Hydatid Cysts—Lacteal Obstruction 
CONTENTS OF VOLUME III. PAGE 
—Non-Malignant Tumors— Lipoma — Fibroma — Diagnosis—Treatment—Myx- 
oma—Adenoma—Malignant Tumors—Sarcoma—Spindle-Celled Sarcoma—Round- 
Celled Sarcoma—Cystic Sarcoma—Causes—Diagnosis — Prognosis—Treatment— 
Carcinoma—Scirrhous or Fibrous Carcinoma—Medullary, Eneephaloid, or Soft 
Carcinoma—Colloid Carcinoma—Melanotic Carcinoma—Epithelial Carcinoma— 
Prognosis—Treatment—Local Remedies—Caustics—Excision—Amputation—En- 
larged Axillary Glands—Recurrence—Early Operations—Excision of the Mamma 
—Preparatory Measures — Assistants—Operation—Closing the Wound — After- 
Treatment .............. 679 
CHAPTER XXXVIII. 
ELECTRICITY IN ITS APPLICATION TO SURGICAL THERAPEUTICS. 
Galvanism—Currents—Use of Currents—Diagnosis—Affections in which employed 
—Electrolysis—Employment—Electro-Cautery 718 
CHAPTER XXXIX. 
OPERATIONS FOR NERVE-STRETCHING AND NERVE-EXCISION. 
Supraorbital Nerve—Infraorbital Nerve—Auricularis Magnus Nerve—Great Occip- 
ital Nerve—Spinal Accessory Nerve—Musculo-Cutaneous, Median, and Ulnar 
Nerves—Great Sciatic Nerve—Peroneal Nerve—Anterior Crural Nerve—Anterior 
Tibial Nerve—Excision of the Branches of the Trifacial Nerve .... 727 
CHAPTER XL. 
MASSAGE. 
History—Qualifications of Masseur—Class of Cases benefited by Massage—Time for 
Massage—General Directions—Divisions—Modus Operandi—Friction—Regions— 
Rolling—Kneading—Compression—Percussion—Movements—In Therapeutics . 734 
CONTENTS OF VOLUME III. 
9 LIST OF ILLUSTRATIONS TO VOLUME III. 
FIG. PAGE 
1687. Laryngeal mirror .... 18 
1688. Reflector ...... 18 
1689. Use of the laryngoscope by sunlight . 19 
1690. Tobold’s lamp 20 
1691. Laryngoscopy by artificial light . 20 
1692. (Edema of the larynx ... 25 
1693. Subglottic oedema of the larynx . 25 
1694. Laryngeal knife .... 25 
1695. Spray inhalation .... 27 
1696. Laryngeal syringe .... 28 
1697. Laryngeal brush . . , . 28 
1698. Insufflator. ..... 28 
1699. Syphilitic gummata and ulceration of 
the larynx,—Cohen, Elsberg . . 30 
1700. Lupus of the larynx,—Elsberg. . 31 
1701. Leprosy of the larynx,—Elsberg . 32 
1702. False membrane in the trachea ex- 
tending into the bronchi . . 39 
1703. False membrane forming a cast of 
the trachea ..... 39 
1704. Mackenzie’s dilator,— Mackenzie . 43 
1705. Forceps for extracting bodies from 
the air-passages .... 50 
1706. Flexible blunt hook .... 50 
1707. Tracheal probe ..... 50 
1708. Mop for larynx ..... 51 
1709. Forceps for holding sponge . . 51 
1710. Bilateral paralysis of the crico-tliy- 
roid and thyro-arytenoid . . 56 
1711. Bilateral paralysis of the thyro-ary- 
tenoid 56 
1712. Unilateral paralysis of the vocal 
cords 56 
1713. Bilateral paralysis of the lateral and 
posterior crico-arytenoid muscles . 57 
1714. Fauvel’s laryngeal electrodes . . 60 
1715. Fibroma of the larynx ... 62 
1716. Papillomata of vocal cords . . 62 
1717. Myxoma ...... 62 
1718. Angeiomata of larynx ... 63 
1719. Cystomata of epiglottis . . .63 
1720. Tobold’s caustic-holder ... 64 
1721. Camel’s-hair brush .... 64 
1722. Modified Voltolini’s galvano-cautery 
for removing tumors of larynx . 64 
1723. Fauvel’s laryngeal forceps . . 65 
1724. Mackenzie’s laryngeal forceps . . 65 
1725. Mackenzie’s canula forceps . . 65 
1726. Durham’s forceps .... 66 
1727. Guillotines 66 
1728. Mackenzie’s cutting forceps . . 66 
1729. Cohen’s cutting forceps ... 66 
1730. Mackenzie’s 6craseur . . .67 
1731. Stoerk’s guillotine .... 67 
1732. False bands between the vocal cords . 67 
1733. Epithelioma of the larynx . . 70 
1734. Epithelioma of the larynx, from a 
specimen in the museum of the 
University of Pennsylvania . . 71 
FIG. PAGE 
1735. Surgical relations of trachea and 
larynx . . . . . .76 
1736. Tracheal canulae .... 78 
1737. Tube with pilot .... 79 
1738. Fixation in tracheotomy ... 80 
1739. Two-bladed dilator .... 80 
1740. Three-bladed dilator. ... 80 
1741. Tracheotomy tube introduced and se- 
cured 81 
1742. Retractors ...... 81 
1743. Silvester plan of imitating respiration 89 
1744. Same completed .... 89 
1745. Double fissure separating nose from 
face,—Mason 93 
1746. Hypertrophy of nasal integument . 94 
1747. Lupus exedens of the nose . . 97 
1748. Epithelioma of nose and face,—Pho- 
tographic Review .... 98 
1749. Rodent ulcer ..... 99 
1750. Belloeq’s canula . 102 
1751. Plugging the nasal cavities . . 103 
1752. Metz’s nasal speculum . . .104 
1753. Fraenkel’s nasal speculum . .104 
1754. Rhinoscopic mirror . . . .104 
1755. Rhinoscopic view of naso-pharyngeal 
region 105 
1756. Scoop for foreign bodies in nose . 107 
1757. Thudichum douche .... 109 
1758. Use of nasal douche .... 110 
1759. Post-nasal syringe, with nozzle for 
the anterior nares . . . .110 
1760. Spray nozzle 110 
1761. Syringe with flexible nozzle for nasal 
cavities 113 
1762. Electrode for galvano cautery . . 113 
1763. Electrode for galvano-cautery . . 113 
1764. Dr. Lincoln's pharyngeal electrode . 114 
1765. Curette ...... 114 
1766. Avulsion forceps . . . .114 
1767. Adams’s forceps for deviations of nasal 
septum ...... 118 
1768. Adams’s screw-plates for keeping sep- 
tum straight . . . . .119 
1769. Blandin punch 119 
1770. Soft polypi to turbinated bone . .. 121 
1771. Polypus forceps 123 
1772. Removing polypus with forceps; and 
with canula and wire . . . 123 
1773. Conjoined agency of finger and for- 
ceps in extracting polypus . .124 
1774. Double canula and wire for polypi . 124 
1775. Fibrous polypus, or fibroma . . 126 
1776. Frog-face ...... 126 
1777. Pattern for flap for nose . . . 137 
1778. Cartilaginous portion of nose lost by 
disease 137 
1779. Nasal flap and parts prepared . . 137 
1780. Suture of Professor Pancoast . . 138 
1781. Same completed • 138 12 
LIST OF ILLUSTRATIONS TO VOLUME III. 
FIG. PAGE 
1782. Flap sutured and nose completed . 138 
1783. Flap from arm, and its position, in the 
Taliacotian operation . . .139 
1784. Nose formed by longitudinal flaps . 139 
1785. Flaps stitched in place . . . 139 
1786. Facial flap to repair chasm from 
syphilitic ulceration of nose . .140 
1787. Flaps in place 140 
1788. Flap from lip to nose . . .140 
1789. Flap stitched in position . . . 140 
1790. Oblique illumination of eye, and use 
of magnifying lens . . . 143 
1791. Carmalt’s perimeter,—Noyes . .145 
1792. Principle of ophthalmoscope shown . 146 
1793. Loring’s ophthalmoscope . . .147 
1794. Direct method of examination . . 148 
1795. Examination of inverted image . 149 
1796. Diagram of inverted image . . 150 
1797. Normal fundus of eye . . .150 
1798. Trichiasis ...... 156 
1799. Cilia forceps ..... 156 
1800. Incision for removing cilia . . 156 
1801. Entropion of both eyelids . . . 157 
1802. Entropion forceps . . . .158 
1803. Operation for entropion . . . 158 
1804. Wound with sutures introduced . 158 
1805. Morton’s forceps and knife . . 159 
1806. Removal of Y-shaped piece in ectro- 
pion 160 
1807. Sutures introduced .... 160 
1808. Dieffenbach’s operation for ectropion . 160 
1809. Ectropion of upper eyelid . . . 161 
1810. Operation for the same . . . 161 
1811. Ankyloblepharon treated by conjunc- 
tival flap . . . . .161 
1812. Operation for symblepharon . .162 
1813. Operation for ptosis . . . .166 
1814. Operation for epicanthus . . . 167 
1815. Millet-grains 168 
1816. Piliferous cyst ..... 168 
1817. Grooved director for canaliculus . 173 
1818. Bistoury for canaliculus . . . 173 
1819. Weber knife 173 
1820. Diagram of canaliculi and lachrymal 
sac 174 
1821. Relations of lachrymal passages . 174 
1822. Passing lachrymal probes . . . 174 
1823. Bowman’s lachrymal probes . . 177 
1824. William’s flexible probes . . . 177 
1825. Style....... 178 
1826. Knives for opening lachrymal sac and 
duct 178 
1827. Positions of knife in lachrymal fistula 178 
1828. Lawrence’s ttrabismometer . . 181 
1829. Galezowski’s strabismometer . . 181 
1830. Rat-toothed forceps .... 182 
1831. Tenotomy scissors .... 183 
1832. Strabismus hooks .... 183 
1833. Operation for strabismus . . . 183 
1834. Turning the eyelids .... 185 
1835. Stopper dropper .... 186 
1836. Catarrhal conjunctivitis . . . 186 
1837. Purulent ophthalmia. . . . 188 
1838. Ophthalmia neonatorum . . . 189 
1839. Gonorrhoeal ophthalmia . . . 191 
1840. Phlyctenular ophthalmia . . . 193 
1841. Granular conjunctivitis . . . 195 
1842. Same with enlarged papillae . . 195 
1843. Pterygium 197 
1844. Incisions for pterygium . . . 198 
1845. Strangulating pterygium . . . 198 
1846. Encanthis ...... 200 
1847. Fibroma of lower lid ... 202 
1848. Pannus ...... 205 
1849. Ulcers of cornea .... 209 
1850. Conical cornea ..... 213 
1851. Spherical staphyloma . . . 214 
FIO- PAGE 
1852. Wound approximated after amputa- 
tion of staphyloma . . .215 
1853. Needle for foreign bodies in the cornea 216 
1854. Multiple staphyloma. . . . 218 
1855. Sclerotitis 218 
1856. Iritis....... 221 
1857. Stop speculum ..... 224 
1858. Fixation forceps .... 224 
1859. Lance-shaped knives . . . 224 
1860. Iris forceps 224 
1861. Iris hook ...... 224 
1862. McClure’s iris scissors . . . 225 
1863. Scissors curved on the flat . . 225 
1864. First step in iridectomy . , . 225 
1865. Scissors applied to iris . . . 225 
1866. Canula forceps ..... 226 
1867. Strangulation of iris .... 226 
1868. Atrophy of choroid after choroiditis 
disseminata ..... 230 
1869. Chorio-retinitis ..... 231 
1870. Posterior staphyloma after chorio- 
retinitis ...... 231 
1871. Hemorrhagic retinitis . . . 236 
1872. Retina in Bright’s disease . . . 237 
1873. Retinitis pigmentosa .... 239 
1874. Detached retina .... 240 
1875. Atrophy of optic nerve,—Noyes . 244 
1876. Excavated optic nerve in glaucoma,— 
Noyes ...... 251 
1877. Cortical cataract .... 254 
1878. Catoptric test illustrated . . . 256 
1879. Spoons for extracting the lens . . 258 
1880. Beer’s knife ..... 260 
1881. Cystotome...... 260 
1882. Curette and cystotome combined . 260 
1883. Blunt-pointed knife to enlarge corneal 
incision ...... 260 
1884. Palpebral elevator .... 261 
1885. Corneal flap by upper section . . 261 
1886. Compelling the exit of the lens . 262 
1887. Lower flap section of cornea . . 265 
1888. Graefe knife ..... 265 
1889. Positions of knife in corneal incision 266 
1890. Iris hook ...... 266 
1891. Liebreich’s incision .... 266 
1892. C. Agnew’s method of lacerating the 
membrane of secondary cataract . 268 
1893. Scissors forceps,—Strawbridge’s . 268 
1894. Cataract needles .... 268 
1895. Hays’s knife, full size . . . 268 
1896. Teale’s suction instrument . .270 
1897. Emmetropic eye .... 277 
1898. Myopic diagram .... 278 
1899. Diagram showing the effect of con- 
cave lens on parallel rays of light . 279 
1900. Focus in hypermetropic eye . . 279 
1901. Effect of double convex lens in hyper- 
metropia ..... 280 
1902. Green’s astigmatic diagram,—Noyes. 281 
1903. Green’s astigmatic card,—Noyes . 282 
1904. Thompson’s astigmatic optometer,— 
Gross 283 
1905. Astigmatic disk,—Noyes . . . 284 
1906. Javal’s astigmatic apparatus,—Noyes 284 
1907. Enucleation of eyeball . . . 285 
1908. Tuning-fork 289 
1909. Rubber syringe for the ear . . 290 
1910. Syringing the ear .... 291 
1911. Fountain syringe for the ear . . 291 
1912. Clark’s ear douche .... 291 
1913. Wilde’s ear speculum . . . 292 
1914. Concave mirror 292 
1915. Ear examined by speculum and lens 293 
1916. Ear probe 293 
1917. Forehead-mirror .... 294 
1918. Toynbee speculum .... 294 
1919. Weber reflector for the ear . . 294 LIST OF ILLUSTRATIONS TO VOLUME III. 
13 
FIG. PAGE 
1920. Politzer’s otoscope .... 295 
1921. Otoscope 296 
1922. Examination with otoscope . . 296 
1923. SiglS’s fenestrated speculum . . 296 
1924. Politzer bag ..... 297 
1925. Using Politzer bag .... 297 
1926. Eustachian catheters . . . 298 
1927. Cranial section showing introduction 
of Eustachian catheter . . . 299 
1928. Fibroma of ear-lobe .... 302 
1929. Aspergillus nigricans . . . 306 
1930. Forceps for growths in ear . . 309 
1931. Ring and lever forceps of Toynbee . 309 
1932. Ear scissors . . . . .310 
1933. Wilde’s snare ..... 310 
1934. Blake’s snare ..... 310 
1935. Livingstone’s flexible caustic probe . 310 
1936. Cretaceous gouty tumor of ear,— 
Turnbull ..... 311 
1937. Tympanum injecting apparatus . 317 
1938. Tympanum steaming apparatus . 317 
1939. Gruber’s tenotomy knife . . . 318 
1940. Tympanic mirrors . . . .321 
1941. Abscess under meninges of brain . 321 
1942. Trephines for mastoid process . . 323 
1943. Bone knife ..... 323 
1944. Yearsley’a tympanum . . . 330 
1945. Field’s tympanum .... 330 
1946. Turnbull’s tympanum . . . 330 
1947. Rubber ear-trumpet .... 330 
1948. Tin ear-trumpet .... 330 
1949. Sharp-pointed tenotome . . . 335 
1950. Blunt-pointed tenotome . . . 335 
1951. Manner of stretching the foot . . 341 
1952. Kolbe’s modified club-foot shoe. . 342 
1953. Shoe adjusted ..... 342 
1954. Night splint ..... 342 
1955. Stretching the foot in old varus . 343 
1956. Kolbe’s foot-stretcher . . . 343 
1957. Club-foot stretcher for adults . . 343 
1958. Shoe with elastic strap for foot-drop . 343 
1959. Talipes equinus .... 345 
1960. Extreme pes equinus . . . 345 
1961. Shoe for equinus .... 346 
1962. Talipes calcaneus .... 347 
1963. Apparatus for paralytic calcaneus ap- 
plied 347 
1964. Talipes varus ..... 348 
1965. Varus in the adult .... 349 
1966. Lines for excision of tarsus . . 350 
1967. Talipes valgus 351 
1968. Steel sole with side-pieces for valgus 351 
1969. Shoe for valgus from Pott’s fracture . 352 
1970. Adducted thighs .... 352 
1971. Splint to abduct the thighs . . 353 
1972. Genu valgum, or knock-knee . . 354 
1973. Knock-knee straightened by manual 
pressure ...... 357 
1974. Apparatus for knock-knee applied . 357 
1975. Apparatus for moderate knock-knee . 357 
1976. In-knee splint applied . . . 357 
1977. Ogston and MacEwen operations . 358 
1978. Osteotomes used for genu valgum . 359 
1979. Apparatus for double paralysis with 
knock-knee ..... 359 
1980. Apparatus for paralysis of one limb . 359 
1981. Bow-legs 360 
1982. Kolbe’s bow-leg shoe .... 360 
1983. Apparatus for anterior curve of leg . 361 
1984. Posterior curve of knee . . .361 
1985. Apparatus for back-knee applied . 361 
1986. Shoe for weak ankles . . . 362 
1987. Best type of normal foot . . . 362 
1988. Flat- or splay-foot .... 363 
1989. Overlapping toes .... 366 
1990. Inward deformity of great toe cor- 
rected by adhesive plaster . . 366 
FIG. PAGE 
1991. Briggs’s apparatus .... 367 
1992. Shoe with case for distorted toes . 367 
1993. Recurved toes 367 
1994. Club-hand ...... 368 
1995. Kolbe’s modified Duchenne’s appa- 
ratus ...... 369 
1996. Kolbe’s modified Delacraux’s appa- 
ratus 369 
1997. Hand strongly flexed on forearm after 
a scald ...... 369 
1998. Same after recovery .... 369 
1999. Supernumerary thumb . . .370 
2000. Supernumerary and normal thumbs 
united . . . . . .370 
2001. Webbed fingers . .... 371 
2002. Incision for webbed fingers . . 372 
2003. Flaps approximated .... 372 
2004. Flexed fingers 373 
2005. Dissection showing bands of con- 
tracted fascia, — British Medical 
Journal ...... 373 
2006. Anatomy of lock-finger . . . 376 
2007. Wry-neck . . . . . .376 
2008. Apparatus for wry-neck . . . 378 
2009. Apparatus applied .... 378 
2010. Tenotomy of sterno-mastoid muscle . 380 
2011. Encysted trichina spiralis,—Gross . 388 
2012. Instrument for extracting muscular 
fibre ...... 388 
2013. Subcutaneous suturing of tendo 
Achillis ...... 393 
2014. Schematic bursa .... 396 
2015. Interior of carpal bursa, showing 
rice-like bodies .... 398 
2016. House-maid’s knee .... 399 
2017. Posterior carpal bursa . . . 399 
2018. Anterior carpal bursa and of long 
flexor tendon of thumb . . . 400 
2019. Bursa of extensor muscles of thumb 401 
2020. Scrivener’s spasmodic writing . . 431 
2021. Scrivener’s tremor in writing . . 431 
2022. Scrivener’s paralytic writing . . 431 
2023. Instrument for scrivener’s palsy . 431 
2024. Instrument for scrivener’s palsy . 431 
2025. Tetanus—from nature . . . 433 
2026. Lymph-oedema—a hospital case of 
author’s...... 448 
2027. Lymphangiectasis,—Holmes . . 450 
2028. Section of a corn .... 465 
2029. Section of a wart .... 466 
2030. Horns growing on the nose and face, 
—Photographic Review . . . 467 
2031. Section of a horn .... 467 
2032. Dermoid fibroma,—Dr. Mastin’s case 469 
2033. Gross’s case of keloid,—Gross . . 469 
2034. Molluscum fibrosum .... 471 
2035. Ford’s case of molluscum fibrosum,— 
American Journal Medical Sciences 471 
2036. Neuroma cutis,—Duhring. . . 472 
2037. Neuroma cutis under microscope,— 
Duhring. ..... 473 
2038. Elephantiasis Arabum of leg,—Pho- 
tographic Review .... 474 
2039. Morton's case of elephantiasis,—Sur- 
gery of Pennsylvania Hospital . 476 
2040. Ulcerative matrixitis of finger . . 485 
2041. Corneous growth from the matrix . 485 
2042. Exostosis of the last phalanx of the 
great toe ..... 485 
2043. Toe-nail ulcer ..... 486 
2044. Cork for inverted toe-nail . . . 487 
2045. Cork applied ..... 487 
2046. Enlarged fibroid goitre . . . 491 
2047. Cystic goitre 493 
2048. Fibrous hypertrophy of the thyroid . 493 
2049. Symmetrical goitre .... 494 
2050. Multiple chancroids .... 512 14 
LIST OF ILLUSTRATIONS TO VOLUME III. 
FIG. PAGE 
2051. Section of a chancroid,—Cornil and 
Ranvier 513 
2052. Phagedaena ..... 516 
2053. Section of indurated chancre,—Cornil 
and Ranvier 520 
2054. Section of same showing infiltration, 
—Cornil and Ranvier . . . 520 
2055. Section of same showing new cell- 
forms,—Cornil and Ranvier . . 521 
2056. Section of indurated part of chancre, 
—Cornil and Ranvier . . .521 
2057. Epidermic, pus, desquamated epi- 
dermic and corneous cells,—Cornil 
and Ranvier ..... 521 
2058. False membrane of a chancre,—Cornil 
and Ranvier ..... 522 
2059. Indurated chancre near the fraenum 522 
2060. Indurated inguinal glands . . 526 
2061. Section of a gumma,—Cornil and 
Ranvier 536 
2062. Condylomata ..... 540 
2063. Lee’s mercury volatilizer . . . 544 
2064. Section showing syphilitic glossitis,— 
Cornil and Ranvier . . . 546 
2065. Syphilitic necrosis of the cranium . 553 
2066. Tubercular ulcerations . . . 554 
2067. Gumma from syphilitic testicle,— 
Cornil and Ranvier . . . 560 
2068. Gutnma from the kidney,—Cornil and 
Ranvier 561 
2069. Gumma from the liver,—Cornil and 
Ranvier...... 565 
2070. Syphilitic teeth,—Hutchinson . . 572 
2071. Biliary calculi taken from the pelvis 
through the neck of a cyst . . 587 
2072. Millet-grains ..... 588 
2073. Section of sebaceous cyst . . . 589 
2074. Cyst removed intact .... 591 
2075. Congenital hydrocele of the neck . 592 
2076. Hydatid cyst removed from side of 
thorax ...... 595 
2077. Lipoma of the neck .... 598 
2078. Fat-tuinor, or lipoma . . . 598 
2079. Normal adipose tissue . . . 599 
2080. Lipoma taken from the thigh . . 600 
2081. Microscopic section of hard fibroma 
of thumb ..... 601 
2082. Fibroma of the mamma . . . 602 
2083. Fibroma of the scrotum . . . 602 
2084. Intramural fibroma of the uterus . 603 
2085. Cavernous fibroma from the uterus . 604 
2086. Keloid of the skin .... 604 
2087. Rhabdomyoma from foetal kidney . 605 
2088. Leiomyoma from the cervix uteri . 606 
2089. Smooth muscular tissue from the uterus 607 
2090. Enchondroma of the fingers . . 608 
2091. Enchondroma arising from the ribs . 608 
2092. Enchondroma from the testicle . 609 
2093. Enchondroma from the knee-joint . 610 
2094. Enchondroma, cartilage-cells imbed- 
ded in a fibrillated and also in a 
granular matrix . . . .610 
2095. Myxomatous enchondroma from thy- 
roid body ..... 611 
2096. Osteoma from the femur . . . 613 
2097. Spongy osteoma from the ulna . . 614 
2098. Soft lymphoma ..... 615 
2099. Leukaemic lymph-gland . . . 616 
2100. Hard lymphoma .... 617 
2101. Myxoma from the peritoneum . . 620 
2102. Angeioma from the tongue . . 621 
2103. Plexiform neuroma .... 622 
2104. Medullated neuroma of sciatic nerve 
in a stump 623 
2105. Non-medullated neuroma . . . 623 
2106. Structure of subcutaneous painful tu- 
bercle,—Gross .... 624 
FIG. PAGE 
2107. Leash of nerve-fibres covering a fibro- 
ma,—Gross ..... 625 
2108. Hard papilloma from a preputial 
wart ...... 626 
2109. A bud from a vegetation represented 
in the preceding figure . . . 626 
2110. Soft papilloma from female bladder . 627 
2111. Fragment of specimen from Fig. 
2110 628 
2112. Cystic papilloma from mucous mem- 
brane of uterus .... 629 
2113. Adenoma mamma? .... 630 
2114. Cystic-colloid degeneration of mam- 
mary adenoma .... 633 
2115. Multiple sarcoma of the arm from a 
contusion ..... 635 
2116. Sarcoma of shoulder and arm, which 
began in the deltoid muscle . . 635 
2117. Periosteal sarcoma which began at 
the femur ..... 636 
2118. Sarcoma in axillary lymph-glands, 
extending eight inches below the 
axilla ...... 636 
2119. Granulation-tissue from an ulcerating 
lipoma 637 
2120. Round-celled sarcoma of the testicle 638 
2121. Alveolar or round-celled sarcoma of 
the foot 638 
2122. Lymphadenoid round-celled sarcoma 639 
2123. Large round-celled sarcoma of breast 640 
2124. Small spindle-celled sarcoma of the 
tibia ...... 640 
2125. Large spindle-celled sarcoma (tunica 
vaginalis testis) . . . .641 
2126. Giant-celled sarcoma (thigh) . . 642 
2127. Melanotic round-celled sarcoma (eye) 642 
2128. Melanotic spindle-celled sarcoma 
(eye) ...... 642 
2129. Osteoid sarcoma (tarsal bones) . . 643 
2130. Central sarcoma of radius . . 643 
2131. Periosteal osteoid sarcoma of femur . 644 
2132. Periosteal osteoid sarcoma of tibia . 644 
2133. Calcified sarcoma .... 644 
2134. Endothelial sarcoma of the mamma 
(first stage) 645 
2135. Same at later stage .... 646 
2136. Same, third stage .... 647 
2137. Glioma from pons Yarolii . . . 649 
2138. Duhring’s case of inflammatory fun- 
goid neoplasm .... 650 
2139. Variously-formed cancer-cells . . 652 
2140. Carcinoma of the uterus . . . 652 
2141. Adenoma transforming into carci- 
noma 653 
2142. Epithelioma of the scalp . . . 659 
2143. Squamous epithelioma from the foot. 660 
2144. Same highly magnified . . . 661 
2145. Cylindrical-celled epithelioma (stom- 
ach) ...... 662 
2146. Tubular epithelioma (nasal fossae) . 662 
2147. Scirrhus, or hard mammary cancer . 665 
2148. Scirrhous carcinoma of the mamma . 666 
2149. Atrophic or cicatricial scirrhus . . 667 
2150. Encephaloid or medullary carcinoma 
(mamma) ..... 669 
2151. Encephaloid simulating sarcoma . 670 
2152. Cancer-cylinders in encephaloid of 
mamma undergoing fatty degener- 
ation ...... 670 
2153. Colloid carcinoma of the leg . . 671 
2154. Hypertrophy of the mammae . . 683 
2155. Suspensory and compressing bandage 
of the breast,—Smith . . . 687 
2156. Post-mammary abscess . . . 690 
2157. Multilocular cyst of the mamma . 694 
2158. Cystic breast with papillomatous out- 
growths ...... 694 LIST OF ILLUSTRATIONS TO VOLUME III. 
15 
FIG. PAGE 
2159. Fibroma mammae .... 697 
2160. “ Adeno-fibroma” of mamma . . 697 
2161. Adenoma of mamma. . . . 701 
2162. Sarcoma of mamma .... 702 
2163. Sarcoma of mamma with fungus . 703 
2164. Retracted nipple, with ulceration . 705 
2165. Scirrhus ulcerating .... 706 
2166. Fungoid granulations in open seir- 
rhus 706 
2167. Scirrhus of mamma, with secondary 
nodules 707 
2168. Section of carcinomatous breast . 707 
2169. Encephaloid carcinoma of the breast, 
with fungus 708 
2170. Ulcerating carcinoma of the male 
mamma, with nodules . . . 714 
2171. Lower incision for excision of mamma 716 
2172. Bandage applied after excision of 
mamma...... 717 
2173. Galvanic battery; ten to sixty cells . 718 
2174. Chemico-magnetic battery . . 719 
2175. Rotatory electro-magnetic battery . 719 
2176. Faradic battery 719 
2177. Electrode for stricture . . . 725 
FIG. PAGE 
2178. Electro-cautery instruments . . 725 
2179. Case containing electro-cautery in- 
struments, etc 726 
2180. Byrne battery 726 
2181. Supraorbital nerve exposed . . 727 
2182. Infraorbital nerve exposed . . 728 
2183. Auricularis magnus nerve exposed . 728 
2184. Occipital and auricular nerves ex- 
posed 729 
2185. Spinal accessory nerve exposed . 729 
2186. Line of incision for the same . . 729 
2187. Axillary nerves exposed . . . 730 
2188. Great sciatic nerve exposed . . 731 
2189. External popliteal nerve exposed . 731 
2190. Anterior crural nerve exposed . . 732 
2191. Anterior tibial nerve exposed . . 733 
2192. Direction of the lymphatics and veins 738 
2193. Applying friction to the fingers . 740 
2194. Applying friction to broad surfaces . 740 
2195. Position of the fingers in rolling and 
kneading 741 
2196. Position of the hands in compression. 742 
2197. Gum-ball muscle-beater . . . 743 
2198. Muscle-beater made of gum tubing . 743 PRINCIPLES AND PRACTICE 
OP 
SUBGEKY. 
CHAPTER XXVII. 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
The affections of the larynx which come within the province of the sur- 
geon are such as arise from inflammation, from the presence of morbid growths 
or foreign bodies in the air-passages, and from conditions affecting the motor 
and sensory nerves of the organ. The invention of the laryngoscope has 
contributed immensely to exact knowledge not only in the diagnosis of 
laryngeal diseases, but also in the successful application of methods for their 
treatment. An admirable history of this instrument has been given by Dr. 
Morell Mackenzie. The seed-thought of the laryngoscope dates back to 
the year 1743, when M. Levret, a French accoucheur, invented a crude in- 
strument for exposing the interior of certain cavities. It was not, however, 
until the beginning of the present century (1804) that the exploration of the 
cavities of the body by illumination began to take a practical shape, through 
the labors of Bozzini, of Frankfort-on-the-Main, who devised an instrument 
in many respects like the present endoscope. The application of the prin- 
ciples developed by these workers to the instrumental inspection of throat 
affections was made in 1825 by M. Cagniard de la Tour, and two years later 
by Dr. Senn, of Geneva, both of whom attempted to obtain a reflected image 
of the larynx by the use of a mirror. In 1829, Dr. Babington, of London, 
introduced two mirrors, one a small one for the throat, and the other large 
and designed to concentrate the rays of light upon the pharynx and in this 
manner to impart distinctness to the image depicted on the small mirror. 
This device of Dr. Babington’s is, practically', the laryngoscope in use at 
present. 
Dr. Bennati, a Parisian physician, in 1832 used for the same object a cylin- 
drical tube with two compartments, one for the transmission of light into 
the fauces, and the other provided at its lower end with a mirror for receiv- 
ing the reflected image of the larynx. The instrument which was subse- 
quently employed for examinations of the throat by M. Baumes, Liston, and 
Warden consisted simply of a small mirror. In 1844, however, Mr. Avery, 
of London, devised an arrangement of mirrors which, like those of Babing- 
ton, embodied, both in construction and in use, the principles of the present 
laryngoscope. In this instrument artificial light was projected on the fauces 
by a frontal reflector. 18 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
In Germany, the application of the instrument to the study of laryngeal 
disease was chiefly due to the labors of Professor Tiirck, of Vienna, whose 
attention was attracted to the subject by the laryngoscopic observations of 
the celebrated singer, Signor Garcia, on the physiology of the voice. 
Thus far sunlight alone, save in the device of Avery, was employed in the 
use of the instrument; but in 1857 Czermak, by making such modifications 
as admitted of the employment of artificial light, brought laryngoscopy to 
its present perfection. 
The largyngoscope for sunlight examinations consists of an oval throat 
mirror, made of looking-glass or of highly-polished steel, attached to a long 
stem, which is fastened in a wooden handle (Fig. 1687). and a large round 
reflector made of the same material and having attached an elastic strap for 
securing it to the forehead. (Fig. 1688.) 
Fig. 1687. 
Fig. 1688. 
Laryngeal mirror. 
In using this instrument, the patient should 
be seated with his back to a window through 
which comes a strong sunlight, with the head 
somewhat thrown back, the mouth open, and 
the tongue protruded. The observer takes his 
seat in front of the patient, and, with the large 
reflector strapped to his forehead, proceeds to 
throw the rays of light into the fauces. This 
may require the angle of the reflector on the 
forehead to be altered from its original position, 
which is readily done by the hand without dis- 
placing the glass from the brow. Having se- 
cured the proper position for illuminating the 
fauces and pharynx, the surgeon takes the 
mirror, and, having warmed the glass over the 
flame of a lamp, with a view to prevent its sur- 
face from being obscured by the condensation of the moisture of the breath, 
applies the back of the instrument to his own cheek, in order to ascertain 
that its temperature is not too high. Satisfied on this point, he seizes the 
tip of the patient’s tongue between the thumb and the index finger, having 
a handkerchief or a piece of linen interposed between the two in order 
that the organ shall not slip, and passes the mirror into the throat, with its 
back resting against, and pushing upward and backward, the uvula and 
velum. If the light is properly directed on the palate by the reflector, and 
the fauces tolerate the presence of the instrument, the image of the parts 
forming the upper portion of the larynx will now probably be seen on the 
face of the mirror. (Fig. 1689.) If not, the position of the latter should be 
changed, not by removing it from the palate, but by elevating or lowering 
the handle, or by inclining it to one side or the other. 
It is scarcely probable that, the beginner will be successful in gaining any 
very satisfactory view of the parts on his first attempts in the use of the 
instrument, but by a little patience and tact in manipulation the necessary 
address will be attained. Should the presence of the mirror cause the patient 
to retch, it had better be withdrawn at once, as the muscular contraction 
not only obscures the parts, but causes so much vascular congestion that, 
even if they are seen, no correct notion of their true condition can be 
obtained. 
Keflector. SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
19 
There are many persons whose fauces are naturally exceedingly irritable, 
and who are thrown into a spasm on the very approach of a mirror. In 
cases of this kind, the irritation can often be overcome and the muscles 
Fig. 1689. 
Use of the laryngoscope by sunlight. 
tamed by repeated handling of the parts with a spatula. When this fails, 
various remedies have been recommended. Mackenzie is partial to the 
use of ice, small lumps of which are to be taken into the mouth, and the 
water swallowed as they dissolve, for a short time before the use of the 
instrument. Cohen has found a solution of tannic acid applied to the 
fauces by means of a spray apparatus an excellent allayer of irritation. 
The same author believes that much of this irritability can be avoided 
by allowing three or four hours to elapse between the meals and the ex- 
amination. I have found that rapid breathing continued for half a minute 
will often lessen very much the sensibility of the throat to the use of the 
mirror. 
The obstacle to the use of the laryngoscope is sometimes a large, fleshy 
tongue, which so arches up when protruded as to occupy all the space in 
front of the fauces, leaving no room for the passage of the mirror. Here the 
tongue-depressor will prove of use. 
Enlarged tonsils may also obstruct the space between the arches to a degree 
which will render the employment of the glass difficult. This obstruction 
may be surmounted by passing the mirror behind these bodies, or, if the ex- 
amination cannot be made in this way, and the case is one imperatively de- 
manding a laryngoscopie examination, by excising and removing the glands 
with the tonsillitome. 
Other obstacles may interfere with the proper exposure of the larynx, 
as the existence of a faucial stricture from old cicatricial contractions, 
or there may be a preternaturally long and pendent epiglottis, which will 
serve to conceal the interior of the organ. The first may be considered 
as irremediable without division, the propriety of which would be question- 
able ; and the second would require that the mirror be carried a little 
farther back, and lower in the pharynx, than is usually the case in laryngeal 
examinations. 20 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
When artificial light is employed in laryngoscopy, a lamp with an illumi- 
nating apparatus sim- 
ilar to that of Tobold 
(Fig. 1690) answers an 
excellent purpose. This 
lamp consists of a glass 
chimney surrounded by 
a metallic cylinder with 
a fenestra, and, for al- 
lowing the light of the 
flame to enter, another 
horizontal cylinder con- 
taining three double 
convex lenses. There is 
also an articulated arm, 
supporting at its free 
extremity a reflector 
with a hole through 
its centre. All these 
parts are attached to 
an upright rod of metal 
which is connected to 
a cast-iron base. In 
using artificial light 
the patient is generally 
placed to the right of 
the lamp, and the room darkened to some extent, so as to exclude the sun- 
light. 
The relative positions of the patient and the observer are the same as 
those described in laryngoscopy by sunlight. The reflector is so arranged 
that the physician looks through the central aperture. (Fig. 1691.) 
Fig. 1690. 
Tobold’s lamp. 
Fig. 1691. 
Auto-laryngoscopy.—A little practice will enable any one to examine his own 
larynx. In doing this, it is necessary to place one mirror before the eyes and 
introduce the other into the throat. By the method of Dr. Johnson, which 
has the advantage of simplicity, a mirror is fixed on a table, and nearly on 
Laryngoscopy by artificial light. ACUTE OR CATARRHAL LARYNGITIS. 
21 
a line with its side, or, rather, a little behind, is placed a lamp. The ob- 
server, having the reflector on his head, seats himself in front of the glass, 
and by shifting the position of the reflector he succeeds at length in throw- 
ing the light on the image of the fauces as seen in the glass. The laryngeal 
mirror is now introduced into the throat, and, if properly adjusted, the image 
of the larynx formed on it will be seen reflected on the glass befoi’e which 
he sits. 
The application of the laryngoscope has been extended through the labors 
of Neudorfer and Czermak to the examination of the larynx and trachea 
through the wound made in tracheotomy, and also through a fenestrated 
tube inserted into the opening of the trachea. 
What may he seen with the laryngoscope.—After becoming familiar with the 
manipulation of the laryngoscope, the observer may commence the critical 
exploration of the larynx, with a view to distinguish its different parts and 
to become acquainted with their normal appearances. The most conspicuous 
image seen will be the epiglottis; then the arytenoid cartilages surmounted 
by the bodies of Santorini on each side of the aryteno-epiglottic folds con- 
taining the cartilages of Wrisberg; between these folds the vestibule of the 
larynx, and below this the vocal cords; between the cords of the two sides 
the rima glottidis, a triangular aperture, the base anterior; and between 
the cords of each side lateral pouches, or chambers, the ventricles of the 
larynx. In addition to these parts, others less difficult of exposure may be 
seen, as the glosso-epiglottic folds between the tongue and the epiglottis, 
with the lingual sinuses between. 
In making a laryngoscopic examination of parts below the vocal mem- 
branes and of the movements of the vocal cords, it is necessary that the 
observer direct certain movements and sounds to be made by the patient. 
For example, when a full inspiration is taken, or a prolonged phonation made, 
as sounding continuously the letters aw, as in maw, the vocal cords separate 
posteriorly, leaving a space between ; in other words, enlarging the glottis, so 
as to expose not only the ventricles, but also, under favorable circumstances, 
the cricoid portion of the larynx and the rings of the trachea. The cricoid 
cartilage will be recognized by its yellow color, and the rings of the trachea 
will be distinguished as circular elevations of the mucous membrane, having 
a pale red or pink color. It is even possible, after becoming familiar with the 
use of the instrument, to obtain an image of the bifurcation of the trachea 
and the openings of the bronchi, which appear, the first as a light-colored 
ridge, and the latter as two round, dark spaces. 
The mobility of the vocal cords, and the alternate opening and closing of 
the glottis, are well exhibited by movements produced in inspiration and ex- 
piration, during which the vocal cords alternately diverge and approach pos- 
teriorly. It is not to be supposed that all the topographical features of the 
larynx enumerated can be brought into the field of observation at one time, 
or that they can be studied from one position of the glass. On the contrary, 
the mirror will require to be frequently changed, that is, inclined upward 
and downward, to one side or the other, in order to receive the incident rays 
from different parts of the organ at an angle necessary for clear defini- 
tion. 
Acute laryngitis is an inflammation of the mucous membrane of the larynx. 
It may commence primarily in the organ, or it may follow a pharyngitis, the 
inflammation being propagated by continuity of structure. In the same 
manner the disease is prone to extend into the trachea (laryngo-tracheitis). 
The morbid action is liable to involve the submucous, muscular, and even 
perichondrial portions of the larynx. 
Causes.—These are idiopathic, traumatic, and constitutional, or they may 
be secondary to other affections, or to blood-disease. 
Acute or Catarrhal Laryngitis. 22 
SURGICAL DISEASES OF TIIE LARYNX AND TRACHEA. 
Among the idiopathic causes, cold and sudden atmospheric changes rank 
first. Adults suffer of'tener than children, and males more than females,— 
probably as a result of the nature of their occupations. 
The traumatic excitants of laryngitis are the presence of foreign bodies in 
the organ, injudicious instrumentation, and the inhalation of irritating sub- 
stances, as the fumes from certain mineral acids, fine particles of silicious 
dust, and steam. To these may be added the swallowing of caustic materials, 
in which the disease extends from the pharynx. 
The constitutional causes are measles, smallpox, erysipelas, pyaemia, rheu- 
matism, syphilis, and certain low fevers, as typhoid. 
Symptoms.—The symptoms of laryngitis vary according to the form of the 
disease, whether superficial or deep, and also according to its causation. 
When superficial, and arising from exposure to cold, the patient complains 
of chilliness, and of dryness and soreness of the throat; the voice is hoarse, 
sometimes high-pitched or shrill and jarring, or, it may be, reduced to a 
whisper. The alterations of phonation or voice are probably due to some 
defect in the innervation of the arytenoid muscles interfering with the proper 
tension of the vocal cords, or producing an inharmonious tension of the latter. 
The cough may be hacking, tickling, or at first entirely absent; swallowing 
is attended with discomfort, and there is usually experienced some sense of 
constriction and slight d}Tspncea, and soreness of the larynx to external 
pressure. 
Children, when attacked by laryngitis, in consequence of the irritability of 
the nervous and circulatory systems which is characteristic of their period 
of life, generally exhibit great restlessness, febrility, and oppression of 
breathing. The breathing is crowing or wheezing, and the throat is filled 
with mucous rales. Towards evening the hoarseness and dyspnoea increase, 
and the child is frequently roused from its troubled sleep by a sense of suf- 
focation due to the accumulation of laryngeal mucus; or these suffocating 
paroxysms may be occasioned by muscular spasm, in which the little one 
struggles for breath, stares wildly, throws the arms about, and becomes 
dark in the face. The secretions, which at first consist of mucus, after a 
time, particularly when the disease extends into the lower air-passages, 
become purulent or mueo-purulent. Painful deglutition is also among the 
phenomena attending the disease, and when marked is always an index to 
the severity of the inflammation of the oesophageal surfaces of the epiglottis 
and arytenoid cartilages with their folds. 
The laryngoscopic appearances presented in the mild catarrhal attacks of 
laryngitis consist simply in increased redness of the mucous membrane of 
the organ, with some desquamative erosion, and here and there adherent 
patches of mucus. 
In the severer or deeper variety of laryngitis, the symptoms of difficult 
breathing and deglutition are greatly increased, in consequence of the plastic 
infiltration of the subcutaneous connective tissue, which, by encroaching on 
the orifice of the larynx, deprives the patient of a sufficient amount of air, 
and if not checked will result in death from sudden asphyxia, or more com- 
monly from defective aeration of the blood, rendering the latter fluid unsuited 
to the demands of the nerve-centres, particularly of the medulla oblongata. 
In these parenchymatous attacks of the disease the overstrained vessels not 
infrequently give way, which explains the appearance of blood in the secre- 
tions from the throat, and also the submucous infarctions that are occasionally 
seen to occur. 
A laryngoscopic view of the larynx in the severe variety of the disease 
reveals a general swollen condition of the tissues around and within the organ; 
that is, an effusion of serum and lymph in the connective tissue of the ary- 
teno-epiglottic folds, the vocal membranes, and that beneath the entire mucous 
membrane of the larynx, and also, to some extent, of the contiguous parts 
of the pharynx and even of the fauces. 
The effect of this fibrinous transudation is to lessen the mobility of the CEDEMA OF THE LARYNX. 
23 
tissues of the larynx and of the anterior wall of the pharynx, and hence 
the distress incident to deglutition, and the increased embarrassment to the 
respiration produced by attempts at swallowing. 
Diagnosis.—Acute laryngitis might be mistaken for croup or diphtheria. 
The shrill, brassy cough of croup, the facility with which the patient swal- 
lows, the slight alteration in the voice, and the presence of the characteristic 
false membranes, will serve to establish the distinction between the two dis- 
eases, aside from those signs of inflammatory redness and swelling of the 
mucous membrane of the larynx and contiguous parts, revealed in laryngitis 
by the laryngoscope. From diphtheria, laryngitis differs in the absence 
of the peculiar throat-deposit, muscular paresis, and general symptoms of 
anaesthesia. 
Prognosis.—The termination of catarrhal laryngitis is usually favorable, 
the disease disappearing in mild cases without much attention, and, even in 
severe cases, seldom continuing more than five or six days before the severity 
of the symptoms begins to abate. 
In the commencement of the disease in its mild form, little more is 
required than to confine the patient to his room at a temperature of about 
70° Fahr., and apply a few leeches to the neck over the thyro-hyoid mem- 
brane, afterwards employing a hot flaxseed-meal poultice, a saline aperient, 
the inhalation of the vapor of hot water rendered more soothing by the 
addition of a little laudanum or a few chamomile flowers, and the inter- 
nal use of the neutral mixture supersaturated with the bicarbonate of soda 
and containing a very small amount of morphia. The nourishment should 
be liquid, taken at considerable intervals, and the patient instructed not 
to use the voice, it being necessary to procure for the larynx the benefits 
of rest. 
When the disease assumes the parenchymatous form, in addition to the 
remedies already named, general blood-letting in a robust subject will be 
proper, or it may be substituted by local scarification of the epiglottis and 
aryteno-epiglottic membranes, after which small doses of calomel (one-quarter 
of a grain) with bicarbonate of soda (three grains), administered every hour 
or two, will exert a decided influence not only in lessening the infiltration, but 
also in favoring the absorption of that already present. Hemorrhage, which 
in exceptional cases has required attention, can be controlled by the local 
application of tannin or the perchloride of iron. 
The atmosphere of the room occupied by the patient suffering from laryn- 
gitis, particularly when the latter is a child, should be kept well supplied 
with moisture. This is readily effected by the steam which escapes from a 
boiling kettle, the ebullition being maintained either on a stove or by means 
of a lamp. 
When suffocative symptoms arise, threatening the life of the patient, there 
ought to be no hesitation in reference to the propriety of tracheotomy, and 
the operation should be done at once. 
After the acute symptoms have been subdued, and the disease begins to 
decline, the utmost care should be observed to prevent relapse; otherwise 
chronic laryngitis will be fastened upon the organ. The patient should re- 
main in his room, and, in order to restore the vessels of the larynx to their 
wonted calibre, a solution of alum, tannin, or nitrate of silver should be ap- 
plied to the parts by means of a spray atomizer, while every evening a cale- 
facient or a mustard-plaster may be applied for a short time to the neck 
over the larynx. 
(Edema of the Larynx.—(Edema of the larynx consists in either a mechan- 
ical or inflammatory extravasation of the submucous tissue of the larynx. 
When of mechanical origin, as from the pressure of a tumor, the exudation 
is made up chiefly of serum, but when caused by inflammation, it consists 
of serum, lymph, and even blood. The pathology of the disease was described 
as early as 1765 by Morgagni, but it was not until the beginning of the 24 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
present century that this affection received, through the labors of Bayle, its 
fullest elucidation. 
Acute oedema of the larynx has a very extended causation. As a primary 
affection it is rare, most cases of the kind being secondaiy to other morbid 
conditions, both local and general. It is seldom observed under the eighteenth 
or twentieth year, and shows a preference for males over females. Sestier,* 
in his exhaustive monograph on oedema of the glottis, found, in 213 cases of 
the disease, only 17 under fifteen years of age; and with regard to sex, of 
187 cases, 131 were in men and 56 in women. 
The traumatic causes which give rise to oedema of the glottis are the inha- 
lation of steam, the swallowing of caustic acids or alkalies, or the sting of 
the honey-bee. With the exception of steam, which no doubt enters the 
larynx and induces the oedema directly, all the causes enumerated operate 
secondarily, the inflammation being propagated from the pharynx to the 
larynx. 
CEdema may also follow or attend various forms of laryngitis, as the ca- 
tarrhal, erysipelatous, tubercular, and syphilitic. The constitutional condi- 
tions which predispose to an attack of the disease are those connected with 
certain exanthemata, as variola, scarlatina, rubeola, erysipelas, and diph- 
theria. CEdema has in rare instances been observed by Fauvel among the 
attendants of disease of the kidneys. 
Symptoms.—The signs of oedema of the larynx will vary according to 
the chronic or acute development of the disease. In both, however, the 
prominent feature of the affection is the impediment to respiration. The 
inspiration, at first coarse, gradually becomes stridulous and whistling, 
and the voice is reduced to a whisper, and at length entirely lost. A 
sense of obstruction leads to constant and fruitless efforts to clear the 
throat, from which, occasionally, a little mucus is brought up. Comparative 
relief from the dyspnoea will at times be experienced for a brief intei’val, 
when, probably, the patient drops off into a doze, only, however, to be 
awakened, after a short time, with a start and an increased feeling of suf- 
focation. As the disease wears on, the breathing becomes more labored and 
difficult, the chest heaves in vain efforts to gain an additional amount of 
air, the face exhibits the signs of defective blood-aeration, becoming of a 
dark blue or leaden color, excessive anxiety is depicted on the countenance, 
the arms are thrown nervously about, and, with the wild stare of the eyes, 
almost starting from their sockets, the scene presented is distressing in the 
extreme. 
In acute oedema there is always an intermittent spasmodic element, which 
accounts for the severe exacerbations of dyspnoea which characterize the 
progress of the disease. One of these spasms may destroy life, even when 
the inflammatory effusion is not sufficient to occlude the glottis. 
The laryngoscopic appearance in oedema of the glottis is characteristic. 
The mucous membrane is not intensely red, as in ordinary laryngitis, but 
is quite the opposite, being even paler than in health. The membrane at 
the root of the tongue, in front of the epiglottis, and that of the epiglottis 
itself, are raised up in extreme cases into a semi-translucent swelling, and 
conceal the opening into the larynx; or the ary-epiglottic folds, from the 
abundance of loose connective tissue which they contain, may be the por- 
tions chiefly affected, the dropsical membranes overshadowing the glottis 
by the contiguity of their swollen surfaces. The same serous swelling 
extends into the interior of the laryngeal box. (Fig. 1692.) There is a 
variety of chronic oedema, first accurately described by Gibb, and named by 
him subglottic, in which the only swelling present is situated below the vocal 
cords, in the areolar tissue of the mucous membrane covering the cricoid 
cartilage. (Fig. 1693.) 
Diagnosis.—While it is possible by the history of the case and exploration 
with the finger to determine the existence of oedema of the glottis, yet the 
* TraitS de l’angine laryngSe SdSmateuse. CHRONIC LARYNGITIS. 
25 
laryngoscope will quickly remove any obscurity which may attach to the 
case, and with the least risk and suffering to the patient, as the pale, semi- 
transparent, bladder-like swelling which char- 
acterizes the disease can in a few moments be 
exposed to the eye. 
Prognosis.—In well-marked cases of oedema 
of the larynx the prognosis is exceedingly un- 
promising, particularly when the affection has 
arisen incidentally to low fevers. Of 213 cases 
of oedema of the larynx analyzed by Sestier, 
158 proved fatal. The greatest mortality oc- 
curs in the young and middle-aged. 
Pathology.—In an examination of the lar- 
ynx and the adjacent parts in fatal cases of 
oedema, the connective tissue of the epiglottis 
and the aryteno-epiglottic folds, and also that 
around the vocal membranes, are found infil- 
trated with a muco-purulent and sanguinolent 
exudate which penetrates deeper than the are- 
olar tissue. A similar extravasation will be 
seen beneath the mucous membrane in the 
larynx, below the vocal cords, extending often into the trachea. It is sel- 
dom in these cases that the larynx alone suffers, the same morbid changes 
being observed in the subcutaneous connective tissue 
of the pharynx and fauces and at the root of the 
tongue. 
Treatment.—Yery slight cases of cedema, such as 
have a catarrhal origin, may yield to a blister applied 
over the thyroid cartilage and thyro-hyoid membrane, 
accompanied by the local use of a solution of tannin 
applied by the atomizer, and the internal administra- 
tion of the iodide of potassium. When, however, the 
disease appears in a pronounced or typical form, all such 
methods are fruitless: decisive measures are impera- 
tively demanded. The swollen tissues must be quickly 
unloaded of their transudation, and this can be done only by scarification. 
For this purpose a curved bistoury, wrapped so as to leave only a small 
portion of its edge near the extremity of the blade uncovered, will answer, 
or the laryngeal bistoury 
used by specialists (Fig. 
1694), if at hand, may be 
employed. Either of these 
instruments can be used un- 
der the guidance of a finger or the mirror. In a case of cedema following 
a burn, a No. 12 gum catheter was introduced into the larynx through the 
glottis, and was afterwards replaced by a rectal tube. The latter was re- 
tained twenty-four hours, after which time the swelling had so far diminished 
as to admit of its removal. When no alleviation follows scarification, the 
only hope for relief lies in tracheotomy. 
The results following tracheotomy are by no means flattering; yet the 
chances of life are certainly enhanced by its performance. In the 58 recov- 
eries which took place in Sestier’s 213 cases, the operation was done twenty 
times. 
Fig. 1692. 
(Edema of the laryux. 
Fig. 1693. 
Subglottic oedema of the 
larynx. 
Fia. 1694. 
Laryngeal knife. 
Chronic Laryngitis. 
Chronic laryngitis is much more frequent than the acute form of the dis- 
ease. It may be considered under three heads,—viz., common, specific or 
constitutional, and traumatic. 26 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
Common, or Simple Chronic Laryngitis.—The causes concerned in the pro- 
duction of this form of laryngitis are a neglected pharyngitis, or a badly- 
treated acute inflammation of the same organ, cold, exposure to dust, and 
the injudicious use of the voice in speaking or singing. 
Symptoms.—Simple chronic laryngitis causes a sense of dryness or irrita- 
tion in the throat, often attended with a slight cough, which is aggravated 
on using the voice. In reading, speaking, or singing, the voice, at first 
husky or hoarse, may clear up after a time, until, perhaps, the usual volume 
and tone are attained, but these disappear again if the effort is continued 
for any great length of time. After and during speaking the chest has a tired, 
weary feeling, which may also extend to the larynx. There is usually very 
little secretion in this form of the disease. 
On examining the larynx with the laryngoscope, the mucous membrane 
covering the epiglottis, arytenoid cartilages, inter-arytenoid membrane, and 
vocal cords is seen to be congested, red, sometimes dry and shining, accom- 
panied in cases of long standing by more or less thickening from a plastic 
infiltration, and dotted at various points with adherent mucus. 
In neglected eases of chronic laryngitis the glandular constituents of the 
organ become involved : this is not an uncommon sequel of the disease, and 
may be considered in this connection. 
Glandular Hypertrophy of the Larynx, sometimes termed clergyman’s sore 
throat, ministers furnishing many examples of the affection, is an inflam- 
mation and hypertrophy of the glands and follicles underlying the mucous 
membrane of the larynx. The disease is often associated with a similar con- 
dition of the fauces and pharynx, and with derangements of the digestive 
organs. 
This variety of laryngitis is rarely seen except in males and during adult 
life. 
Causes.—Though generally attributed to overtasking the voice either in 
speaking or in singing, it is probable that, without the influence of other 
violations of the laws of health, this inflammation would rarely develop. 
Most of the cases of this disease which have come under my own observa- 
tion have been in persons who have led sedentary or student lives, taking 
little exercise in the open air, and who at the same time suffered from con- 
stipation and disordered digestion. In the Methodist denomination follicular 
laryngitis is rarely seen among the itinerancy. Stump-speakers are exempt, 
and but few professional singers suffer. 
When examined with the laryngoscope, the mucous membrane covering 
the arytenoid cartilages, ventricles, and laryngeal surface of the epiglottis 
presents numerous isolated spots, the orifices of the excretory ducts of the 
glands, which, being pale, contrast strongly with the surrounding areola of 
red and congested mucous membrane. When following an old chronic laryn- 
gitis, in addition to the other appearances, superficial erosions of the mucous 
membrane will be soen. 
Nor does the larynx alone suffer. Frequently an inspection of the pharynx 
will reveal a coexisting folliculitis of that structure: indeed, in not a few 
instances the disease of the larynx has succeeded to that of the pharynx, the 
inflammatory condition having traveled down. 
Another and vei’y important element which is found to accompany chronic 
pharyngitis, particularly when associated with a noticeable amount of areolar 
infiltration, is a certain degree of muscular paresis, unilateral or bilateral, in- 
terfering with the movements of the arytenoid cartilages, and necessarily, 
also, with the vocal cords, which is to be attributed to the combined opera- 
tion of mechanical pressure and the insufficiency of the motor nerves dis- 
tributed to the parts. 
Diagnosis.—As chronic laryngitis may result from pulmonary tuberculosis, 
the distinction can be made only by a physical exploration of the chest, and 
by laryngoseopic examination of the larynx. (See Tubercular Laryngitis.) GLANDULAR HYPERTROPHY OF THE LARYNX. 
27 
Prognosis.—Unassociated with tuberculosis, chronic laryngitis, though 
exceedingly persistent and rebellious to treatment, cannot be said to be in- 
curable. In most instances much relief can be obtained, though the ten- 
dency to relapse is undoubtedly great. 
Treatment.—In commencing the management of a case of chronic laryn- 
gitis, the physician must ascertain what part occupation plays in the pro- 
duction of the disease. If it arises from exposure to fine particles of dust, 
silicious or metallic, the patient must withdraw from the influence of such 
agents; and equally important is it, in case tho patient has contracted the 
disease in the exercise of the voice in continued speaking or in singing, that 
both of these practices shall be discontinued. 
The treatment comprehends both local and constitutional medication. 
The local remedies can be applied in three ways,—by means of the atomizer, 
the camel’s-hair brush or probang, and the insufflator. The astringent and 
alterative agents employed are tannin, muriate of ammonia, alum, and sul- 
phate of copper or sulphate of zinc. Any of these articles may be dissolved 
in rose-water in the proportion of three to five grains of the astringent to one 
ounce of the water, and inhaled in the form of a spray two or three times a 
day. (Fig. 1695.) In the same manner 
the different preparations of iron, as the 
perchloride or persulphate, can be used, 
twenty to thirty grains of the salt being 
dissolved in half an ounce each of water 
and glycerin. 
Among the most efficient local applica- 
tions are nitrate of silver and chloride of 
zinc. As the former, when used with the 
atomizer, is liable to stain the face and 
teeth, it should always be inhaled by taking 
the neck of the funnel into the mouth. 
The strength of the nitrate of silver must 
vary from ten to forty grains of the salt 
to one ounce of distilled water; and that 
of the chloride of zinc, from two to eight grains to a like quantity of the 
solvent. 
There is some diversity of opinion among surgeons in regard to the topical 
application of medicinal solutions to the interior of the larynx by the brush 
or sponge, some even denying the possibility of passing the glottis without 
great risk to the patient. Among the names early associated with this prac- 
tice was that of I)r. Horace Green, of New York. It is generally known to 
the profession that a committee of medical men, in order to determine this 
point, waited on Dr. Green, and, after a careful practical examination of the 
subject, the instruments employed being curved catheters, came to the con- 
clusion that the attempted introduction of instruments through the glottis 
and into the trachea has in almost every instance been a failure. Of the 
feasibility of passing instruments through the glottis there can be no doubt, 
but the intense spasms which are excited by the use of the sponge probang 
in doing so, and the convulsive attempts to establish the respiratory move- 
ments, sometimes accompanied by vomiting and straining, are often calcu- 
lated, from the resulting congestion of the mucous membrane, to do serious 
harm. Indeed, I have seen such distress follow the operation as to cause me, 
for a time, considerable anxiety. I do not believe, therefore, that it is either 
necessary or advantageous to attempt any application bejmnd the limits 
of the vocal cords; but within these limits very great advantage will be re- 
alized from the use of the nitrate of silver, applied either from the nozzle of 
the laryngeal syringe (Fig. 1696) or by the brush (Fig. 1697), and directed 
to the affected parts by the aid of the laryngoscope once every three or 
four days, the spray, consisting of some of the remedies named, being used 
daily in the intervals. 
Fig. 1695. 
Spray inhalation. SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
The application of powdered substances to the affected surface of the 
larynx, as nitrate of silver, tannin, calomel, iodoform, and alum, is made by 
means of the insufflator. 
(Fig. 1698.) The pow- 
der is introduced into the 
tube through an aper- 
ture in its side, and then 
blown upon the parts by 
a sudden compression 
of the elastic ball. 
Strong counter-irritation has in a great measure been abandoned, yet 
it can be employed with decided advantage. For this purpose the neck 
should be freely painted with 
tincture of iodine, or capsicine 
plaster may be worn constantly. 
The constitutional treatment 
in old cases of chronic laryngitis 
is not less important than the 
local. The digestion will require 
correction by regulating the diet, 
by exercise, and by the administration of tonics, as cod-liver oil, quinine, 
iron, and strychnine. The influence of a mild and uniform temperature con- 
28 
Fig. 1696. 
Laryngeal syringe. 
Fig. 1697. 
Laryngeal brush. 
Fig. 1698. 
Insufflator. 
stitutes another valuable auxiliary in the treatment of cases of long standing, 
and, when circumstances will allow, the climate of our Middle and Northern 
States can be advantageously exchanged for one farther south. 
Tuberculous Laryngitis.—This variety of laryngeal inflammation is rarely, 
if ever, a primary affection, being generally one of the secondary accidents 
of phthisis pulmonalis, and ending quickly in ulceration. Indeed, the exist- 
ence of tubercular irritation of the larynx has been denied by a number of 
writers. I can conceive of no anatomical reason which would preclude a de- 
position of tubercle in this locality more than in any other organ or tissue of 
the body, but it is extremely improbable that tuberculosis of the larynx ever 
occurs as a primary affection. The laryngeal inflammations and ulcerations 
which sometimes precede tuberculosis of the lungs commence, it is believed 
by Buhl, as perichondritis, while Waldenberg attributes these lesions to fol- 
liculitis, with which opinion Dr. Cohen in the main agrees. As a secondary 
condition, however, of pulmonary consumption it is by no means uncommon. 
Louis observed it 63 times in 193 cases of pulmonary consumption,—a fre- 
quency not greater than that since noticed by other writers. 
Symptoms.—The earliest rational sign of tubercular laryngitis is a weak- 
ness, or occasionally a loss, of the voice. Talking, reading aloud, or speak- 
ing is attended with a sense of fatigue in the muscles of the chest and 
the throat, with failure of voice; the collection of laryngeal mucus excites 
constant clearing of the throat, or there may be only a sensation which 
gives rise to a slight hem or cough. The signs of detective general nutri- 
tion are rarely absent, as indicated by loss of flesh. A physical examination TUBERCULOUS LARYNGITIS. 
29 
of the chest seldom fails to establish, in such cases, the coexistence of tuber- 
cular disease of the lungs. 
The laryngeal disease usually begins, it is said by Friedreich, on the side 
answering to the diseased lung; but this statement is not sustained by the 
observations of Heinze and Mackenzie. It is not common in adults after 
twenty or twenty-five years of age. 
The laryngoscopic appearances vary according to the time at which the 
examination is made. In the early stage of the inflammation the mucous 
membrane, besides being of a paler red than normal, exhibits a granular 
appearance, numerous small elevations the size of a millet-seed appearing 
over its surface, particularly noticeable on the laryngeal surface of the epi- 
glottis and on the inner face of the aryteno-epiglottic folds. Less frequently, 
patches or strips, congested and inflamed, with desquamation of the deeper 
layers of epithelium, will be noticed, imparting to the mucous membrane an 
excoriated appearance. Accompanying these signs there is also an inflam- 
matory infiltration, which produces localized thickening of the mucous mem- 
brane, situated generally at the summit of the arytenoid cartilages and over 
the vocal membranes. This swelling, affecting particularly those parts con- 
cerned in phonation and the admission of air, is announced by the hoarse- 
ness and feebleness of the voice, and by the more hurried respiration, with 
increased mucous secretion and cough. The granulations finally undergo ul- 
ceration, the ulcers enlarging in all directions. While some of these spread, 
in others a work of repair may commence, ending in cicatrization; in others, 
again, the granulations becoming redundant, fragments are broken off in 
coughing and discharged in the expectoration. 
Nor are the inflammatory ravages restricted to the mucous membrane. 
The disease, in time, invades the subjacent connective tissue, perichondrium, 
epiglottis, and arytenoid and cricoid cartilages. The order in which the 
latter bodies suffer is very much that in which they have been named. 
The development of chondritis and epichondritis is apt to be followed by 
abscesses and by necrosis of portions of the affected cartilages. Structural 
changes of such a character cannot occur without giving rise to purulent 
expectoration, severe dyspnoea, and difficult digestion, all of which are fre- 
quently observed as rendering the last weeks or months of a consumptive 
exceedingly distressing. 
Treatment.—The constitutional treatment is that suited to phthisis pul- 
monalis, and consists in securing the best hygienic surroundings, the best 
food, and tonics. Among the first, climate is pre-eminent. In this country 
these benefits will result more from a residence in Colorado, Minnesota, or 
California, provided such a change is possible in the early stage of the dis- 
ease, than from all other agencies combined. Many, however, are precluded 
from the benefits of such a change; and to such persons a life in the open 
air, whenever the weather will permit, constitutes an essential part of the 
treatment. The body and feet must be well protected against cold and atmos- 
pheric changes, and in the house an equable temperature throughout should 
be maintained during the winter months. Milk, concentrated broths, meat, 
eggs, bread, and butter constitute the best articles of diet. Tho remedial 
agents which have secured the widest approval are cod-liver oil, iodide of 
iron, preparations of the phosphates, quinia, and whisky. Among local ap- 
plications, iodine, iodoform, tannin, and nitrate of silver are the best. Any of 
these can be applied by the brush, by insufflation, or in the form of a spray. 
In order to secure rest to the larynx, tracheotomy and the introduction of 
a tube have been recommended. 1 adopted this measure in one case, but 
without producing any amelioration of the laryngeal symptoms. Where the 
ulceration is connected with pulmonary tuberculosis, I do not think any- 
thing is to be gained by a procedure of this kind. Tracheotomy, however, 
may become necessary on account of laryngeal stenosis from tumefaction, 
perichondrial abscess, or accidents connected with the necrosis and exfolia- 
tion of the cartilages. 30 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
Syphilitic disease of tho larynx is by no means uncommon. When oc- 
curring during the period in which secondary manifestations prevail, it is 
often an accompaniment of a general erythematous condition of the mouth 
and throat, or, if a higher grade of inflammatory action prevails, mucous 
patches may be formed. The symptom which is most characteristic of syph- 
ilitic laryngitis of the above character is the altered voice, which is slightly 
hoarse and wanting in volume. No difficulty of breathing is experienced. 
The throat is not sore, though there is some dryness complained of in the 
pharynx. As the swelling of the mucous membrane is not sufficient to ex- 
plain the huskiness of the voice, either from obstruction of the glottis or 
from rigidity of the tissues in consequence of infiltration, it seems probable 
that there is a temporary paresis from defective innervation consequent 
on the blood-poison, analogous in some degree to the muscular derangement 
which exists in diphtheria. 
It is, however, in tertiary syphilis that we meet with the more serious 
structural changes in the larynx, such as condyloma, gumma, and ulceration. 
(Fig. 1699.) In whatever form the syphilide appears, 
it is likely to end in ulceration. These ulcers exhibit 
a preference for the lingual surface of the epiglottis, 
and in time, if not checked, perforate and cut away 
its structure until it is almost wholly destroyed. The 
vocal cords, vocal membranes, and arytenoid carti- 
lages also suffer. 
Fungoid vegetations, or warty growths, also spring 
up around the ulcerated lesions of the mucous mem- 
branes covering the vocal cords and other portions 
within the larynx, and, by obstructing the glottis, 
greatly embarrass respiration. Deformity likewise results from the organiza- 
tion of the transudation, which, though in the areolar tissue beneath the 
mucous membrane, appears to possess the contractile quality of cicatricial 
tissue. This, with the cicatrization of the granulations and the formation 
of false threads or bands, serves to check the proper movements of the car- 
tilage articulations and of the vocal cords, to modify the shape of the glottis, 
and to drag certain cartilages out of line, particularly the epiglottis and the 
arytenoids. 
Necrosis of the cartilages is also among the serious lesions which syphilis 
produces in the larynx. These bodies die, generally, in consequence of a 
previous perichondritis, the membrane being detached from the cartilage by 
the inflammatory infiltration. The dead piece, bathed in pus, either disinte- 
grates piecemeal and is ejected in the expectoration, or dies in larger masses, 
which, by becoming displaced and obstructing the tube, may occasion sudden 
death. Syphilitic ulceration is not limited to the larynx, but often extends 
downward into the trachea, and upward into the pharynx, arches, and soft 
palate. 
Diagnosis.—It is generally not difficult to recognize syphilitic disease of 
the larynx. An inspection of the throat and of other portions of the body 
will bring to light traces of old lesions which betray the presence of the 
constitutional malady, even when the patient is unwilling to reveal the 
secret. 
Prognosis.—The slight inflammatory or eruptive blushes which appear in 
the larynx in the course of secondary syphilis have little tendency to pro- 
duce any lasting alterations of structure. They are quite manageable, 
readily disappearing under judicious treatment. Those lesions, however, 
which are among the accidents of advanced or tertiary syphilis are of much 
more importance, and rarel}7- disappear without leaving some thickening, 
contraction, or other deformity which forever after affects both the voice 
and the respiration, the former remaining husky and the latter slightly 
Syphilitic Laryngitis. 
Fig. 1699. 
Syphilitic gummata and ulcera- 
tion of the larynx. LEPRA 
31 
stridulous. These are among the local effects of the disease. As regards 
their cure, the prospect is almost always encouraging. Few people die from 
laryngeal syphilis who apply early for relief and whose cases are properly 
treated. 
Treatment.—Constitutional remedies are chiefly demanded in the treat- 
ment of syphilitic laryngitis of the mild grade, which yields readily to a 
gentle course of mercury. Blue mass and the mild chloride are the prepara- 
tions of this drug which produce the happiest effects; but they must never 
be pushed to salivation. 
Where ulceration or any of those morbid changes of structure which have 
been described as belonging to tertiary syphilis exist, and where it is neces- 
sary to make an immediate impression on the destructive process, the iodide 
of potassium is to be preferred, and should be given boldly, or in such quan- 
tities as may be tolerated by the stomach, until the disease is arrested and 
repair begins, after which it may be combined with some form of mercury, 
preferably the bichloride. When, as is likely to be the case, the general 
health is impaired from previous outbreaks of the constitutional disease, 
iodide of potassium, iron, and cod-liver oil will be required as tonics, and also 
to improve the nutrition. Local treatment must not be underestimated. The 
agents employed in laryngitis arising from other causes will often be found 
useful here, and complications may arise which will require a resort to op- 
erative measures, as the laryngoscopic division of bands or threads which 
obstruct the glottis, and the subsequent introduction of sounds to prevent 
their reunion; the extraction of necrosed fragments of cartilage; and, in 
the event of threatened suffocation from cedema, abscess, or other causes of 
pressure, tracheotomy. 
Lupus.—A few cases of lupus have been described by Tiirck, Ziemssen, 
Berringer, and others. The disease was seated in the upper portion of the 
larynx ; the majority of the patients were females. In nearly all the reported 
cases the ulcerations in the larynx were associated with similar lesions on 
the surface of the face or nose. Accompanying the ulcerations in the larynx 
there were in some instances thickening and isolated nodules of indurated 
tissue over the epiglottis and other portions on the interior of the larynx 
(Fig. 1700), with similar formations in dif- 
ferent parts of the mouth and pharynx. 
The disease bears in many particulars 
a strong resemblance to syphilitic, phthi- 
sical, and carcinomatous ulcerations. A 
differentiation from syphilis can be formed 
only by considerations based on the ex- 
ternal existence of lupoid ulceration and 
the inefficiency of ordinary antisyphilitic 
remedies to control the disease in the 
larynx. The absence of tubercular de- 
posit in the lungs would serve to elimi- 
nate the question of phthisical ulceration, 
Avhile the ulceration resulting from epithelioma does not usually begin 
within the larynx, as in the case of lupus. 
Treatment.—Cod-liver oil and Fowler’s solution of arsenic are the only 
remedies which appear to exert any influence over the disease, though they 
are powerless to effect a cure. 
Fig. 1700. 
Lnpug of tho larynx. 
Lepra.—This affection is rarely witnessed in this country. I)r. Elsberg, of 
New York, has recorded two cases, in both of which the patients had been 
residents of Cuba. The disease is common in those Eastern and Northern 
countries where leprosy prevails. 
The symptoms are those which characterize laryngeal thickening and 
irritation.—namely, a shrill, high-pitched voice, resulting finally in aphonia, 32 
SURGICAL DISEASES OE THE LARYNX AND TRACHEA. 
cough, and expectoration, the sputa changing from a clear mucus to a bloody 
expectoration, with difficult breathing and a foul breath. 
The microscopic appearances, as described by Schroeder, consist in a gen- 
eral tumefaction and thickening of the mucous membrane lining the supra- 
glottic cavity of the larynx, and over the sur- 
face numbers of small elevations, isolated 
hyperplasias of the submucous connective 
tissue, tuberculous granulations according to 
Virchow, (big. 1701.) The morbid process 
extends to the lower portions of the larynx, 
resulting in ulceration. Accompanying the 
laryngeal disease there are the external man- 
ifestations peculiar to leprosy, which aid in 
the diagnosis. 
Treatment.—The disease is incurable. The 
remedies which have been found to afford re- 
lief are bromine and iodoform, both internally and externally. Tonics are 
required to counteract the depressing effects of the disease, and tracheotomy 
may become necessary when suffocation is impending. 
Fig. 1701. 
Morbid appearance of the larynx in leprosy. 
Perichondritis.—This disease rarely occurs except as an effect of tubercu- 
losis, syphilis, or typhoid fever. Occasionally it has a traumatic origin. In 
the case of an aged gentleman whose larynx had been opened for the re- 
moval of a growth 1 saw perichondritis follow, with considerable necrosis 
of the thyroid cartilage. The cartilages of the larynx often sustain injuries 
in attempts at suicide by cutting the throat, from which necrosis may follow. 
The affection occurs most frequently between the ages of twenty-five and 
forty, the period of life at which manifestations of syphilis or consumption 
are most usually observed. Males suffer much oftener than females from 
the disease. When perichondritis appears as a primary affection, it is gen- 
erally after mature life. 
According to Mackenzie, the cricoid and arytenoid cartilages are affected 
in tubercular perichondritis with about equal frequency ; the thyroid is more 
apt to escape. 
Symptoms —The general signs of perichondritis are pain or soreness ex- 
perienced in the larynx, particularly on pressure, and difficult deglutition; 
but, as these are common to other affections of the larynx, they can have 
little weight in forming a diagnosis ; and, indeed, unless suppuration and ulcer- 
ation occur in the neck, enabling the surgeon to make an examination with 
the probe, much obscurity will attend the case. Some diagnostic importance 
should be attached to the expectoration of pus and to a noticeably fetid 
breath, the coexistence of which signs would furnish ground for supposing 
the death of some portion of the laryngeal skeleton. 
The prognosis is very unfavorable. Even if exfoliation occurs, the con- 
traction which follows in the soft part of the larynx after the loss of the 
whole or a part of one of the cartilages, with attending inflammatory thick- 
ening, is calculated to offer a serious impediment to the passage of air, in 
consequence of the diminished calibre of the tube. 
Treatment.—If the disease is detected early, something may be effected 
by local remedies tending to relieve the inflammation, as the application of 
a few leeches in the vicinity of the larynx. When suppuration has taken place 
and the cartilage is undergoing dissolution, the treatment will be chiefly ex- 
pectant, the indications being met as they arise. If the pus is accessible from 
the surface of the neck, an external opening should be made for its escape. 
As the cartilage disintegrates and becomes loose, it must be extracted. The 
occurrence of oedema will necessitate incisions or the use of the tracheal 
canula. Stenosis must be counteracted by the use of metallic bougies of 
graduated sizes, and dangerous obstructions to the entrance of air will 
require the operation of tracheotomy. LAR YNGO- TRACHEITIS— CRO UP. 
33 
I shall not enter at any length into the discussion of the question as to 
the unity or duality of croup and diphtheria. This subject belongs to a 
work on the practice of medicine, rather than to one on surgery: it is not, 
however, without practical interest to the surgeon, as it will exercise no 
small influence in determining his action in cases where operative measures 
are contemplated for the relief of the disease. 
There are many distinguished names arrayed on each side of this question, 
though perhaps the weight of authority will be found to be in favor of the 
theory of identity. I say theory, for I think that even the strongest advo- 
cates of this view will admit that there are some points connected with the 
relationship between the two affections which have not been satisfactorily 
explained, and which militate against the unqualified acceptance of the 
doctrine of the unicist. 
I believe that diphtheria and croup are two distinct diseases, and this 
opinion is based not so much on anatomical as on clinical evidence. It will 
be proper in this place to speak of those clinical and anatomical features in 
which the two affections agree, and those in which they disagree. 
First, those in which diphtheria and croup agree clinically.—Both frequently 
commence with catarrhal prodromes; in both there is a shrill hoarse voice; 
in both there are false membranes in the larynx and the trachea; in both 
there Is obstructive stenosis, with labored, stridulous breathing; in both there 
are paroxysms of suffocation; and in both death may follow carbonic acid 
poisoning. 
Second, the clinical differences.—These will appear the more striking by being 
placed in contrast: 
Laryngo-Tracheitis—Croup. 
IDIOPATHIC CROUP. 
DIPHTHERITIC CROUP. 
Almost always a disease of childhood. 
Second attacks rare. 
Hereditary tendency marked. 
Generally sporadic. 
Not traceable to specific local causes. 
Incapable of extension by personal communi- 
cation. In other words, neither infectious nor 
contagious. 
Occurs at all ages. 
Not uncommon. 
No influence. 
Generally either endemic or epidemic. 
Frequently traceable to such causes as bad 
drainage and poisonous exhalations. 
Both infectious and contagious. 
In regard to the last-named distinction, the general evidence is altogether 
in one direction. No physician attaches any importance to the exhalations 
from the breath of a patient laboring under simple croup; but how many 
can testify to the ill effects resulting from those received into the throat from 
diphtheritic cases! 
Exudation is primarily seated in the larynx 
and trachea. 
Commonly in the fauces and pharynx. 
With reference to the original difference of locality, it is alleged by some 
writers that croup usually begins in the pharynx. Mackenzie says that the 
cases in which it does not begin there do not exceed 10 or 12 per cent. If 
it is meant that the false membrane in croup is primarily formed in the 
pharynx, I must dissent from the opinion, as being utterly at variance with 
my own observation. 
Exudation invariable and present throughout 
the entire attack. 
Exudation non-inoculable. 
Does not affect the nasal and naso-pharyngeal 
mucous membranes. 
Not characterized by feeble circulation or other 
sign of general weakness. 
May be very slight, or even absent. 
Inoculable. 
Affection of both among the ordinary phe- 
nomena of the disease. 
Asthenic symptoms a prominent feature 
throughout the attack. 34 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
No attendant or consecutive paralysis. 
Never poisons wounds. 
Destroys life only by physical obstruction of 
the air-passages. 
Albuminous urine uncommon. 
The pulse-rate less disturbed than the respira- 
tion. 
Pulse generally full and strong. 
No accompany ing enlargement of the lymphatic 
glands. 
Paralysis common. 
Will certainly do so. 
Proves fatal altogether independently of such 
obstruction. 
Common. 
The frequency of the pulse greater than can be 
accounted for by the respiration. 
Small and feeble. 
Such enlargements common. 
The comparative immunity of the glands of the neck from swelling in 
croup is attributed to the absence of communication between the lymphatics 
of the larynx and the cervical lymph-glands; but if, as stated by Mackenzie, 
croup generally begins in the pharynx, the lymphatics of which sustain a 
close relation to the lymph-glands of the neck, how is this exemption of the 
latter to be explained ? 
The anatomical appearances were at one time regarded as differential. 
Yirchow maintained that the structural change peculiar to diphtheria con- 
sisted in necrosis of the submucous connective tissue. The exceptions, how- 
ever, to this anatomical distinction are so numerous that even Yirchow has 
been compelled to abandon this view as fallacious. 
Notwithstanding the dissent of pathology, there are still a number of 
competent observers who adhere to the doctrine of the duality of these two 
affections. 
The knowledge acquired from enlarged observation and experience in con- 
tact with the sick must not be too strictly limited by the knife and glass of 
the pathologist when the two sources of information do not yield harmonious 
results. 
I do not mean to underestimate the importance of morbid anatomy in 
solving the various problems of disease, but wish merely to remind those 
who anchor their faith too exclusively on pathological statements that, in 
interpreting the phenomena involving the profoundest secrets of chem- 
ical and vital action, the pathologist himself is liable to err. Examples are 
not wanting to establish the truth of this statement in the subject under 
consideration. 
Wagner maintains that the membrane found in croup and diphtheria is 
not an exudation from the blood, but is the product of epithelial degenera- 
tion, while Studener excludes the epithelium from any participation in the 
formation of the matrix of the membrane, regarding it as a fibrinous sub- 
stance derived from the plasma and white corpuscles of the blood. Other 
observers also, as Yirchow and Kindfleisch, believe that it is the result of the 
coagulation of a fibrinous exudation derived directly from the blood; while 
not a few, as Halker, Oertel, Klebs, and others, attribute its production 
chiefly to a parasitic origin. 
Material objects may possess so many points of similarity that in no par- 
ticular is it possible, either by the mechanical aids to vision or by the re- 
actions of the chemist, to discover any distinction, and yet, through the 
observation of the clinician, they may be found to be wholly dissimilar both 
in their nature and their effects. What, for example, more alike than the 
pus from a chancroid ulcer and that from an ordinary abscess? Will any 
one assume to differentiate the two by mere physical tests ? And yet what 
more unlike than the results of their inoculation ? 
Plastic infiltrations indistinguishable from One another by physical exam- 
ination are constantly witnessed among the phenomena of diseases alto- 
gether dissimilar and never confounded in clinical nosology. And what is 
true of infiltrates may be equally so of those fibrinous translations which 
assume the form of false membranes. We know, indeed, that inflammatory 
coagulations occur from traumatic causes, which possess no special charac- 
teristics to distinguish them from diphtheritic membranes, and in cases where 
the idea of blood-poisoning cannot for one moment be entertained. LARYNGO- TRA CHEITIS— CR 0 UP. 
35 
There can be no objection to using the term croup in a generic sense, just 
as one would employ the word fever or gangrene to express a general or 
local condition caused by diverse agencies. In this sense there is a propriety 
in adopting the divisions of idiopathic or non-contagious croup and diphtheritic 
or contagious croup. 
Diagnosis.—While the differential signs which have been formulated dis- 
tinguish, as I believe, idiopathic croup from diphtheria, there is a catarrhal 
laryngitis, or false croup, which is liable to be confounded with the true. The 
differences, however, between the two affections may be recognized without 
much difficulty. In false croup the voice is less hoarse, the cough is never 
so barking and brassy, and the dyspnoea is never so severe or continuous: 
the attacks being sudden and due to spasmodic rather than to obstructive 
causes. 
False croup, moreover, is rarely attended with any marked febrile excite- 
ment, exhibits no evidence of membranous formations either in the sputa or 
in the throat, and is often accompanied by other catarrhal symptoms, as 
lachrymation, sneezing, and a rather loose cough. 
Prognosis.—Croup, whether idiopathic or diphtheritic, is a very fatal dis- 
ease. Steiner observes that, excluding those treated by tracheotomy, he 
never witnessed more than three recoveries. Mackenzie estimates the mor- 
tality at about 90 per cent. In this country, however, I am sure that no such 
mortality exists. I am of opinion that with American practitioners the recov- 
eries without operation are at least 50 per cent. Age does not materially 
affect the result, though the fatality is probably greater in the very young 
than in children of more advanced years. Much depends in diphtheritic 
croup upon the prevailing nature of the malady, it being less serious in 
sporadic than in epidemic cases. The signs which forebode a fatal termi- 
nation are severe dyspnoea, with constantly-recurring exacerbations of suf- 
focation, a livid appearance of the lips and face, intermittent pulse, and 
stupor. 
Treatment.—The medicinal treatment of idiopathic croup and that of 
diphtheria differ in some respects. As soon as a patch of false membrane is 
discovered in the fauces or pharynx, the surface should be vigorously attacked 
by agents calculated to modify the mucous membrane of those parts. Strong 
solutions of nitrate of silver should be applied with a camel’s-hair brush. 
Other articles are used with a view to their solvent power over the exuda- 
tion, as hydrochloric acid, lactic acid, tincture of chloride of iron, and the 
steam from slacked lime. The latter, which is equally appropriate to diph- 
theria and to idiopathic croup, can be utilized by allowing the vapor from 
slacked lime to escape into the room and be inhaled, or by conducting the 
vapor from the vessels in which the ebullition is going on, by means of a 
gum hose, to the mouth of the patient. 
In croup, however, the constitutional treatment is by far the more im- 
portant. When of the diphtheritic form, chlorate of potash, with tincture 
of chloride of iron and capsicum, has in my own practice yielded the most 
satisfactory results; while in idiopathic croup alterative doses of calomel 
and bicarbonate of soda promise the best effects. As the membranous 
formations are often loosened or partly detached by the mucous secretion 
beneath, efforts should be made from time to time to dislodge them by 
tickling the fauces with a brush or feather and exciting efforts at emesis. 
This I regard as preferable to exhibiting emetics, which tend to depress and 
weaken the system, especially the preparations of antimony, which at one 
time were so much in vogue. 
Operative treatment.—The operative treatment of croup includes the use of 
the forceps and the tube, and the performance of tracheotomy. 
When portions of the false membrane can be recognized as loose or flap- 
ping, their extraction by means of tho laryngeal forceps is sometimes practi- 
cable, or the same result may be obtained by introducing a camel’s-hair brush, 
attached to a flexible wire handle, into the larynx, guided by a finger, and 36 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
by retracting it wipe off the exudation, which is subsequently expelled in 
coughing or vomiting. 
Bouchut attempted to keep the air-passages pervious by the introduction of 
a tube; but the irritation which attends proceedings of this nature is too 
great for the method to be jiroductive of any good. 
Tracheotomy.—It is to surgery that we must look for the means of re- 
ducing the formidable mortality of croup. Since 1825, when Bretonneau 
made public his first successful case of tracheotomy for croup, the operation 
has been slowly gaining ground in the estimation of the profession. There 
are a number of reasons why a procedure of this kind should not be withheld 
in so grave a disease as croup. 
First. The operation in itself is not a dangerous one, and, consequently, 
does not add any material complication to the case. 
Not over one death occurs in thirty-fivo cases, in which the windpipe is 
opened, which can legitimately be attributed to the operation. 
Second. The propriety of the operation, I think, is sustained by statistical 
data. Trousseau, in his last report to the French Academy of Medicine, fur- 
nished 466 cases of tracheotomy performed in the Children’s Hospital, Paris, 
in nine years, 126 of which recovered,—a mortality of almost 60 per cent. 
Fischer and Bricheteau, in 1863, collected 1011 cases from different sources, 
hospital and otherwise, with 754 deaths and 257 cures,—a mortality of about 
70 per cent. From 1854 to 1875, tracheotomy for croup was performed at 
the Ilopital Sainte-Eugenie 2312 times, with 509 cures, 1713 deaths, and 90 
uncertain, or 1 cure in 4.54. 
At another French hospital, the Hopital des Enfants Malades, from 1851 
to 1875, the same operation for croup was done 2351 times, with 614 cures, 
1661 deaths, and 76 uncertain, the proportion of cures being 1 in 3.82. 
Dr. Cohen, in an exhaustive paper on the subject of tracheotomy in croup, 
read before the Philadelphia County Medical Society, has brought together 
a very large amount of statistical information in elucidation of this subject: 
I shall profit by his labors in its further presentation. Guersant states that 
between 1850 and 1861 lie, with his assistants, had performed in hospital 781 
tracheotomies for croup, with 191 recoveries. 
In condensing the information which Dr. Cohen has collected from Ger- 
man sources, 1 find 1765 cases of tracheotomy performed for croup, with 
548 recoveries,—not quite 1 in 3. This result does not materially differ 
from the percentage of cures (31) claimed by Kronlein at the hospital in 
Berlin. 
The statistics from Scotch and London sources amount to 325 cases of 
tracheotomy, with 110 cures. 
The American cases of tracheotomy for croup, which have been very 
carefully collected and analyzed by Dr. William M. Mastin,* of Mobile, Ala- 
bama, amount to 863, with 178 recoveries (more than 1 in 5) and 658 deaths. 
The tables of Dr. Baumf contain 1066 operations performed for croup, 
with 301 cures and 765 deaths, or 71.76 per cent. 
A report from a Berlin hospital furnishes the results of tracheotomy in 
diphtheria for a period of sixteen years. The operation was done on 756 
children, 512 of which number died, 237 recovered, or 31.16 per cent., and 
7 were removed from the hospital, not cured. 
The aggregate of the cases thus collected amounted to 11,696 tracheoto- 
mies for croup, with 3071 recoveries, 8425 deaths, and 200 undetermined, or 
one recovery in every 3.77 cases. 
Cohen, in 166 selected cases of tracheotomy, generally private, in which 
the operation was done under the most favorable circumstances for success, 
records 110 recoveries, or nearly 70 per cent. 
I am unable to bring together anything like a corresponding number 
* Tracheotomy for Croup in the United States, 
f Baum’s manuscript tables on tracheotomy in croup. TRACHEOTOMY. 
37 
of cases which have been treated exclusively by medication, but I think 
the experience of every physician who has seen much of croup will confirm 
the opinion—even admitting that some of the recorded cases of operation 
might have recovered without the use of the knife—that the number of 
cures after tracheotomy considerably exceed those which ordinarily occur 
under purely medical treatment. 
Causes which influence the success of tracheotomy in croup.—Among these may 
be mentioned the age of the patient. As a rule, patients under two years of 
age are exceedingly unfavorable subjects for operation; so much so, indeed, 
that some surgeons have condemned it in cases of the kind. 
While there can be no doubt that children under the age specified bear 
tracheotomy badly, there are sufficient exceptions to this rule to justify a 
careful and deliberate study of all cases at any age before excluding the 
patient from the benefit of an operation. 
Cohen* has collected 20 successful cases of tracheotomy in children whose 
ages varied from 7 months to 23 months. Dr. Baum,f who has analyzed 
105 cases of tracheotomy in children under 2 years of age, finds the result 
to be 11 cures and 94 deaths, or a mortality of 89.52 per cent.; while 
Mastin, in his collection of 47 operations performed between birth and two 
years, gives 15 successful, or one in every 3.1. Seventeen of these 47 oper- 
ations were performed on children between 6 and 18 months old, of which 
number 4 recovered, a success which is quite equal to the best results ob- 
tained at the period deemed most favorable to the operation. Bourdillat, 
in analyzing 700 tracheotomies done for croup, finds the average of recovery 
to be as follows: 
At 2 years 
U 
From 2£ to 3 years 
H 
“ 3£ to 4 “ 
30 “ “ 
u 
“ 4i to 5 “ 
u 
“ 5j to 6 “ 
it 
Above 6 years 
it 
There is thus found a gradually increasing success from 2 years to over 6 
years. 
The statistics of Bartels bearing on the same question, which embrace 
335 tracheotomies with 103 recoveries, while they vary somewhat from those 
of Bourdillat, concur with them in establishing the great success of the oper- 
ation. 
Between the 6th and the 7th year the recoveries are 15 out of 33 operations, 
or nearly 50 per cent. The details will be found below : 
Age. 
Number of 
Tracheotomies. 
Number of 
Recoveries. 
6 
0 
* 
56 
15 
“ 3 and 4 ' “ 
69 
22 
74 
18 
57 
20 
“ 6 and 7 “ 
33 
15 
“ 7 and 8 “ 
21 
5 
“ 8 and 14 " 
19 
8 
In further elucidation of the influence of age on the success of the opera- 
tion, we give the following analysis by Masting of 320 operations, with 92 
cures and 228 failures : 
* Cohen, Tracheotomy in its Relation to Croup, p. 23, 
f Manuscript collection of cases of tracheotomy under two years. 
J Tracheotomy for Croup in the United States, p. 28. 38 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
Number of Cases. 
Ages. 
Successes. 
Failures. 
1 
From birth to 6 months. 
0 
1 
21 
“ 6 months to 18 months, inclusive. 
4 
17 
25 
“ 18 months to 2 years. 
6 
19 
23 
“ 2 years to 2J years. 
6 
17 
36 
“ 2* “ to 3 “ 
9 
27 
11 
“ 3 “ to 3J “ 
2 
9 
40 
“ 3£ “ to 4 “ 
12 
28 
18 
“ 3 “ to 4 “ 
4 
14 
62 
“ 4 “ to 5 “ 
25 
37 
30 
“ 5 “ to 6 “ 
8 
22 
7 
“ 2 “ to 6 “ 
0 
7 
13 
“ 6 “ to 7 “ 
5 
8 
12 
“ 7 “ to 8 “ 
7 
5 
7 
“ 8 « to 9 “ 
2 
5 
5 
“ 9 “ to 10 “ 
0 
5 
1 
« 10 “ toll “ 
0 
1 
2 
“ 11 « to 12 “ 
0 
2 
2 
14 years. 
0 
2 
1 
19 “ 
0 
1 
1 
35 « 
1 
0 
1 
40 “ 
0 
1 
1 
52 “ 
1 
0 
320 
92 
228 
These figures differ somewhat from those already quoted, though, if the 
numbers in which the exceptional differences exist were greater, it is probable 
that the slight want of agreement would disappear. 
The most notable difference between the tables of Mastin and those of 
others, it will be noted, is in the period between 4 and 5 years, when the 
successes (25 in 62 operations) equal or exceed those obtained above the 6th 
year, the period most fruitful in good results in the tables of Bourdillat and 
Bartels. 
It may be assumed, then, that the period between 21 years and 61 years 
is that which offers the fairest prospect of success from the operation of 
tracheotomy. 
We are not in possession of a sufficient number of cases in which trache- 
otomy has been done on account of croup following exanthematous diseases 
to form any reliable conclusions; but, so far as these can be interpreted, the 
operation holds out very little hope of recovery. 
Time.—Another element which no doubt will influence the success of 
tracheotomy in croup is the period at which the operation is performed. 
Unfortunately, there is such a repugnance to the knife that too often the 
aid of a surgeon is solicited as a last resort, and either at a time when the 
pseudo-membrane has extended into the lower portion of the trachea and 
the bronchi (Figs. 1702 and 1703), or after the child has been hopelessly ex- 
hausted from carbonic acid poisoning or blood-infection. Whenever the dis- 
ease manifests no tendency to abate under medical treatment, and attacks of 
dyspnoea occur, the operation should not be withheld. These signs may arise 
very early, that is, within twenty-four hours from the commencement of the 
attack, or they may be delayed for several days. After examining a large 
number of tracheotomies with a view to determine this question of success 
in relation to time of opei’ation, I find the exact period stated in so few 
cases that it would not be safe to attempt any generalization. The results 
of the inquiry, however, although limited, indicated that in most instances, 
especially where there was reasonable ground for believing the cases to have 
been idiopathic croup, early operations are decidedly to be preferred. 
Mastin has analyzed 250 cases to determine this question, and the general 
conclusion of the writer is in favor of early operation. 
In urging, however, the importance of early operative interference, I TRACHEOTOMY. 
39 
would by no means discourage a late resort to the knife, if there is reason 
to believe that death is threatened simply by obstructive causes. Numerous 
instances of cures have taken place even where 
death appeared to be imminent. 
In one case, in which I assisted Dr. Drysdale, 
the knife seemed to promise little more than an 
easy death, and in another case in which the 
same surgeon operated, the child was more 
dead than alive; yet in both instances the 
patients recovered. Dr. Hodge did a success- 
ful tracheotomy for croup on a child who was 
moribund at the time of the operation, but who 
was resuscitated by artificial measures. Spence, 
of Edinburgh, operated seven times upon chil- 
dren said to be in extremis, three of the patients 
recovering; and of 62 of Mastin’s cases where 
the operation was done very late, 16 recovered. 
The chances of success are greatly lessened 
when the plastic formations extend low down 
into the trachea or enter the bronchi; and yet 
unless the windpipe is opened death almost in- 
variably follows. In determining such mem- 
branous extension, the evidence derived from 
physical exploration is not decisive, as has been 
shown by Pepper. The vesicular murmur, 
which it might be supposed would be destroyed 
or greatly modified by the presence of pseudo- 
membranous formations in the division of the 
bronchi, may continue in defiance of such ob- 
struction, and, again, may be absent when the 
disease is confined to the larynx. 
The late Dr. Meigs observed that the exten- 
sion of the membrane to the bronchi is indi- 
cated by increasing frequency of pulse and a 
gradual approach of the symptoms of asphyxia. 
Form of disease.—Tracheotomy will be more successful in idiopathic than 
in diphtheritic croup. Of 24 operations per- 
formed at Guy’s Hospital* in cases believed 
to be diphtheritic, 22 died and 2 recovered, a 
death-rate of 91.66 per cent. Dr. Ilofinake'j* 
has for the same disease performed trache- 
otomy 18 times, with 17 deaths. At the Ho- 
pital Sainte-Eugenie,! Paris, M. Cadet de Gas- 
sicourt operated on 41 cases, of whom 36, or 
87.08 per cent., died. Mastin gives 296 cases 
of diphtheritic croup in which the windpipe 
was opened, with 41 cures and 255 deaths, and 
194 cases of unmistakable idiopathic croup, 
with 47 cures and 147 deaths. 
In diphtheria, where the signs of local lesions 
are associated with those of general blood-in- 
fection, as seen in the discharges of the nasal 
fossa? and in a general exhaustion altogether 
disproportionate to the obstruction of the air- 
passages, operations are useless. Many of these 
patients die independently of laryngeal or tra- 
cheal obstruction, and can derive no benefit from the opening of the windpipe. 
FlG. 1702. 
False membrane in the trachea, extend- 
ing into the bronchi. 
Fig. 1703. 
False membrane forming a cast of the 
interior of the trachea. 
* Guy’s Hospital Reports, vol. xxii. f British Medical Journal, June 25, 1879. 
\ Medical Times and Gazette, Nov. 22, 1879. 40 
SURGICAL DISEASES OF THE LARVNX AND TRACHEA. 
Indications for operation.—I have already stated that the time, in my judg- 
ment, to operate in cases of idiopathic croup is as soon as suffocation attacks, 
or when paroxysms of dyspnoea make their appearance. Hueter attaches 
much importance to the recession of the lower border of the thorax. Such 
a change in the form of the chest indicates great mechanical obstruction to 
the entrance of air into the lungs. The failure in the latter to expand 
allows the diaphragm to preserve its concave form, and thus to retract 
the lower end of the sternum and the cartilaginous border of the thorax, 
while the extraordinary action of the inspiratory muscles to dilate the upper 
portion of the chest gives rise to the sunken appearance. The urgency for 
interference is still greater when the supra-sternal fossa becomes exaggerated, 
the space receding deeply into the neck at each forcible inspiration. 
Subjects connected with the operation.—Several important subjects are to be 
considered in tracheotomy for croup. 
First. Anaesthetics.—There can be no possible objection to the use of anaes- 
thetics under proper restrictions. It is not necessary to produce full an- 
aesthesia. When no signs of asphyxia are present, the influence of the 
anaesthetic may be kept up so as to control the movements of the child until 
the operation is completed. When these signs are somewhat developed, it 
will be better to use the anaesthetic only while the incisions are being made 
through the skin and subcutaneous tissue; and when suffocative paroxysms 
exist, it should be dispensed with entirely. A patient whose blood is charged 
with carbonic acid will experience little pain from the use of the knife. 
Form of the tracheal opening.—Two forms of incision are generally em- 
ployed,—the vertical and the elliptical. The first answers every purpose 
when the tube is employed, but when this is not used the second is prefer- 
able. When the opening is elliptical and no tube is used, the superincumbent 
soft parts should be kept asunder by retractors, secured to the sides and 
back of the neck with strips of adhesive plaster. When it is necesary to 
keep the trachea open for some time, the tube should be adopted ; otherwise 
the opening in the trachea may become obstructed by granulations. 
On opening the trachea, a portion of false membrane may enter the orifice 
and oppose the introduction of the tube, or the latter, on being pushed into 
the trachea, may become filled with fragments of the membrane, or dislodge 
a portion of the latter, forcing it down or across the air-passages. In any 
event, the danger of suffocation to the patient is imminent unless the diffi- 
culty is recognized and speedily corrected, which can be done only by with- 
drawing the tube and extracting with the tracheal forceps the false mem- 
brane ; or, in case the obstruction is below, by passing a catheter or canula 
down the trachea, which will serve the twofold office of loosening the ob- 
struction and of being used as a tube for blowing air into the lungs and 
keeping up the respiration. 
To avoid these accidents, it is always a wise precaution to extract any 
portion of the pseudo-membrane which can be discovered before introducing 
the canula. It is not difficult to keep the opening in the trachea expanded 
by the dilator for this purpose until the false membrane has been expelled. 
Or it may happen that the child is in extremis when the trachea is opened, 
and that respiration has just ceased. In such an event the patient should bo 
inverted, and artificial respiration maintained by alternately blowing into the 
tube and compressing the walls of the chest. 
The double metallic tracheal tube is to be preferred, the various forms of 
which are described under the head of tracheotomy. 
Whether the canula is used or not, the surface of the wound should be 
covered with a strip of gauze kept moistened with hot water, to arrest 
foreign matters and warm the inspired air. The temperature of the room 
in which the patient is placed should not be allowed to fall below 75° Fahr. 
It may be necessary, after the operation, in order to secure reaction, to 
apply external heat about the limbs and body of the patient. 
The treatment, however, does not terminate with the completion of the TRACHEOTOMY. 
41 
operation. Many children perish from the want of an experienced attendant 
to take care of the management of the case. An assistant should never be 
absent from the bedside for any length of time. The tube must be kept free 
from obstruction by mucus or shreds of false membrane. This can be done 
properly only by removing the former with a brush as soon as it appears in 
the eanula, and, as the membrane often occurs in considerable pieces, a pair 
of forceps will be required for its extraction. It will also be necessary to 
remove every twelve hours or oftener the inner tube of the eanula, in order 
more perfectly to keep the passage clear. 
Tracheotomy is not designed to supersede medicinal treatment, but only 
to open a way for air and to secure rest to the air-passages above the eanula 
until the mercurial and alkaline treatment shall have conquered the inflam- 
mation. 
Time to remove the eanula.—No fixed time can be indicated for the removal 
of the eanula. Its permanent withdrawal as long as inflammatory products 
continue to accumulate in the air-passages, or in cases of diphtheria, while the 
muscles of the larynx are incapable of regulating the glottis so as to allow 
of the free entrance of air, is, of course, improper. 
The time at which to dispense with the tube will vary from five to thirty 
days, though the usual period is somewhere between the sixth and the four- 
teenth day. To test the ability of the child to do without the tube, its ori- 
fice should be closed with a finger, thus forcing the patient to breathe through 
the larynx. When this is repeated a number of times and the respiration 
continues free and unembarrassed, the time has arrived. In applying this 
test, the patient should not be informed of what is being done. A knowledge 
of the fact will often be sufficient to excite a nervous spasm, which will give 
a fictitious importance to the ensuing respiratory embarrassment. 
The fatal termination, when it occurs after tracheotomy in idiopathic croup, 
is rarely postponed beyond four or five days after the performance of the 
operation. Frequently it takes place within twenty-four hours. In diph- 
theria, death may be delayed for a much longer period of time. 
It is difficult to formulate any exact general directions in reference to 
tracheotomy in croup. While I feel warranted in recommending the oper- 
ation in idiopathic croup, and in very exceptional cases of diphtheritic 
croup, on the grounds of the procedure in itself not being dangerous, yet 
when I take into consideration the numerous recoveries, under my own 
observation, which have taken place where operations have been declined, I 
cannot believe that intrinsically tracheotomy in croup has diminished the 
mortality of the disease to the extent claimed by a number of writers. 
Intubation, as a substitute for tracheotomy, is growing in favor. The 
operation requires two or three sizes of metallic tubes suited to subjects 
of different ages, and well gilded, a gag to keep the jaws apart, and a holder. 
(Fig. 1703*.) 
Fio. 1703*. 
Operation.—An assistant holds the child in the erect position, 
with the head well extended ; a gag is placed between the jaws, 
resting on the hack molar teeth, while the operator, inserting 
the holder into one of the tubes, carries it into the pharynx, 
and, guided by a finger which hooks forward the epiglottis, 
deposits the tube in the larynx, and immediately disengages 
the holder. After having served its purpose, the tube is to be removed by 
inserting into its cavity the end of the holder. 
Intubation tube and holder. 42 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
Dr. Stern* has analyzed 519 cases of intubation for croup, giving per 
cent, of recoveries,—a success equal to that of tracheotomy, which does not 
exceed 2fl£ per cent. Montgomery and others, of Philadelphia, have also 
met with encouraging results from the same operation. 
Stricture of the Larynx and of the Trachea. 
Stricture of the larynx and of the trachea is among the inflammatory 
accidents which befall these portions of the vocal and respiratory apparatus, 
occurring sometimes in consequence of the lesions which the parts have sus- 
tained during the progress of certain exanthemata, as small-pox, typhoid 
fever, etc. Frequently the stenosis is the result of cicatrization of syphilit ic 
or tuberculous ulcers; or it may be caused by morbid changes accompanying 
and following diseases of the cartilages, or traumatic injuries of the larynx. 
Symptoms.—These are such as attend any mechanical obstacle to the admis- 
sion of air,—namely, a prolonged wheezing inspiration, diminished voice, the 
respiration hurried after deglutition, the latter sometimes being difficult. 
The degree of dyspnoea will depend on the amount of stenosis which may 
be present. 
Diagnosis.—The diagnosis of stricture from other affections of the larynx 
and trachea must be made from the history of the case and from physical 
exploration. The disease will be found to have been preceded by some local 
or constitutional affection, and to have developed slowly. The laryngoscope 
and the sound will often furnish to the eye and to the hand the palpable 
evidences of constriction. 
The greatest difficulty in diagnosis will be encountered when the stricture 
exists low in the trachea, where, indeed, it is most frequently found, and 
where its presence can be inferred only by the passage being clear above, by 
the slight movement of the larynx in respiration, by the faint and muffled 
voice, and by the diminished vesicular murmur. 
In the use of the sound, the same liberty cannot be taken in tracbeal as 
in laryngeal stenosis. Indeed, its use is not unattended with danger, and 
had better be avoided ; but the laryngoscope will in many cases, when the 
stricture is not too low down, furnish important information. 
There is one form of paralysis of the vocal cords, that of the posterior 
crico-arytenoid muscles, which closely imitates tracheal stenosis, inasmuch 
as the dyspnoea is unattended with any marked alteration in the voice. 
This paralysis, which is bilateral, can be recognized by the use of the laryn- 
goscope, the narrow fissure between the cords being abnormally diminished 
during inspiration. 
The trachea may be compressed by various morbid growths in the neck, as 
cancer, aneurism, and other tumors, which give rise to symptoms of stricture, 
but whose presence can usually be discovered by the eye, the ear. or the touch. 
Prognosis.—Stenosis of the larynx and trachea is an incurable affection, 
but the danger to life is not great where the seat of the stricture is not too 
low down to admit of tracheotomy and the constant use of a canula. 
Treatment.—Little is to be gained by dilatation or incision, unless in cases 
where the stenosis is in the larynx and is due to the contraction of a slight 
band. In such a case the division of the latter by the knife or the electro- 
cautery may remove the obstruction. Tracheotomy, however, is the rule, 
and must not be postponed too long, as the parts about the stricture, par- 
ticularly when in the larynx, are liable to attacks of sudden congestion, or 
to be followed by muscular spasm, either of which may destroy the patient. 
After the introduction of the canula, and when the patient has become 
accustomed to its presence, it may be found desirable to commence the dila- 
tation of the stricture. This process has perhaps been carried to greater 
perfection by Professor Schrotter, of Vienna, than by any other person. The 
first part of this method consists in establishing a tolerance in the parts to 
the presence of instruments by the frequent introduction of catheters from 
* Ninth International Medical Congress, vol. iv. p. 92. STRICTURE OF THE LARYNX AND TRACHEA. 
43 
above, after tracheotomy has been performed. When the parts have be- 
come accustomed to this kind of handling, he removes the canula from the 
neck, and through the opening in the trachea passes a catheter through the 
stricture, which is allowed to remain as long as the breathing of the patient 
will permit. This process is repeated from time to time with graduated 
rubber or tin bougies modelled after the natural shape of the glottis, until 
the coarctation has been overcome. Mackenzie employs for the same pur- 
pose a three-bladed dilator (Fig. 1704), the degree of separation in the 
blades being indicated by a dial or gauge attached to the handle of the 
instrument. 
Fig. 1704. 
Mackenzie’s dilator. 
As the passage of air has a tendency to oppose the contraction of a stric- 
ture, it is important to take advantage of this fact by substituting for the 
ordinary tracheotomy tube, after the dilatation has made some progress, an- 
other, with a valve, which, while it admits freely the inspired air, compels 
the patient to expire through the natural passage. 
Strictures of the larynx and trachea, however, rarely admit of being over- 
come sufficiently to warrant the permanent removal of the canula. Like 
cicatrices elsewhere, though they admit of being stretched, they have a ten- 
dency to recur, commencing with the cessation of instrumental treatment, 
so that in the large proportion of cases the canula will become a permanent 
fixture. 
In cedematous stenosis of the larynx, or in oedema of the glottis, the in- 
troduction of tracheal tubes by the mouth promises to replace, in some cases 
at least, the operation of tracheotomy. The passage of such tubes may be 
said to have originated with Desault, who in two cases of laryngeal obstruc- 
tion employed with success this method to maintain an unembarrassed res- 
piration. The tubes in each instance were introduced through the nose. 
Macewen, who has historically traced the operation, records the efforts made 
by Bouchut in 1858, before the French Academy of Medicine, to popularize the 
practice. This surgeon introduced tubes into the larynx through the mouth 
by means of a sound or guide, the latter being withdrawn as soon as the canula 
was passed through the glottis. To prevent the instrument from falling into 
the larynx, it was furnished with two arms, which rested upon the vocal 
cords, and to facilitate its removal a silken cord .was attached to the top of 
the tube. Tracheal catheters have assumed considerable importance through 
the labors of Trendelenburg and Schrotter, who have Ireated stenosis of the 
larynx with triangular metal bougies and have attained good results. The 
introduction of tubes into the larynx has also of late years been practiced by 
Macewen and by Hack. The round tube is preferred by these operators. 
In order to conduct the tube into the larynx, the head must be well thrown 
back, the patient being seated on a stool or a low chair, and while the epi- 
glottis is hooked forward by the index finger, passed along the dorsum of the 
tongue until the cartilage is touched, the catheter or canula is conducted over 
the dorsum of the finger through the glottis and onward into the larynx. 
In order to ascertain that the instrument has gone into the larynx, and 
not into the (esophagus, the surgeon must notice whether the air passes into 
the tube during inspiration and is expelled during expiration, the reverse SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
44 
being the case when the canula has entered the gullet. The escape through 
the tube of mucus and other secretions of the larynx and trachea is another 
evidence that the instrument is in the air-passages. The time during which 
it is deemed proper to wear these canula; without their removal and cleansing 
varies from six to twelve hours. 
Fistulae. 
Fistul® of the larynx or trachea may be congenital or acquired. Congen- 
ital fistula; were first described by Dzondi in 1829. These fistula; may have 
one or more external openings, situated near the sterno-elavicular articulation, 
between the two portions of the sterno-cleido-mastoid muscle, or they may 
be bilateral, one on each side of the neck, and at corresponding points. In 
the only case I have ever seen (which occurred in a female) the cutaneous 
orifice was immediately below the thyroid cartilage, and barely admitted a 
bristle. In one instance three orifices, linearly arranged, were observed by 
Aschcrson. Paget has met with 3 cases, Heusinger* has collected in all 46, 
and Eldridge records 22. 
The internal orifices of these fistula; may open into the larynx, pharynx, 
or trachea, or may end in the cellular tissue of the neck. Those which 
communicate with the trachea are the least common, and are met with ex- 
clusively in females. 
The existence of these fistula; depends on an arrest of development, or on 
imperfect closure of the third and fourth branchial clefts, in cases where the 
external opening is lateral, and of the third and fourth bronchial arches when 
it is in the median line of the neck. Fragments of rudimental cartilage have 
occasionally been found in connection with the fistula;. 
They are lined with a mucous membrane, which furnishes a mucous secre- 
tion. 
Diagnosis.—The existence of these fistula; can be inferred when an open- 
ing is discovered on the neck in the localities already named, which, from the 
passage of air, or the admission of a delicate probe, furnishes the evidence of 
a communication existing with the air-passages. 
Treatment.—When terminating in a blind pouch in the connective tissue 
of the neck, they should be laid open and made to heal by open granulation. 
When they communicate with the air-passages or the pharynx, cauterization 
of the tract by nitric acid or the galvano-cautery has been recommended ; but 
it is very improbable that any operation will succeed in effecting a cure, and, 
where the inconvenience is of sufficient importance to require interference, 
it must be combated by judicious pressure. 
Fistula; communicating with the larynx or the trachea, but without any 
external orifice, are occasionally seen. They are characterized by an external 
swelling, more or less diffused, resonant on percussion, and crepitating under 
pressure. Operative treatment will promise little success in a condition of 
this kind. Other fistulee of the larynx and trachea will be considered under 
the head of tracheotomy. 
The introduction of foreign bodies into the air-passages may occur in 
various ways. Generally they are drawn in during a sudden inspiration. 
Sometimes the entrance takes place during vomiting, or during the regurgi- 
tation of certain substances, as pieces of meat, into the pharynx at a moment 
when the muscles which protect the opening into the larynx have been found 
offguard and have been taken by surprise. Some risk of this kind is encoun- 
tered during the vomiting of patients under the influence of an anaesthetic. 
The substances which may enter the trachea are very numerous, the most 
common being grains of corn or of coffee, citron- or melon-seeds, cherry-stones, 
pebbles, buttons, and small pieces of coin. The form of these substances is 
Foreign Bodies in the Air-Passages. 
-* Virchow’s Archiv, January, 1877, p. 26 : Cohen. FOREIGN BODIES IN THE AIR-PASSAGES. 
45 
favorable to their intrusion ; but there are other bodies which enter the air- 
passages, the shape and character of which would render such an accident 
highly improbable; for example, the ears of rye or wheat, and other grasses, 
the cockle-bur, irregular pieces of bone, and portions of the shell of the 
almond or chestnut. 
The size of some of the bodies which pass the glottis is also very remarkable. 
Professor Gross, in his monograph on “ Foreign Bodies in the Air-Passages,” 
gives a number of cases which illustrate this point. Among the articles 
which have been found in the larynx and trachea may be mentioned a shawl- 
pin three inches in length, a plate of artificial teeth, a brass pen-holder, etc. 
Dr. Charles Hall, of Vermont, removed from the trachea a pipe-stem one 
inch and three-quarters in length. In another case Dr. Jewett, of the same 
State, extracted from the windpipe a nail almost two inches in length. In 
a case reported by Cohen the body extracted was the bladder of a rubber 
trumpet, and in another, recorded in the New York “Archives of Clinical 
Surgery” for December, 1876, a toy locomotive passed through the glottis 
into the larynx. Parasitic worms have in several instances found their way 
into the trachea, and the same is true of leeches which have been used in 
abstracting blood from the inside of the mouth. 
Foreign bodies have entered the trachea during operations on the mouth 
or the larynx. A patient lost his life in this city, while under the influence 
of nitrous oxide gas, a cork which had been placed between the jaws pre- 
liminary to the extraction of a tooth, slipping into the windpipe. In another 
instance a portion of a forceps broke off' and passed into the trachea while a 
surgeon was attempting the removal of a laryngeal tumor. 
Similar accidents have happened from a tracheal canula becoming detached 
from its collar, either through erosion or defect in construction. The en- 
trance of a foreign body into the trachea is sometimes effected by pressure and 
ulceration. It is in this manner that pins and needles detained in the oesoph- 
agus have found their way at length into the windpipe; and by a similar 
process a bronchial or a cervical gland has destroyed a portion of the walls 
of the tube and entered its cavity, terminating life by becoming impacted 
in the glottis.* 
Portions of the clothing are occasionally buried in the lungs in shot 
wounds, in time find their way into one of the bronchial tubes, and are dis- 
charged by the mouth. A patient of my own, a young physician, who was 
shot in the chest during the late war, after the lapse of three years expecto- 
rated a portion of his shirt, which had been carried before the ball. 
Middledorpf,f in a case of supposed suffocation from alimentary impaction 
of the pharynx, discovered, on introducing a finger, that the larynx was 
obstructed by a dislocated epiglottis. In one instance I relieved symp- 
toms of suffocation by dislodging a displaced epiglottis from the top of the 
larynx. 
Sometimes the air-passages may be flooded with a liquid, as in the rupture 
of a post-pharyngeal or tonsillar abscess. 
Sometimes a foreign body penetrates the neck and reaches the trachea. 
The case related by De la Martiniere, which secured for him the reputation 
of great sagacity, was of this nature. A boy, while cracking his whip, was 
suddenly seized with dyspncea and pain in the neck: it was found that a 
brass pin attached to the lash had been separated from the whip and driven 
through the neck into the trachea. Children much more frequently than 
adults are the subjects of the accidents under consideration. 
Place of arrest.—The situation at which the foreign body becomes arrested 
will depend on its magnitude and shape. Large, irregular substances may 
become impacted in the vestibule of the larynx or in the glottis. Small and 
irregular-shaped substances sometimes lodge in one or both of the ventricles, 
while smooth or round bodies, after passing the larynx, soon descend through 
* Mackenzie, Diseases of the Pharynx, Larynx, etc., vol. i. p. 563. 
f Monatsschrift fur Ohrenheilkunde. 46 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
the trachea and enter one of the bronchial tubes, usually the right, which is 
more frequently penetrated on account of its greater size and its horizontal 
direction, and especially by reason of the ridge or spur which rises at the 
bifurcation of the trachea. 
The body which has passed into the bronchus does not necessarily remain 
in this situation : frequently it is forced up into the trachea, or even into the 
larynx, during paroxysms of coughing, or it may ascend and descend during 
the movements of respiration. In a few instances the body has been expelled 
in the act of coughing. 
Change which the foreign body undergoes.—This will depend on the nature 
of the intruded substance. Grains of corn not only imbibe moisture and 
swell, but even begin to germinate in consequence of the surrounding tem- 
perature. In a seed-corn which I removed from the trachea of a child, where 
it had remained for four weeks, this change was quite apparent. Beans and 
pieces of bread also absorb moisture and enlarge. 
Metallic substances, when long retained, may become eroded, while other 
materials slowly undergo softening, disintegration, and loss of bulk, or may 
become the nucleus for a mucous, muco-purulent, or chalky incrustation. 
Morbid effects of a retained foreign body.—A foreign body cannot remain for 
any length of time in the air-passages without causing inflammation of the 
mucous membrane, more or less diffused, and accompanied by profuse mucous 
and muco-purulent secretion. Ulceration and thickening of the mucous 
membrane are also lesions likely to occur. When the body enters one of 
the smaller divisions of the bronchi and becomes fixed, the persistent local 
irritation will be likely to extend to the parenchyma of the lungs, causing 
local or general pneumonia, and also pulmonary abscess. An abscess of this 
kind, I was informed by Dr. Walter F. Atlee, occurred in the practice of his 
father, Dr. John Atlee, of Lancaster, Pa., and was ruptured while an attempt 
was being made to extract the foreign body. Sometimes fatal hemorrhage 
follows the entrance of the foreign body from injury of blood-vessels. Roki- 
tansky records an instance in which the innominate artery was wounded by 
the point of a dart inhaled into the windpipe, and which, during a fit of 
coughing, was driven through the trachea into the vessel; and in another 
case, related by Mr. West, of Birmingham, England, and recorded by Gross, 
a needle two inches in length entered the right ventricle of the heart through 
a bronchial tube, causing the death of the patient. 
The bronchial irritation and inflammation may extend not only to the lungs, 
but also to the pleura, uniting its layers by strong bands of lymph. Adjacent 
organs and parts, as the pericardium, the liver, and the cartilaginous com- 
ponents of the vocal and respiratory tubes, have also participated in the 
inflammatory changes. 
On the other hand, foreign bodies have been known to remain a long time 
in the air-passages without giving rise to serious results. Royer-Collard has 
supplied a case recorded by Mackenzie, in which a piece of bone remained 
harmlessly for six years in the left bronchus. Cohen mentions a case in 
which a married woman expelled in coughing a pebble which had entered 
the air-passages twelve years before; and Gross records one in which a piece 
of bone was retained sixty years and then expelled in a fit of coughing. 
Symptoms.—The symptoms which attend and follow the intrusion of a 
foreign body into the windpipe vary with the nature, form, and size of the 
substance. A piece of meat entering the larynx may completely occlude 
the opening of the glottis, or the contents of an abscess may suddenly inun- 
date the larynx and trachea so as abruptly to exclude the entrance of air, 
and destroy the patient. 
Should the body be temporarily arrested in the glottis, and its form be such 
as partly to close this opening, there will be experienced a sudden and dread- 
ful sense of suffocation, to overcome which the individual makes extraor- 
dinary efforts to inspire, coughs violently, and, looking wildly around, with 
eyes starting from their sockets, and dismay depicted in every feature of the FOREIGN BODIES IN THE AIR-PASSAGES. 
47 
countenance, clutches at his throat, or grasps wildly and aimlessly at the 
nearest object within reach. Should the body in the mean time slip through 
into the trachea, or, what is still more desirable, be expelled by the rejection 
of the contents of the stomach in vomiting, these formidable symptoms 
subside; but if neither of these events takes place, he falls into a state of 
unconsciousness, during which, if no one interferes for his rescue, death 
may occur. Even during complete insensibility, however, if the spasm of the 
glottis yields, permitting the body to pass down, the ingress of air and resus- 
citation follow. 
In some instances, when the substance is small and smooth, it may be 
swept through the rima glottidis so quickly as to cause only a temporary 
paroxysm of coughing; and in not a few cases so insignificant have been 
the symptoms at the time of inhaling the foreign body that its presence 
has not been suspected. Even when a patient escapes the dangers incident 
to the passage of the body, there are other more remote effects, which occa- 
sion great distress, and which are not unattended with danger. Paroxysms 
of coughing will frequently occur, during which the body may be driven 
up into the larynx and become fastened in the ventricles or the glottis, the 
countenance growing livid and suffocation being threatened. The expecto- 
ration, which at first is scanty, consisting of mucus, in time becomes abundant, 
thick, and tenacious, and is often mixed with blood and pus, the odor from 
which is exceedingly offensive. Moist rales can be heard in the trachea 
through the chest on the affected side when the body occupies one of the 
bronchial tubes. When the body is small, rising and falling during respiration 
or coughing, its movements can sometimes be detected by the hand or fingers 
applied over the windpipe. If the dimensions of the intruder are such as to 
cause it to become impacted in one of the bronchi, thus opposing the admis- 
sion of air into the corresponding lung, there will arise a sudden difficulty in 
the breathing, accompanied by exaggerated respiratory movements on the 
sound side of the chest, recession of the walls of the thorax on the affected 
side, and absence of the vesicular murmur. The voice of the patient is some- 
times weak, hoarse, and husky, at other times unchanged. It is notably 
affected when the foreign body occupies the larynx, a matter of material 
significance from a diagnostic point of view. 
More or less soreness is experienced in the chest, and is increased, as is also 
the cough, by the recumbent posture of the body. 
Diagnosis.—On several occasions the windpipe has been opened under the 
supposition of a foreign body being lodged in the air-passages without any 
such being found. As the symptoms produced by the presence of a foreign 
body in the windpipe may be simulated by spasm of the glottis, by cramp, 
by substances impacted in the pharynx or oesophagus, and by the pressure 
of tumors or dislocations of the epiglottis, the diagnosis must be based on a 
careful inquiry into the history of the case. In one instance I successfully 
diagnosed the existence of a foreign body in the windpipe of a child, although 
no one had been present when it entered, by learning that on the day the 
accident was believed to have occurred the mother had been engaged in pre- 
serving citron. The offending substance, which I removed by tracheotomy, 
was a citron-seed. The sudden accession of symptoms of suffocation in a 
child previously in good health, with recurring attacks, and the presence of 
a spasmodic cough and difficult expiration, are not without significance as 
distinguishing the accident from croup, in which the approach of the disease 
is more gradual, the voice shrill and brassy, and the inspiration more difficult 
than the expiration. The laryngoscope will furnish valuable information, 
particularly when the body is in the larynx or trachea. The loss of the 
voice following a suffocative attack is also an important sign often pres- 
ent when the substance occupies the larynx. A finger introduced into the 
pharynx will detect the existence of any substance impacted in this part of 
the gullet, or any displacement of the epiglottis, while the probang will de- 
termine the presence of any obstruction in the oesophagus, and thus enable SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
48 
the surgeon to eliminate these sources of possible error from the consideration 
of the case. 
Prognosis.—A patient having a foreign substance in the air-passages is in 
great peril so long as it is allowed to remain. Any of the evils which have 
been enumerated as belonging to the pathology of the accident are liable to 
occur. 
The first few days are fraught with the risk of suffocation by the body’s 
becoming fastened in tho larynx during the frequent paroxysms of coughing 
which are provoked by the new and strange impressions made on the sensitive 
mucous membrane of the tube. If this danger is passed, the patient may 
enjoy a few weeks of comparative comfort, hut further on there arise in- 
flammatory lesions, which again place life in jeopardy. 
Treatment.—Various measures have been employed at different times to 
secure the expulsion of foreign bodies from tho air-passages, the principal 
being the use of emetics and sternutatories, succussion, and gravity or inver- 
sion. They have all been successful, but are attended with some risk of im- 
pelling the body into the glottis without imparting sufficient momentum to 
force it through. 
A physician of Lancaster County, of more than ordinary ability, but who 
was both rough and eccentric, was called in the night in great haste to a 
neighboring village, where the wife of a highly respectable farmer was in 
great distress from a bone which had become caught in the larynx, and 
where it remained despite several attempts made for its extraction. When 
he entered the room he found the woman on the floor, resting on her hands 
and knees. Without a moment’s hesitation, the doctor, taking in at once the 
urgency of the situation, gave her a forcible kick, which turned the patient 
head over heels, and during the semi-revolution dislodged the bone from her 
throat. The fortunate issue, in the deliverance of the patient from suffoca- 
tion, atoned somewhat for the rudeness of the treatment, and gave a wonder- 
ful reputation to the doctor, whose boot had proved more potent than the 
instruments of his predecessors. 
When it is proposed to try inversion, the body is suspended by the heels, 
or laid upon the breast on an inclined plane, with the head downward : if 
the substance does not escape into the pharynx, its expulsion is to be favored 
by striking the chest a few smart blows with a pillow. 
The first recorded instance of the successful application of inversion to the 
removal of a foreign body was given by Sir Christopher Wren,* in the case 
of an English engineer, who was relieved by this plan from a bullet which 
in swallowing passed into the windpipe. 
It is with substances like this, round and having considerable weight, that 
the experiment by inversion is likely to succeed. 
Pins, needles, and fragments of bone, when fixed in the larynx, can be 
removed by the laryngeal forceps under the eye of the surgeon, guided by 
the laryngoscope. Leeches have also been extracted from the larynx in 
this manner. 
The treatment which most surely promises relief in cases of foreign bodies 
in the air-passages is tracheotomy or laryngotomy. If, therefore, after an 
exploration of the pharynx and the larynx by the laryngoscope, it is shown 
that the offending substance is not above the glottis, immediate preparations 
should be made for the performance of the operation. When the laryngoscope 
is itot at hand, the pharynx can be satisfactory examined by the finger. 
When it can bo determined that the body is lodged in one of the ventricles 
of the larynx, laryngotomy is generally to be preferred. 
Cases may occur in which a substance alien to the air-passages becomes 
fastened in the larynx, threatening suffocation, under circumstances in which 
the medical attendant is either unprovided at the moment with the neces- 
sary instruments for performing tracheotomy, or feels disqualified to attempt 
a surgical procedure of the kind. 
* Mackenzie, Diseases of the Pharynx, Larynx, etc., p. 570. FOREIGN BODIES IN THE AIR-PASSAGES. 
49 
In such an emergency life may be saved by dividing the crico-thyroid 
membrane,—an operation so simple that the merest tyro might carry it into 
effect with the blade of a pocket-knife,—thus furnishing a sufficient opening 
for the admission of air until more decided measures can be adopted. 
In performing tracheotomy for removing foreign bodies in the windpipe, 
the opening in the trachea should be longer than that made for the intro- 
duction of the canula, exceeding in the adult one inch and a quarter, and 
about one inch in the child. A free incision always enhances the probability 
of the immediate and spontaneous extrusion of the body, on account both 
of the large volume of air which rushes through the opening, and of the ab- 
sence of any impediment from the sides of the latter. An anaesthetic should 
always be administered previous to beginning the operation. Agents of this 
kind exert a beneficial influence in quieting the excitement of the patient 
and preventing spasm. 
When the windpipe is opened, there is usually a gush of frothy mucous 
and inuco-purulent secretions, which fill the opening through the trachea, 
and indeed the entire wound. The patient should at this time be turned 
over on the breast, with the head dependent, in order to favor the escape 
of the secretions and of any blood which may have entered the air-passages. 
Frequently, at the moment of incising the trachea, the foreign body, if a 
grain of corn, melon-seed, cherry-stone, or pebble, will be expelled through 
the opening. The blades of a tracheal dilator may be introduced into the 
opening in the windpipe, and its sides expanded. A cough, which, if it does 
not now occur spontaneously, can bo excited by touching with a camel’s-hair 
brush the mucous lining of the trachea, will probably cause the expulsion 
of the alien substance through the wound. Should this not occur, the oper- 
ator may invoke the assistance of gravity by suspending the patient head 
downward, adding, if necessary, succussion, by striking the chest a few 
smart blows with a pillow or cushion. 
A striking example of the success of the plan of inversion is supplied in 
the case of the distinguished English engineer Brunei, who accidentally 
inhaled into his windpipe a half-sovereign with which he had been amusing 
some children. The coin was dislodged and expelled by inversion after 
tracheotomy, though the gravity posture had been practiced unsuccessfully 
before the operation, and with no small risk to his life, in consequence of the 
suffocation which ensued from some change in the position of the foreign body. 
The objections against inversion before opening the windpipe of course do 
not exist after that operation has been done. 
It is not always the case that the foreign body escapes through the opening 
made in the windpipe: it may be forced upward through the glottis into the 
pharynx, and be expelled from the mouth; or, after passing into the pharynx, 
it is sometimes swallowed, to the great annoyance of the surgeon, leading, as 
it may, to the supposition on the part of friends that an error in diagnosis 
has been committed and that the patient has been subjected to an unneces- 
sary operation. Cohen mentions a case in which a lady having a beef-bone 
in the larynx was sent to him by a brother practitioner, in order that the 
body might be removed. The bone was readily discovered by means of the 
laryngoscope, and an ineffectual effort made to extract it with the forceps. 
The spasms which followed the attempt were so violent that it was deemed 
safer to open the windpipe than to make further attempts through the mouth. 
Tracheotomy was performed, but the alien body could not be found, having 
been, doubtless, thrown into the pharynx and swallowed during one of the 
paroxysms of coughing which followed the incision into the trachea. 
If the foreign substance is not expelled, the surgeon may next resort to 
the use of instruments. Before doing so, however, the finger should be 
employed. The information conveyed to the mind by the tact of a digit 
must always be more accurate than that derived through the medium 
of insensate matter. The projecting portion of the nail should be covered, 
before introducing it into the windpipe, by scraping the end of the finger 50 
SURGICAL DISEASES OF TIIE LARYNX AND TRACHEA. 
over a piece of soap. If, after a digital examination, the body can be 
located, its extraction may be effected by some one of the instruments 
described below. 
The forceps, including the handles, should be six or seven inches long, and 
delicately constructed, the blades, at their termination, somewhat expanded, 
rounded, and serrated on the inner surfaces, and joining the bandies at an 
angle of about thirty-five degrees. (Fig. 1705.) These should be warmed 
Fig. 1705. 
Forceps for extracting bodies from the air-passages. 
previous to being used, a proper precaution before the employment of any 
laryngeal or tracheal instrument, and when carefully and gently manipulated 
may enable the operator to grasp substances like pieces of coin, nails, etc. 
A body like a piece of pipe-stem, a nail, or a pin is liable to become fastened 
crosswise in the air-passages. In such an event, the blunt hook (Fig. 1706) 
Fig. 1706. 
Flexible blunt hook. 
will render good service by enabling the surgeon, after passing the instru- 
ment below, and then retracting it, to catch the body and disengage it from 
its hold in the mucous membrane. 
When uncertain as to the locality of the intruder, which does not appear 
at the wound, it maj7 become necessary to make an exploration beyond the 
reach of the finger; and for this object a long, blunt-pointed probe (Fig. 1707) 
is best adapts 
Fig. 1707. 
Tracheal probe. 
When the breathing after opening the windpipe continues to be difficult, 
the presumption is that the body is below, in the trachea or bronchus. If, 
on the contrary, respiration is easy, the inference is that it is above, in the 
larynx. 
Mops consisting of small pieces of soft sponge securely attached to a rod 
of whalebone five inches long (Fig. 1708), or long curved forceps holding a FOREIGN BODIES IN THE AIR-PASSAGES. 
51 
piece of sponge (Fig. 1709), will also be found useful for cleaning the air- 
passages of mucus and other accumulations. 
Fig. 1708. 
Mop for larynx. 
The cautions proper to be observed in the use of all instruments in 
the windpipe are great gentleness and care neither to push the body 
into more inaccessible positions nor to prolong the manipulation. 
Neglect on these points is likely to be followed by violent paroxysms 
of cough, muscular spasm, inflammation, and lesion of the mucous 
membrane and lungs. 
Should the foreign substance fail to escape, the wound must be kept 
open, not by introducing a canula, which would effectually prevent 
the escape of the substance, but by retractors, previously figured, which can 
be fastened to the neck with tapes or with adhesive plasters. The opening 
in the external parts will re- 
quire to be protected against 
the entrance of extraneous sub- 
stances, and an assistant must 
remain close at hand, ready, in 
case the foreign body makes its 
appearance at the opening in 
the trachea, to seize and remove it. 
The causes which prevent the expulsion of substances that have entered 
the air-passages are usually of four kinds: 
1. Impaction, the body having been forced into the tube in such a manner 
that, if flat, its edge is caught between the cartilaginous rings, the two 
fitting like mortice and tenon. 
2. The substance, after being driven into the bronchus by the inspired air, 
is retained by the inflammatory swelling of the mucous membrane, which 
forms a collar in front of and behind the intruder. 
3. The body, if a pin, nail, pipe-stem, or some similarly-shaped object, 
sometimes becomes fixed transversely across the tube, the extremities being 
buried in the mucous membrane. 
4. The body may lodge in one of the ventricles or elsewhere, and be 
retained by bands of lymph. An interesting case of this kind occurred in 
the practice of Dr. John H. Brinton, of this city. 
When the expulsion does take place, whether at the time of operation or 
subsequently, the sides of the wound are to be brought together, and retained, 
in the first case, by interrupted sutures, and in the last, by adhesive strips. 
When, after the lapse of three or four weeks, no sign of the foreign body 
is discovered, and the granulations have begun to encroach on the tracheal 
opening, there remains the alternative of allowing it to close or of intro- 
ducing a canula. There are objections to either course. If the opening into 
the windpipe is permitted to heal, the necessity of a second tracheotomy 
is not improbable; if, on the other hand, the tube is worn, a mechanical 
obstacle to the escape of the extraneous substance exists. On the whole, 
I prefer the use of the canula, as, in the event of the necessity arising, it 
can be easily removed, and the way opened for the passage of the body. 
Results.—The results following the entrance of foreign bodies into the air- 
passages, and the measures adopted for their removal, will appear from the 
analysis of 554 cases published by Mr. Durham, of 159 cases by Professor 
Gross, and of those which have been collected for me by Dr. Baum. 
Of the 554 cases of Durham’s collection, 271 were not the subjects of 
operation, and of this number 156 recovered and 115 died. Of these 271, 
Fig. 1709. 
Forceps for bolding a piece of sponge. 52 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
95 died without expulsion of the extraneous body; 104 got rid of the foreign 
substance by spontaneous expulsion, 5 with the aid of emetics,—the latter 
having failed in 4G cases,—and 7 after a long time, through the agency of 
thoracic abscess. Of the 283 that were the subjects of operation, 213 re- 
covered and 70 died. In these 283 cases laryngotomy was performed 14 
times followed by the riddance of the body, with 13 recoveries and 1 death ; 
and 3 times not followed by expulsion, with 3 deaths. Tracheotomy was 
performed 231 times, with 170 recoveries and 61 deaths. Laryngo-trache- 
otomy was adopted 20 times, with 15 recoveries and 5 deaths. Extraction 
through the mouth was practiced 3 times, with 3 recoveries; and inversion, 
combined with succussion, 12 times, with 12 recoveries. 
The difference in mortality, therefore, between those subjected to operative 
measures and those left to nature is that between 24.08 per cent, and 42.05 
per cent., a mortality in those without operation nearly twice as great as 
in those who had the benefit of surgical aid. 
Of the 159 cases analyzed by Professor Gross, 57 were not operated on, 
the foreign body being expelled spoiltaneously, followed by 8 deaths; 11 
cases were treated by inversion, with 5 successes and 6 failures; 68 by tra- 
cheotomy, with 60 recoveries and 8 deaths; 17 by laryngotomy, with 13 
cures and 4 deaths; 13 by laryngo-tracheotomy, followed by 10 cures and 3 
deaths. In the 98 cases in which the knife was employed, 83 recovered and 
15 died, or 1 death in every 5£. 
Baum’s collection, made since that of Durham, in 1870, includes 154 cases of 
foreign bodies in the air-passages, 121 of which recovered and 33 died. The 
results with and without operation will be seen in the following analysis: 
Cases. 
Immediate, or in less than 24 hours 
1 
In from 1 to 8 days 
“ 8 to 30 days 
“ 30 days to 1 year 
3 
Total 
Spontaneous Expulsion and Recovery. 
No Operation performed. 
Death without expulsion 
Spontaneous expulsion 
Expulsion after emetics (emetics useless in 4 cases) 
Discharged at later period through thoracic abscess 
Total. Recovered. 
4 4 
Died. 
19 
1 
Total cases not operated upon 
20 
Operative Measures. 
Total. 
Recovered. 
Died. 
Laryngotomy 
2 
Laryngo-tracheotomy 
6 
... 
Tracheotomy, body found 
38 
5 
Tracheotomy, body not found, but expelled later 
17 
1 
Tracheotomy, body not found, but patient relieved 
3 
7 
Direct extraction 
15 
Inversion and succussion 
3 
Subhyoidean laryngotomy 
1 
External incision, air-passages not opened 
1 
Alum blown into larynx 
1 
87 
13 
Entire number of cases 
121 
33 
Adding together Durham’s and these recent cases, we have a total of 708 
cases of foreign bodies in the air-passages, with 490 recoveries and 218 deaths, 
classified as follows: NEUROSIS OF THE LARYNX. 
53 
Cases. 
Immediate, or in less than 24 hours 
6 
In from 1 to 8 days 
“ 8 to 30 days 
21 
72 
“ 1 to 17 years 
31 
Total 
Spontaneous Expulsion and Recovery. 
No Operation performed. 
Total. 
114 
Recovered. 
Died. 
114 
Spontaneous expulsion 
176 
16 
Expulsion after emetics (emetics useless in 50 cases) 
9 
9 
Discharged at late period through thoracic abscess 
5 
5 
Total cases not operated upon 
190 
135 
Operative Measures. 
Laryngotomy and expulsion 
Total. 
. 16 
Recovered. 
15 
Died. 
1 
Laryngotomy, and body not expelled 
. 3 
3 
Laryngo-tracheotomy 
. 26 
21 
5 
Tracheotomy 
. 274 
208 
66 
Tracheotomy, and body expelled later 
. 18 
17 
1 
Tracheotomy, body not found, but patient relieved 
. 10 
3 
7 
Direct extraction 
. 18 
18 
Inversion and succussion 
. 15 
15 
Alum blown into larynx, and external incision and subhyoid laryngotomy.. 
. 3 
3 
Total operative cases 
. 383 
300 
83 
Entire number of cases 
. 708 
490 
218 
Dr. West, of the United States Army, has collected 1000 eases of foreign 
bodies in the air-passages. The result of his analysis is as follows: in 63 
cases the body was extracted by forceps, having been in some instances 
located by the aid of the laryngoscope ; 599 cases were not subjected to 
operation, of which number 460 recovered and 139 died; the remaining 338 
cases were subjects of operation, and of these 245 recovered and 93 died. 
Neurosis of the Larynx. 
Anaesthesia of the larynx arises from either diphtheritic poison or bulbar 
paralysis. In extreme cases of anaemia the sensibility of the larynx and the 
adjoining parts is greatly reduced. The affection may he partial or complete, 
unilateral or bilateral. It may involve also the trachea. The diminished 
sensibility is due to functional impairment of the superior laryngeal nerve, 
or to structural changes in the floor of the fourth ventricle of the brain. 
Diagnosis.—The diagnosis of the disease is based on the impunity with 
which the interior of the larynx can be handled with instruments, evoking 
no cough, and on the tendency of portions of food, both solid and liquid, to 
enter the air-passages during deglutition. 
Prognosis.—When the affection is the result of diphtheritic or anaemic 
causes, the prospect of recovery is good; if it depends on bulbar disease, the 
case is hopeless. 
Treatment.—Little is required beyond good nourishment, pure air, and 
the internal administration of strychnine and iron. When the improvement 
is very slow, advantage will be derived from faradization, applying the nega- 
tive electrode to the inner walls of the larynx, and the positive electrode, 
armed with a moist sponge, to the side of the neck below the angle of the 
jaw. When the food cannot be diverted from the larynx, the patient must 
be fed through the oesophageal tube, care being taken that it does not enter 
the larynx. 54 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
Hyperaesthesia of the larynx may be a congenital or an acquired condi- 
tion. When acquired, it is generally referable to inflammatory or to hys- 
terical causes,—sometimes to the agency of irrespirable gases. 
Diagnosis.—The phenomena which characterize hypenesthesia are intol- 
erance of the presence of instruments, hacking cough on inhaling cool air, 
and muscular spasms excited by the simple movements of deglutition. 
Treatment.—Associated as this affection generally is with feeble health, it 
will be necessary to improve the general strength and vigor by the adminis- 
tration of tonics in combination with antispasmodics, at the same time correct- 
ing as far as possible any local disease discoverable by the laryngoscope. In 
the absence of inflammation, inordinate sensibility can be lowered to some 
extent by inhaling the volatile products of camphor, or by applying directly 
to the parts solutions of bromide of potassium, aconite, or nitrate of silver. 
Children, and sometimes adults, are subject to sudden attacks of laryngeal 
spasm, characterized by a stridulous inspiration, fright, livid countenance, 
convulsive movements of the limbs, and asphyxia. The attack generally 
occurs in the night, wakening the patient from a sound sleep. 
The spasm is due to reflected irritation, spinal, dental, or gastric, trans- 
mitted to the inferior laryngeal nerves through the spinal accessor}', trifacial, 
or pneumogastric nerves. 
The asphyxia which follows the exclusion of air from the windpipe is gen- 
erally the signal for relaxation of the spasm, when the alarming symptoms 
disappear, and may never return, though in some instances the child perishes 
in an attack. 
The muscles involved in the spasm have not been absolutely determined, 
some believing that the obstruction to the admission of air is caused by the 
aryteno-epiglottic muscles dragging the epiglottis into the vestibule of the 
larynx ; others attributing it to the contraction of the arytenoid, or to paral- 
ysis of the posterior crico-arytenoid muscles, thus closing the glottis in either 
event. 
Diagnosis.—Laryngeal spasm is frequently confounded with croup, but 
may be distinguished by considering the manner of onset, the character of 
the voice, and the state of the circulation. The symptom of asphyxia is 
gradually developed in croup, and is the culmination of a considerable period 
of dyspnoea; whereas in laryngismus stridulus it is the phenomenal feature, 
and sudden. The voice in the latter is lost; not so in croup. Febrility, 
which is present in croup, is absent in spasm. 
Treatment.—The treatment will embrace that proper during the spasm, 
and that which is designed to prevent the recurrence of the disease. To 
resolve the spasm, the tongue should be dragged forward, and the child im- 
mersed in water as hot as can be borne, the face and breast being at the 
same time switched with a napkin wet with cold water. A finger should also 
be passed behind the root of the tongue, in order to ascertain if the epiglottis 
is displaced, and. if so, to restore that cartilage to its place. 
After the child is revived, a careful search should be instituted to ascertain 
the probable cause of the disease. If the teeth are pressing against an in- 
flamed and swollen gum. their eruption must be assisted by a gum lance. If 
improper food is being used for the sustenance of the child, it will have to be 
discarded and other more suitable substituted; and in the event of disease 
of the vertebral being discovered, the recumbent position on the back should 
be enforced. When the nervous system is particularly irritable, the use of 
the bromides will have a good effect in preventing a repetition of the spasm. 
When the disease occurs in an adult, there is generally a constitutional vice 
in the background.—syphilis or tuberculosis,—the spasm being developed 
by local conditions of inflammation or ulceration. It is in such cases that 
tracheotomy may be called for to save the patient from suffocation. 
Spasm, Spasmodic Croup, or Laryngismus Stridulus. PARALYSIS OF THE MUSCLES OF THE LARYNX. 
55 
The general treatment will be indicated by the diathesis,—the iodide of 
potassium in the syphilitic, and cod-liver oil in the tuberculous. 
Paralysis of the Muscles of the Larynx. 
Motor paralysis of the larynx may be limited to one or more of its muscles, 
and may bo either unilateral or bilateral. 
Anatomical Considerations.—It is essential to the proper understanding 
of paralysis of the vocal apparatus that a brief physiological description be 
given of the action of its muscles, and of the nerves which endue them with 
sensation and motion. 
The intrinsic muscles of the larynx are concerned in two distinct offices,— 
one set in closing the vestibule, and the other set in regulating the tension 
of the vocal cords and the form of the glottis. The first office, which might 
be termed the shutting down of the lid of the superior opening of the larynx, 
is the work of the thyro-epiglottic muscles, while the varying changes of 
tension in the vocal cords and in the form of the glottis are produced by 
the action of four sets of muscles, which have been classed, according to 
their physiological action, as adductors and abductors, tensors and relaxors. 
These are,—first, the crico-arytenoid and the arytenoids, which bring the 
vocal cords towards each other and diminish the size of the glottis ; second, 
the posterior crico-arytenoids, which are the antagonists of the first group, 
and separate the cords from each other, thus increasing the capacity of the 
glottis ; third, the crico-thyroid and the internal thyro-arytenoids, which 
make tense the vocal cords; and, fourth, the thyro-arytenoid muscles, which 
relax the cords. 
The nerves which are concerned in conferring sensation and motion on the 
larynx are the superior laryngeals, which, with the exception of branches to 
the inferior constrictors of the pharynx and to the crico-thyroid, the thyro- 
epiglottic, and, possibly, the aryteno-epiglottic muscles, are distributed to the 
interior of the larynx and constitute its sensory supply. The inferior or re- 
current laryngeals given off by the pneumogastrics at the top of the thorax are 
distributed wholly to the muscles, and are their motor nerves. These nerves, 
though in company with the pneumogastric, belong rather to the spinal ac- 
cessory of Willis. The rima glottidis, which is the space between the vocal 
cords, in an adult rarely exceeds four-fifths of an inch in length. The form 
of the glottis is, consequently, under the control of the inferior laryngeal nerve. 
Observed under the laryngoscope during inspiration and expiration, the 
form of the glottis is seen to be that of an isosceles triangle, the apex being 
anterior and the base posterior. During strong expiration the sides of the 
glottis approach each other and become parallel, diminishing the interme- 
diate space, while under a full inspiration they separate, thereby enlarging 
the glottis, under favorable circumstances, to about one-half inch at the base 
of the triangle. 
Suspension of the Functions of Laryngeal Occlusion.—The loss of power 
in the larynx to prevent the intrusion of foreign substances, under ordi- 
nary circumstances, is due to paralysis of the thyro-epiglottic muscles, by 
which the epiglottis is unable to guard, by its descent, the opening into the 
larynx. 
The causes which give rise to this affection are infective, central, mechanical, 
and traumatic. Under the first head comes diphtheria; the second comprises 
those structural alterations in the floor of the fourth ventricle which origi- 
nate the phenomena of bulbar paralysis; the third includes pressure from en- 
larged tymphatic glands, or from other tumors of the neck; and the fourth, 
wounds. The paralysis is produced, therefore, through the spinal accessory 
or pneumogastric nerves, or particularly through a branch of the superior 
laryngeal nerve. The fact that this affection is frequently associated with 
diminished sensation in the larynx, and with impairment of both sensation 56 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
and motion in the pharynx, tends to confirm the view that the superior 
laiyngeal nerve is the defective line of communication. 
Symptoms.—These are, the tendency of food or liquids to pass into the 
larynx during deglutition, more or less difficulty in swallowing, and the fixed 
state of the epiglottis as seen by means of the laryngoscope while the move- 
ments of deglutition are being imitated. 
Prognosis.—This will be influenced by the determining cause. When that 
is infective, recovery may be anticipated ; so, also, when it is mechanical, 
if the compressing body is removable. The unfavorable cases are those re- 
sulting from bulbar sclerosis and wounds. Patients who persist in swallow- 
ing food in the natural way run great risk of perishing from pneumonia, 
developed by the passage of portions of the aliment into the air-passages. 
Treatment.—The medical treatment consists in the use of iron and strych- 
nia, and, in protracted cases, in the direct application of electricity to the 
muscles at fault. The food should be highly nutritious, and when, in conse- 
quence of the unguarded state of the larynx by reason of the paralysis 
of the thyro-epiglottic muscles and the absence of those reflex sensations 
which induce cough, there is danger attending deglutition, it must be ad- 
ministered through the oesophageal tube. 
In case of paralysis from the pressure of enlarged glands or other growths 
in the neck, extirpation by the knife is the proper course to be adopted when 
there are no contra-indicating conditions, and when the neoplasm is not 
amenable to less radical measures. 
Suspension of the Functions regulating the Tension of the Cords and the Form 
of the Glottis.—This is the result of paralysis of those muscles which regulate 
the movement of the rima glottidis. 
1. Paralysis of the Crico-Thyroid and Thyro-Arytenoid Muscles may be 
unilateral or bilateral,—generally the latter. The loss of power is seldom 
complete, and is produced by any cause which interrupts the transmission of 
nerve-force through the superior laryngeal nerve, as the pressure of tumors, 
traumatic injury of the nerve-cords, or excessive use of the voice. 
The s3rmptoms which indicate paralysis are those which are attributable 
to a loss of tension in the vocal cords. The control over the voice is lost to 
a greater or less degree, the patient being unable to regulate either the pitch 
of the lower notes, the only ones generally possible to utter, or any regular, 
unbroken passage from one note to another. As the crico-thyroid muscles 
are quite accessible to the touch on the outside of the neck, their want of 
action may be detected during phonation by the finger placed on the side of 
the larynx, between the thyroid and cricoid cartilages. When examined by 
the laryngoscope, in well-defined cases the absence of the normal tension in 
the vocal cords can be discovered during phonation, and when both muscles 
are implicated the naturally straight line of the glottis is changed to one 
somewhat undulating, or it assumes a fusiform shape. (Figs. 1710, 1711.) 
Fig. 1710. 
Fig. 1712. 
Fig. 1711. 
Bilateral paralysis of the crico-thy- 
roid and thyro-arytenoid of one side. 
Bilateral paralysis of the thyro- 
arytenoid. 
Unilateral paralysis of the vocal 
cords. 
When the paralysis is unilateral, the vocal cord of the affected side occupies 
a plane a trifle higher than that of the sound side, and remains reflexed, 
while its fellow contracts in inspiration. (Fig. 1712.) PARALYSIS OF THE MUSCLES OF THE LARYNX. 
57 
Prognosis.—When the paralysis can be ascertained not to depend on 
nerve-lesions, as in wounds of the neck, recovery may be anticipated. The 
prognosis is less favorable in bilateral than in unilateral loss of power. 
Treatment.—All speaking, singing, or continuous talking must be sus- 
pended, and the patient placed on a course of iron and strychnia, followed, 
after a period of entire vocal rest, by the local employment of electricity, 
the induced current answering best in some cases, and the faradic in others. 
When the affection comes on suddenly and is accompanied with congestion 
of the mucous membrane of the larynx, a few leeches over the larynx, fol- 
lowed by a blister, will sometimes do great good. 
2. Paralysis of the Lateral Crico-Arytenoid Muscles.—This may be either 
bilateral or unilateral, the former being the more common. The inferior 
laryngeal nerves, occupying a locality contiguous to structures which are 
frequently the subjects of morbid growths and other enlargements, are par- 
ticularly exposed to compression, which will explain the frequency of this 
form of paralysis. Thus, it is seen in aneurism of the arch of the aorta and 
of the innominate artery, in enlargements of the thyroid and bronchial 
glands, and in malignant disease of the oesophagus. It frequently exists 
independently of any organic disease, being purely hysteroidal or functional. 
The symptoms which chiefly characterize paralysis of the vocal cords are 
vocal. When the loss of power is complete, the voice is almost completely 
extinguished, the patient being obliged to converse in whispers. All efforts, 
voluntary or involuntary, at explosive expiration, as in coughing or clearing 
the throat, are aphonic. When the paralysis is incomplete, the voice comes 
and goes. All attempts at speaking, whether the loss of power is complete 
or incomplete, are attended with a sense of fa- 
tigue in the throat and chest. 
Examined by the laryngoscope, the vocal cords 
are seen to be slightly more separated and the 
glottis a little larger than normal. (Fig. 1713.) 
The vocal cords cannot be made to approach by 
any effort of the patient. 
When the paralysis arises from functional 
causes, there is sometimes a singular caprice in 
vocal sufficiency, the voice being quite distinct 
for a few moments, and then suddenly disap- 
pearing. 
The prognosis in cases of bilateral paralysis is 
always unfavorable when it is due to thoracic dis- 
ease, as aneurism or carcinoma; and the same 
is true when it depends on malignant affections 
of the thyroid gland, or on traumatic injuries of the inferior laryngeal nerve. 
When it has a functional origin, a cure may be confidently anticipated, 
even in cases of long standing; though there is danger that chronic disease 
of the adductor muscles may result in atrophic degeneration from defective 
nutrition. In a case of functional paralysis of the vocal cords in a female 
who was one of my first patients after I began the practice of my pro- 
fession, the affection persisted for seventeen years, during which time not a 
word was uttered. Her recovery took place apparently in a moment, and 
occurred during an attack of quinsy. 
Treatment.—The management of a case of paralysis of the adductor mus- 
cles of the vocal cords, when the disease depends on functional and hysterical 
causes, is to be conducted with a view to the invigoration of the general 
system, as well as to imparting muscular vigor by local stimulation. For 
these objects, quinine, iron, strychnia, and arsenic, with ample food, sea- 
bathing, and exercise out of doors, will serve to improve defective nutrition, 
and, when there is a nervous element present, the use of bromides, assafoetida, 
and other antispasmodics will prove beneficial. The local treatment is often 
Fig. 1713. 
Bilateral paralysis of the lateral and 
posterior crico-arytenoid muscles. 58 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
singularly efficient, even when there is reason to believe that the agent em- 
ployed has no therapeutical application to the case except through the im- 
pression made on the mind. Specialists in this department of surgery give 
numerous examples where the simple introduction of the mirror has been 
immediately followed by the return of the voice. The use of stimulating 
sprays, as tincture of capsicum, alcohol, iodine, etc., frequently does good 
by rousing the dormant muscles into activity. Electrization of the affected 
muscles is also among the valuable remedial measures to be employed. 
3. Unilateral Paralysis of the Crico-Arytenoideus Lateralis.—Lateral paral- 
ysis, or loss of motor power in one vocal cord, implies the interruption of 
nerve-force through the inferior laryngeal nerve of the corresponding side, 
the left being most commonly affected. 
The causes do not materially differ from those producing bilateral paralysis. 
Every one has observed diminished power of voice as a common accompani- 
ment of phthisis pulmonalis. In many instances this phenomenon is attrib- 
utable to pressure upon the recurrent laryngeal nerve by the consolidated 
pulmonary tissue. On the left side the nerve, from being deeply situated in 
the chest, where it passes behind the arch of the aorta, is especially exposed 
to such pressure. 
Symptoms.—The symptoms of unilateral paralysis are hoarseness and par- 
tial loss of voice, and on inspection of the laryngeal image in the laryngoscopic 
mirror the paralyzed cord is seen to remain quiescent during phonation, 
while its fellow is drawn or adducted possibly beyond the middle line. In 
respiration the paralyzed cord remains in an abducted state, taking no part 
in the movements executed by its fellow. 
Prognosis.—The prognosis of unilateral paralysis is extremely unfavor- 
able, depending, as it generally does, on diseases which are incurable. 
4. Paralysis of the Posterior Crico-Arytenoid Muscles.—Paralysis of these 
muscles destroys the power of abduction in the vocal cords, and, of course, 
allows their opposing muscles to draw the cords together and close the glottis. 
Males are more frequently affected than females, and children less than adults. 
This variety of laryngeal paratysis is not common. 
The causes are not always discoverable, but usually the disability can be 
traced to local pressure from both intra- and extra-laryngeal growths, and 
to inflammatory conditions affecting the cartilages of the larynx, to central 
degeneration affecting the roots of the spinal accessory or pneumogastric 
nerves, or to the local effects of cold, syphilis, consumption, and struma. 
Symptoms.—The prominent symptom is dyspnoea. Inspiration is attended 
by stridor, most marked in sleep; the expiration is free, and the voice is 
not materially changed. The laryngoscopic appearances are characteristic. 
During inspiration the vocal cords, winch, normally, should separate and en- 
large the glottis, remain almost in contact with each other, converting the 
usual triangular aperture into a mere fissure, which presents a serious im- 
pediment to the entrance of air. The difficulty of breathing is increased by 
slight exertion. The symptoms so closely imitate laryngismus stridulus that 
Ley regarded the latter affection as due to paralysis of the abductors. 
Prognosis.—Unless there are signs pointing to pressure from a gumma, 
which might be inferred if a history of constitutional syphilis existed, or to 
catarrhal or hysteroidal conditions, the prospect of recovery will be very 
slight. 
Treatment.—When the paralysis is bilateral and so pronounced as to cause 
much difficulty in breathing, tracheotomy is imperatively demanded. It is 
stated by Mackenzie that the necessity for the operation is greater in myo- 
pathic cases than in those depending on structural changes affecting the 
roots of the nerves. 
Burow opened the windpipe seventeen times in thirty-four cases. 
After the canula has been introduced into the trachea, the patient is de- livered from the dangers incident to obstruction of the glottis, as well as from 
others which are connected with an embarrassed cerebral circulation. 
When the paralysis is unilateral, affecting one abductor or one posterior 
crico-arytenoid muscle, the same symptoms follow as in the bilateral affection, 
though in a less marked degree; that is, there are inspiratory stridor and 
dyspnoea, increased on exercise, with very slight alteration in the voice. 
Examined with the laryngoscope, the affected cord, during respiration, will 
be seen to remain near tho median line, while the sound one moves naturally 
in both phonation and respiration. 
Causes.—The causes of the paralysis are cold, syphilis, pressure, and injury. 
Prognosis.—The restoration of power in the affected muscle may be an- 
ticipated, provided its loss is not due to intra-thoracic pressure or to degen- 
eration in the fibres of the muscle. 
Treatment.—By whatever cause the paralysis is produced, the patient 
must avoid all active exercise. If it is the result of cold, it will probably pass 
away in time without any special medication, or, if not, after the subsidence 
of the catarrh a course of strychnia may be directed with advantage. If it 
is of syphilitic origin, the use of iodide of potassium will be indicated. Elec- 
trization, in cases the progress of which towards recovery is slow, will be 
found to act beneficially. Tracheotomy may become necessary. 
PARALYSIS OF THE MUSCLES OF THE LARYNX. 
59 
5. Anchylosis of the Crico-Arytenoid Articulation.—A few instances of 
this atfection have been observed by Tiirck, Ziemssen, Schrotter, Mackenzie, 
and others, attributable to various causes, as rheumatism, cold, or perichon- 
dritis following typhoid fever or syphilis. The anchylosis may be unilateral 
or bilateral. 
The laryngoscopic appearance of the cords and glottis will depend on the 
position in which the arytenoid is fixed by the anchylosis; that is, if the 
cartilage is united to the cricoid in its vertical or normal position, the vocal 
cords will be immovably retained in the middle line, in which case there will 
be difficulty of breathing. If, on the contrary, the arytenoid occupies the 
outer surface of the articulating face of the cricoid cartilage, the corresponding 
cord will be drawn away from the middle line, and, it being fixed in this posi- 
tion, there will follow more or less loss of voice. As the appearance of the 
glottis and cords in the conditions named does not materiall}7 differ from that 
produced by the paralysis of muscles which are concerned in adduction and 
abduction, it is not easy to establish a differential diagnosis. As there is, 
however, in the production of anchylosis an antecedent inflammatory con- 
dition which is likely to give rise to thickening or some deformation of the 
parts, the recognition of any such structural changes would be useful in 
identifying the disease. 
Crico arytenoid anchylosis is irremediable. When the cords are fixed in 
the median position, dilatation has been suggested, preceded, of course, by 
tracheotomy. 
Electrization of the Larynx. 
For the therapeutical application of electricity in the treatment of laryn- 
geal paralysis the profession is indebted to Dr. Morell Mackenzie, of London. 
His apparatus consisted of a necklet surrounding the neck and connected 
with either a galvanic or an electro-magnetic machine and a curved 
wire electrode, terminating in a metal ball, and supported in a non-conducting 
handle, at the junction of which with the wrire was placed an ivory lever having 
on its under surface a metal point, which, on the lever being pressed with 
the thumb, came in contact with the wire of the electrode, and completed 
the circuit for the passage of the electric fluid. 
Fauvel modified this mechanism by uniting the two electrodes in one 
handle. (Fig. 1714.) With this instrument one branch can be placed on one 
of the vocal cords or over a particular muscle, and the other on the external 
surface of the aryteno-epiglottic fold. 60 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
In the absence of this improved electrode, the treatment can be carried out 
by-applying one pole, the positive, over the crico-thyroid membrane, and the 
Fig. 1714. 
Fauvel's laryngeal electrodes. 
other within the larynx, by the aid of the mirror, as near as possible to the 
muscles at fault. If it is desired to act on the inter-arytenoid muscles, the 
laryngeal electrode must be carried behind and between the arytenoid carti- 
lages ; if on the posterior crico-arytenoid, down in the lateral part of the 
pyriform sinus; if on the lateral crico-arytenoid, in the lateral recess between 
the pharynx and the larynx; and if on the thyro-arytenoid muscle, the polo 
must be carried within the larynx. 
It will answer, though less perfectly, when the requisite skill for intra- 
laryngeal manipulation is not possessed, to apply both poles externally, one 
over the crico-thyroid membrane, or below the inferior horn of the hyoid 
bone, in order to be in the position of the laryngeal nerves, and the other 
over the opposite side of the larynx. 
Tumors of the Larynx. 
Before the application of the laiyngoscope to the study of laryngeal dis- 
eases, morbid growths were only subjects of inference, and, except by post- 
mortem examination, did not admit of demonstration. 
The neoplasms which occur in the larynx do not materially differ from 
those which appear in other portions of the body. The benign growths 
are fibromata, papillomata, myxomata, angeiomata, cystomata, lipomata, and 
adenomata. 
Causes.—Laryngeal growths in a great many instances are attributable 
to an inflammatory origin. Thus, we find them following catarrhal attacks, 
measles, smallpox, erysipelas, scarlet fever, etc. Occupation exerts a deter- 
mining influence. Thus, persons whose professional calling requires the con- 
stant use of the voice, and persons who are exposed to irrespirable gases, 
are those most commonly affected. Mackenzie states that 21 per cent, of 
patients suffering from polypi who have reached an age sufficiently ad- 
vanced to have an occupation come from the first-named class. Syphilis and 
tuberculosis are also concerned in the production of laryngeal growths. 
Climate appears to exert some influence in the formation of these tumors. 
In regions, whether cool or warm, in which the atmosphere is dry and the 
changes of temperature are neither sudden nor extreme, they are much less 
common than in places where the opposite conditions exist. Thus, these 
growths are, so far as I can ascertain, more common in the Middle and 
Northern States of America than in the Southern. 
Sex.—Males are oftener affected than females, probably in consequence of 
the former, from their occupations, presenting conditions more favorable to 
the development of these tumors. 
These growths are not confined to any age, and in some instances are con- 
genital. 
The large majority of laryngeal neoplasms are benign in their nature. 
Symptoms.—The rational signs wrhich point to the existence of a growth 
in the larynx depend more on the locality and magnitude of the tumor than 
on its nature. They may he enumerated as follows: 
Vocal.—One of the most common symptoms is alteration of the voice. TUMORS OF THE LARYNX. 
61 
This may consist in huskiness, weakness, or complete aphonia. The degree 
of such disability will be influenced by the form and the situation of the 
tumor. When attached to the vocal cord, and having a broad base, the vi- 
brations of the former must necessarily bo more impeded than when the 
attachment is less extensive, and consequently the aphonia and d}’sphonia 
are more pronounced. It has been observed that the extent of the base of a 
laryngeal growth when implanted on a vocal cord, more than its bulk, de- 
termines the degree of voice-disability. Growths seated in the membranes 
or bands of the larynx seriously interfere with vocalization only when they 
attain considerable size. When the growth is developed in the ventricles, 
the vocal effect depends on the sessile or pedunculated character of its attach- 
ment, and on its magnitude, the dysphonia being greatest when the base of 
the tumor is broad and its size considerable. Infra-glottic neoplasms which 
are sufficiently large and movable to admit of being forced up during expira- 
tion into or against the glottis will temporarily extinguish the voice, which 
is restored when the mass recedes. 
Epiglottic neoplasms, when situated a considerable distance from the vocal 
cords and glottis, do not affect the voice. 
Difficulty in breathing exists in all degrees, from slightly hurried respira- 
tion to dyspnoea, asphyxia, or suffocation. The degree in which this dis- 
tressing symptom is present will depend upon the bulk and position of the 
gx-owth. As it acts obstructively, the nearer it is to the glottis the greater 
will be the embarrassment to respiration. The dyspnoea, like the aphonia, 
may be paroxysmal or intermittent, the attachment allowing the growth to 
be carried into the glottis, again to be expelled either by positions of the head 
or by the forcible expiration of air, as in coughing. When the obstruction 
occurs during expiration, the tumor is probably infra-glottic, and when it 
follows forcible inspiration, supra-glottic. 
Cough is by no means a constant attendant of laryngeal tumors. Its ex- 
istence depends much on the locality of the latter. The nearer to the vocal 
cords or the glottis, the greater the irritation and the greater the tendency 
in the neoplasm to create cough. The character of the cough varies. When 
the growth is sufficiently large to offer a considerable impediment to the en- 
trance of air through the glottis, it may be brassy and shrill, as in croup. 
If the tumor presses on one or both vocal cords, even though it may have 
no vital connection with the latter, the cough will, like the voice, be husky 
or rough, in consequence of the vibrations of the cord being interrupted. 
The mucus which collects on laryngeal growths also provokes some cough. 
The expectoration not unfrequently contains blood, and, if the tumor is soft 
and friable, detached fragments of the growth. 
Pain is an exceptional effect of laryngeal tumors, though a feeling of un- 
easiness in the organ is among the common phenomena belonging to these 
growths. It is the annoying sense of a foreign body being in the throat and 
requiring to be expelled that often creates the cough. 
Dysphagia is present only when the oesophageal orifice is encroached upon. 
This will be likely to arise when the tumor springs from the upper boundaries 
of the vestibule of the larynx and attains considerable size. 
In an analysis of 56 cases of laryngeal tumors, I find that in all but 6 
either aphonia or dysphonia was present. Disturbed breathing and dyspnoea 
were noted 40 times,—once amounting to suffocation,—and dysphagia twice. 
Mackenzie, in 100 tabulated cases, found the voice more or less affected in 
92 ; dyspnoea 30 times,—serious in 15 of these,—and dysphagia 8 times. 
Diagnosis.—Though the existence of a laryngeal tumor maj7 be con- 
jectured from the signs above described, yet it is only by a physical exam- 
ination that any degree of certainty can be attained. Mot only does the 
laryngoscope enable the observer to discover any growth which may exist, 
imaged in the mirror, but its exact locality in the larynx may often thus 
be determined. Where the tumor is supra-glottic, its presence may also be 
ascertained by a digital exploration of the parts. 62 
SURGICAL DISEASES OF THE LARVNX AND TRACHEA. 
Prognosis.—In non-malignant growths the prognosis in regard to the life 
of the patient, in the event of an operation being made, is favorable. In 
many instances the voice is not only preserved, but improved or entirely re- 
stored, particularly when the operation is done through the larynx. Without 
an operation the danger is very great: indeed, in pedunculated growths, life 
is suspended literally on a thread. In malignant disease of the larynx little 
hope can be entertained of recovery by any plan of treatment. 
Fibromata are generally solitary, smooth or irregular on the surface, round 
or oval in form, frequently pedunculated, of a red color, and vary in size from 
a pea to a cherry. (Fig. 1715.) They usually 
grow from one of the vocal cords, and have 
their origin in the submucous connective tis- 
sue. 
Papillomata are the most common of laryn- 
geal growths. They are frequently multiple, 
though generally occupying one or both vocal 
cords. They are not confined to these struc- 
tures, but may exist in any part of the larynx. 
Their attachment is most frequently sessile, 
sometimes pedunculated. Examined microscop- 
ically, their surfaces often present a strawberry 
appearance, being red, irregular, granular, or 
wart-like. 
Papillomata, as a rule, are not so red as 
fibromata, and are often interrupted by spots 
of white. (Fig. 1716.) In size they may vary from a mustard-seed to a 
shell-bark, and they grow more rapidly than fibromata. 
Fig. 1715. 
Fibroma of the larynx. 
Myxomata are among the rarest of laryngeal neoplasms. They grow from 
the vocal cords, preferably near the angle of their junction (Fig. 1717), are 
for the most part solitary, smooth, semi-transparent, of a pink-red color, and 
rarely exceed a grain of corn in size. 
Fig. 1717. 
Fig. 1716. 
Papillomata of vocal cords. 
Myxoma. 
Angeiomata, like myxomata, are rare. They have been observed both 
within the larynx and on its pharyngeal surface. They are dull red or dark 
in color, having a granular surface (Fig. 1718), and resemble somewhat in 
appearance a blackberry. TUMORS OF THE LARYNX. 
63 
Cystomata usually select either the epiglottis or one of the ventricles for 
their location. They are spherical, translucent, have a broad base, and are 
of a pale red color. In one case which was under my care, the cyst, which 
was attached to the epiglottis (Fig. 1719) and was as large as a pigeon’s 
egg, could be made to rise on the dorsum of the tongue, or descend, at the 
pleasure of the patient. The contents of these cysts are sometimes glairy, 
albuminous, resembling bursal fluid; at other times, thin, serous, and tinged 
with blood. 
Fig. 1718. 
Fig. 1719. 
Angeiomata of larynx. 
Cystomata of the epiglottis. 
Lipomata.—Only a single instance of lipoma of the larynx has been ob- 
served,—that of Bruns. The tumor in this case was very large, and was 
attached to one of the aiytenoid cartilages. 
Adenomata.—The development of these neoplasms is often due to long- 
persisting catarrh of the larynx. They take their origin in the glands and 
follicles of the mucous membranes covering the epiglottis, the arytenoid 
cartilages, or the folds between the latter and the epiglottis. They exhibit 
a tendency, as they grow, to become pedunculated. When sessile, they are 
usually round, and have either a dusky red or a flesh color. As the surface 
of these tumors is generally surmounted by papillary eminences, they may 
be regarded as combining the histological components of both the glandular 
and the papillomatous neoplasms. 
Enchondromata.—Cartilaginous growths have been noticed in two or three 
instances growing from the cricoid cartilage. As described by Virchow, they 
present a variety of form, being flat, uneven, or knobbed on the surface, with 
sometimes a broad and at other times a narrow, attachment. Their great 
density, as compared with other laryngeal neoplasms, constitutes a feature of 
considerable differential importance. 
Treatment.—It is generally conceded by specialists in this department 
of surgery that laryngeal growths which are small, show little or no dispo- 
sition to increase, and do not give rise to any serious symptoms, should be 
let alone. 
There are two methods of removing laryngeal tumors,—namely, the intra- 
laryngeal, and that of opening the larynx by external incision. 
Intra-laryngeal operations are performed with the aid of the laryngoscope, 
and consist in cauterization, and in twisting, or cutting, or crushing the 
morbid growth from its interior attachments. Previous to attempting any 
operation through the mouth it may be necessary to institute some prepara- 64 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
tory treatment, such as handling the different parts of the fauces with the 
spatula, in order to lessen their sensibility or irritability, or, in the event of 
there being any inflammatory condition of the pharynx or fauces, to apply 
such remedies as will relieve the parts and restore them as nearly as possible 
to a healthy state. 
Cauterization.—The caustics employed are nitrate of silver, acid nitrate of 
mercury, nitric acid, caustic soda and quick-lime,—generally known as Lon- 
don paste,—chromic acid, and the galvano-cautery. Small papillomata may 
be destroyed or greatly repressed by the repeated use of nitrate of silver or 
of the more potent London paste. 
When the nitrate of silver is used, it may be applied either in the solid 
stick or in a very strong solution. When in the former state, the instrument 
of Professor Tobold, which is a curved canula containing a stylet, by which 
the caustic can at the proper moment be pushed out (Fig. 1720), should be 
Fig. 1720. 
Tobold’s caustic-holder. 
Fia. 1721. 
Camel’s-hair brush. 
used. A very simple plan is to take a piece of silver wire, and, after bending 
it into the proper form, dip the extremity into strong nitric acid. A little 
film of nitrate of silver is immediately formed on the wire, which can be 
applied to the diseased spot. When the solution of this salt is used, it must 
be brought in contact with the surface to be treated by means of a camel’s- 
hair brush. (Fig. 1721.) 
Fig. 1722. 
Modified Voltolini’s galvano-cautery for removing tumors of the larynx. 
The removal or destruction of morbid growths by the galvano- 
cautery is effected either by the loop of platinum wire as devised 
by Yoltolini, of Breslau (Fig. 1722), or by the knife of Cohen. In 
employing the wire, a loop of the latter is pushed a little in ad- 
vance of the guide attached to the handle of the instrument. As 
soon as the noose can be placed around the growth and drawn 
tight, which of course can be done only with the aid of the mirror, 
the electro-galvanic current is turned on by pressing the thumb-piece belong- 
ing to the handle, when, by screwing the button of the handle, the constric- 
tion is increased, and the tumor burned through. This operation is one 
requiring not only skilled assistants, but also more than ordinary manipu- 
lative tact, and is not likely to become very popular. TUMORS OF THE LARYNX. 
65 
Evulsion consists in seizing the growth with forceps and twisting it off 
from its attachment. There are several instruments which effect this object 
Fig. 1723. 
Fauvel’s laryngeal forceps. 
most satisfactorily, as those of Fauvel ,(Fig. 1723), of Cusco, and of Mac- 
kenzie (Figs. 1724, 1725). 
Crushing, which in many cases is as efficient as evulsion, is done by seizing 
Fig. 1724. 
Mackenzie’s laryngeal forceps. 
the growth and compressing its structure with sufficient vigor to destroy its 
vitality and cause the damaged tissue to disintegrate and slough away. 
Both processes may be combined; that is, the tumor may be crushed, and 
Fig. 1725. 
Mackenzie’s canula forceps. 
afterwards twisted away in pieces. The forceps employed in evulsion answer 
equally well for crushing. For the removal of small soft neoplasms, the 
forceps of Durham (Fig. 1726) can be used with advantage. 
Cutting.—The excision of a laryngeal growth can be effected by the cutting 66 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA 
forceps, by scissors, by some of the different ecraseurs, by guillotines (Fig. 
1727), and by lancet-shaped knives. 
Fig. 1726. 
Durham's forceps. 
The cutting forceps represented in Figs. 1728 and 1729 have a wide range 
of application, and are well adapted, by the shape of the blades and their 
strength, to divide the tissue of a growth. 
Fig. 1727. 
The scissors of Tobold, which can be used for cutting either horizontally 
or perpendicularly, may sometimes be substituted for the forceps. The 
ecraseur (Fig. 1730), which 
from its simplicity and fa- 
cility of being worked 
combines all the requisites 
of such an instrument, is 
that of Mackenzie. 
The loop consists of 
wire, which, being con- 
cealed in a guard of metal, 
can be placed over the tu- 
mor, and the constriction 
made by the cog-wheel at 
the handle of the instru- 
ment, worked with a single 
finger. 
The guillotine devised 
by Professor Stoerk (Fig. 
1731) is perhaps the best 
instrument of the kind for 
laryngeal operations. A number of different-sized guillotines can be fitted to 
the same handle. 
Guillotines. 
Fig. 1728. 
Mackenzie’s cutting forceps. 
Fig. 1729. 
Cohen’s cutting forceps. TUMORS OF THE LARYNX. 
67 
Knives employed for cutting away laryngeal neoplasms require to be used 
with great delicacy and exactness, and do not meet with very general favor. 
Fig. 1730. 
Mackenzie’s 6craseur. 
The lancet-shaped knife of Tobold is one among a number of similar instru- 
ments. 
False bands occasionally cross the glottis from one vocal cord to the other 
(Fig. 1732), preventing 
their proper movements, 
and will require division 
either by the laryngeal 
knife or by the galvano- 
cautery. 
Circumstances which for- 
bid intra-laryngeal opera- 
tions.—A growth in the 
larynx may be so hard, 
and attain such magnitude, or the surface involved in the disease may be so 
extensive, its position so inaccessible, or its vascularity so great, as to forbid 
all attempts at removal by any of the intra-laryngeal 
methods of treatment. 
Even should none of these contra-indicating condi- 
tions exist, there may be some unusual sensibility or 
irritability in the fauces or about the glottis, which 
not only renders all manipulations through the mouth 
impossible, but, if persisted in, exposes the patient 
to the danger of laryngeal spasm. The bulk of a 
tumor is not so great an obstacle to its removal by 
intra-laryngeal methods as the character of its con- 
nection with the parts on which it rests. A pedunculated growth, even 
though of large size, can be extracted through the mouth, when one com- 
paratively small, but with a sessile base, will defeat the best-applied efforts 
for its destruction. 
While thus presenting the conditions which contra-indicate intra-laryngeal 
methods of treatment, it is proper to say that -no case should be subjected 
to external operation until the former plans have been tried and have failed. 
Not unfrequently a compromise may be made, in which a laryngeal growth 
utterly unmanageable by intra-laryngeal operation can be removed with 
entire success and safety if tracheotomy is first performed. 
External incisions.—When a laryngeal growth is not amenable to intra- 
laryngeal plans of treatment, and when, from its increase, the symptoms 
which follow indicate danger to life, it will be proper, if the disease is not 
of an incurable nature, to expose the cavity of the larynx by external in- 
cisions, and in this manner extirpate the growth. If the affection is malig- 
nant and probably incapable of being eradicated, it is the duty of the surgeon 
to provide against the dangers of obstruction by opening the trachea and 
introducing a respiratory canula. 
Fig. 1731. 
Stoerk’s guillotine. 
Fig. 1732. 
False bands between the vocal 
cords. 68 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
The operations which are included under the head of external incisions or 
extra-laryngeal methods are laiyngotomy and tracheotomy. 
Laryngotomy.—Under the head of laryngotomy are included thyrotomy, 
which consists in separating the two halves of the thyroid cartilage by an 
incision in the median line, and crico-thyrotomy, sometimes called laryngotomy, 
or the division of the crico-thyroid membrane. Two of these methods are 
sometimes combined, as when the incision separating the aim of the thyroid 
cartilage is continued upward through the thyro-hyoid membrane.—laryngo- 
pharyngotomy; or as when, in tracheotomy, the cricoid cartilage is severed, 
and the incision continued through the crico-thyroid membrane,—tracheo- 
laryngotomy; if the division of the crico-thyroid membrane preceded that 
of the trachea, and the cricoid is divided from above downward, the opera- 
tion is called laryngo-tracheotomy. Even when it is found necessary to 
perform laiyngotomy in order to extract a tumor the operation will some- 
times require to be preceded by tracheotomy, the former following the latter 
after the patient has become thoroughly accustomed to the pressure of the 
tracheal tube. The necessity for observing such an order will depend upon 
the presence of dyspnoea or the magnitude of the growth and the probabilities 
of hemorrhage. 
When tlyrotomy is executed and the opening is not found adequate to 
the demands of the case, it can be enlarged in either direction, upward or 
downward, by dividing the thyro-hyoid membrane. 
Cautions in operating.—When the larynx is opened by thyrotomy for the 
purpose of extracting a tumor, great care must be observed to make the 
incision exactly in the median line at the angle of junction between the two 
alae of the thyroid cartilages. Any deviation to either side exposes the vocal 
cords, which are attached at the receding angles of the cartilages, to injury. 
To avoid this I find it convenient to cut from above downward, as the thy- 
roid notch constitutes an excellent guide to the median junction. When the 
disjunction has been accomplished, the two halves of the thyroid should be 
held widely apart by retractors, one on each side, and intrusted to the hands 
of an assistant. It will be found of great importance at this stage of the 
operation to have the patient so disposed that the interior of the larynx shall 
be well illuminated either by direct or by reflected light. 
In extracting the growth, which can be done by forceps and scissors, 
damage to the vocal cords must be carefully avoided, and should the bleeding 
be profuse, the passage of the blood into the trachea must be prevented by 
tamponing the upper orifice of the trachea with a soft piece of sponge having 
a cord attached, in order to be under the command of the operator. If 
tracheotomy has not been previously done, the air-passages may be protected 
against the intrusion of blood and the respiration maintained by introducing 
into the windpipe, at the lower angle of the wound, a bent tracheal tube, the 
longest limb being two inches and a half, to which is secured, one inch from 
its extremity, a soft sponge. This arrangement is more easily extemporized 
than the rubber bag of Trendelenburg. After freeing the larynx of the 
neoplasm it will often be proper, with a view to prevent its reproduction, 
to treat the surface from which it has been removed with nitrate of silver, 
acid nitrate of mercury, or chloride of zinc, after which the sides of the car- 
tilage are to be brought together and retained by silver sutures. When the 
patient is wearing a tube in the trachea at the time of the operation, it will 
be best not to remove it for some time after, or until the danger of inflam- 
matory swelling, which may succeed the operation, is past, and sufficient 
time has elapsed to render the return of the disease improbable. 
However skillfully performed, the effect of th}7rotomy on the voice is 
very disastrous. Mackenzie states that in 38 instances in which the opera- 
tion was performed for the removal of laryngeal neoplasms, the voice was in 
20 cases either entirely lost or greatly injured, and was retained or restored 
in only 18. 
In 56 cases of thyrotomy collected by Dr. Baum, 17 remained aphonic, 10 TUMORS OF THE LARYNX. 
69 
dysphonic, 6 with impaired voice, 12 were restored normally, and in 11 the 
result was unknown. 
Another objection which is urged against the operation, except when it is 
performed under circumstances of pressing necessity, is the fact that the 
recurrence of the disease for which the larynx is often opened is quite as pos- 
sible as when it is treated by the intra-laryngeal plan, and requires in the 
end either a return to the latter plan of treatment or a second thyrotomy, 
which would be annoying to the surgeon and distressing to the patient, and 
most probably would be declined by the latter. 
In my own collection of 56 cases, the disease for which thyrotomy was 
done is mentioned in 40 ; 24 were cases of papillomata, 7 of carcinomata, 
7 of fibromata, 1 of sarcoma, and 1 of villous growth. The disease was noted 
as recurring 18 times. 
Taking, for comparison, papilloma, which constitutes the large proportion 
of all laryngeal growths, Bruns has analyzed 39 cases of the diseases treated 
by thyrotomy,—17 children and 22 adults. Of the former 8 were cured, and 
in 9 the growth recurred ; in the latter 10 were cured, and in 12 the disease 
returned: thus, in the two classes there were 18 cures and 21 recurrences. 
Contrasting this with the result of intra-laryngeal treatment of the same 
growths, this writer selects 64 cases; of this number 47 were cured, and 
in 17 cases the disease returned. Or, taking children and adults together, 
there were 39 eases treated by thyrotomy, with 18 cures and 21 recurrences; 
while by the endo-laryngeal method there were treated 90 cases, with 60 
recurrences. The conclusions, therefore, from the foregoing figures are 
that in thyrotomy the recurrences of the disease exceed the cures, while by 
the intra-laryngeal mode of treatment the cures are twice as many as the 
relapses. 
Bruns’s collection of thyrotomies since 1878, as analyzed by Albert HofFa,* 
shows only 4 deaths in 94 operations. In 60 of the above, the voice re- 
mained unchanged in 39, hoarse in 15, and aphonic in 6. 
When a laryngeal growth is attached to the tracheal side of the vocal 
cord, or lower in the larynx or trachea, and cannot be extracted through the 
mouth, infra-thyroid laryngotomy or tracheotomy will become necessary. 
In infra-thyroid laryngotomy the incisions through the skin and subcu- 
taneous tissue should be made transversely, and, after reflecting the flaps 
upward and downward, the crico-thyroid membrane must be cut away in the 
same direction, in order to furnish as large a space as possible for inspection 
and manipulation when the neck is extended. If necessary, the cricoid 
cartilage can be divided, and the incision carried into the trachea; or, in the 
event of tracheotomy having been previously performed, the wound may be 
continued upward through the cricoid cartilage and crico-thyroid membrane 
to the thyroid cartilage. An interval of three or four days should elapse 
between the opening of the windpipe and the operation for removing the 
laryngeal growth, during which time the patient can wear a canula. 
When the tumor is to be extirpated, the tube must be removed, and the 
larynx inspected with a small mirror introduced through the opening into 
the trachea. The operator will probably be able to locate the growth, and 
also to ascertain the exact extent of its connections, after which, on the 
withdrawal of the glass, the forceps can be introduced, and the tumor seized 
and drawn away. The same precaution in regard to wearing the tracheal 
tube for some time after the operation is necessary after thj-rotomy. 
The operation of pharyngotomy, proposed by Malgaigne and Yidal de 
Cassis, was first executed by Dr. Prat, a surgeon of the French navy, in 
1850, for the removal of a fibroid growth attached to the base of the epi- 
glottis, which, from its size, caused severe dysphagia. 
The operation consisted in dividing transversely the thyro-hyoid membrane 
with the superincumbent structures. The tumor was successfully removed 
through this space. Follin repeated this operation with success in 1853, for 
® Annual of Universal Medical Sciences, vol. iv. p. 30. 70 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
the removal of a tumor at the top of the larynx. As it is not attended with 
any peculiar danger, there can be no objection to employing this surgical 
resource when the neoplasm is supra-glottic and has resisted other means for 
its extirpation. 
Morbid growths similar to those which develop in the larynx are occasion- 
ally met with in the trachea. The rareness of tracheal as compared with 
laryngeal growths is most probably to be accounted for on anatomical and 
physiological grounds, the latter tube being adapted only to purposes of 
respiration, while the larynx is both a respiratory and a vocal apparatus, 
and, consequently, is subjected to influences which strongly predispose it to 
inflammatory accidents. 
Tracheal growths are more difficult to diagnose, but can be detected by 
the aid of the laryngoscope. Unless they grow to a large size, they do not 
give rise to the same urgent symptoms as do neoplasms situated about the 
glottis. When they occupy the upper part of the trachea, and are peduncu- 
lated, death may suddenly occur by the tumor being swept, during expira- 
tion, into the glottis. There is a windpipe in the museum of the University 
of Pennsylvania which was taken from a man who perished in this way 
without the cause being suspected. The growth is a pedunculated fibroma 
attached to the top of the trachea. 
Tracheal tumors are to be treated on the same general principles as those 
which are laryngeal, namely, by intra-laryngeal methods, or, when these fail, 
by opening the windpipe and destroying the neoplasm through the artificial 
aperture. 
Tumors of the Trachea. 
Malignant Growths of the Larynx. 
Carcinoma of the larynx is generally primary. The epitheliomatous form 
of the disease is that generally observed. In 141 cases of carcinoma of the 
larynx collected from Mackenzie, Ziemssen, and Schrotter, 119 were classi- 
fied as epithelioma, 18 as encephaloid or scirrhous, and 2 as villous. Sar- 
coma is also met with. 
The disease may commence on either aspect of the larjmx; that is, on the 
inside of the organ, or on the pharyngeal surface. When on the lateral, it 
is prone to extend beyond the limits of the larynx to contiguous parts. The 
most common site for the disease when beginning within the larynx is above 
the glottis, and near one or both of the vocal membranes. (Fig. 1733.) 
Males are more liable to the disease than females. Age 
exerts no small influence on the frequency of laryngeal 
cancer, it being seldom seen under 40. The largest 
number of cases occur between 60 and 70. The 
earliest age at which it has been observed is 6 years. 
Three cases of the disease at this early period are re- 
ported by Ziemssen. 
Symptoms.—Among the first symptoms of laryngeal 
cancer is pain, or some degree of uneasiness referred to 
the larynx. Sometimes, even before any pain is ex- 
perienced, the earliest indication of trouble is a change 
in the voice, which becomes hoarse. If the disease 
begins on the pharyngeal surface of the larynx, dysphagia is among the early 
signs, and if on the interior of the organ, more or less difficulty of breathing 
is present. When ulceration occurs, there follow cough, a bloody expecto- 
ration, often hemorrhage; the breath becomes exceedingly foul; severe 
pain is experienced along those branches of nerves in communication with 
the laryngeal nerves and leading to the side of the neck and the ear. The 
flesh and strength waste ; the introduction of septic matters into the blood 
gives rise to an irritative fever; dyspnoea supervenes, and death ensues, 
either from exhaustion incident to hemorrhage and blood-poisoning or from 
Fig. 1733. 
Epithelioma of the larynx. MALIGNANT GROWTHS OF THE LARYNX. 
71 
asphyxia. When examined by the laryngoscope, there may, in the com- 
mencement of the disease, be nothing discovered calculated to disclose the 
character of the malady, as the tumid appearance of the mucous membrane 
does not materially differ from that caused by syphilis, catarrh, and other 
diseases. After a time, however, the infiltration gives rise to a swelling pos- 
sessing more definite characters. It is irregular in its outline, not sharply 
defined, somewhat nodulated on the surface, has an angry, red color, often 
interspersed with spots of steel-gray, and is probably located near one of the 
vocal membranes. (Fig. 1734.) When ulceration 
occurs, the edges of the sore are irregular, and its 
bottom covered with fragmentary granulations and 
stained with bloody discharges. The disease con- 
tinues to spread both in depth and in circumference, 
until at length the epiglottis and other cartilages 
of the larynx, and even the adjacent organs, are in- 
vaded. 
The only ulcerations with which laryngeal car- 
cinoma can be confounded are those due to syphilis. 
I have certainly met with cases of the latter which 
bore so strong a resemblance to epithelioma that 
only after the adoption of a specific treatment was 
I able to form a diagnosis. 
Prognosis.—A patient laboring under carcinoma 
of the larynx is doomed, and the question to be 
considered by the surgeon is not how to cure, but 
how to prolong life and relieve suffering. The usual 
duration of the disease varies with the form of car- 
cinoma. Epithelioma is more rapid than either 
scirrhus or encephaloid, the patient rarely lasting 
longer than from fifteen to twenty months, while 
the latter affections may continue for two or even 
three years before life is destroyed. 
Treatment.—The treatment is medicinal and 
operative. The former consists in the inhalation 
of sprays charged with tannin, dilute liquid per- 
nitrate or sub-sulphate of iron, in order to control 
bleeding, and the internal use of iron, arsenic, 
and quinine as a tonic. The nourishment will require to be liquid, and 
must embody the largest amount of nutriment in the smallest bulk. The 
operative measures are thyrotomy, tracheotomy, and extirpation of the 
larynx. 
The results of thyrotomy have been investigated by Bruns, and, as might 
be expected, with a result altogether unfavorable to the operation. In 20 
cases in which this procedure was adopted the disease very soon recurred,—in 
some as early as two weeks after the operation, in others in from two to four 
months; and in all cases where histories were obtainable, with the excep- 
tion of one in which the patient lived eighteen months, and another in which 
he lived twenty-two months and died of cancer of the kidney, the disease 
returned within six months. 
Tracheotomy, however, is a valuable palliative measure, and whenever the 
obstruction to the respiration becomes threatening, the patient should always 
have the benefit of this operation. Fauvel, in illustration of the advantage 
derived from opening the windpipe in encephaloid and epithelial carcinoma 
of the larynx, compares 7 cases of the former left without operation, the aver- 
age duration of life being 3 years, with 8 in which tracheotomy was done 
and in which the mean duration of life was 3 years and 9 months. Of the 
latter, or those laboring under epithelioma, 6 were left without operative in- 
terference, the average length of life being 1 year and 11/months, while in 7 
in which tracheotomy was performed the mean duration of life was 4 years. 
Fig. 1734. 
Epithelioma of the larynx.— 
From a specimen in the museum 
of the University of Pennsylvania. 72 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
In 3 cases of epithelioma of the larynx with the treatment of which I have 
been associated, though the operation was done almost in extremis, one, who 
without assistance could not, humanly speaking, have lived many days, lived 
over a year, a second about the same time, and the third is at present doing 
well, six months after the tracheotomy. 
Extirpation of the Larynx.—There is no achievement in surgery which 
displays greater boldness on the part of the operator, or which more fully 
demonstrates the power of the human body to endure mutilation, than the 
extirpation of the larynx. As a last resort, I may say as a desperate expe- 
dient, it has been proposed and carried into effect for the cure of laryngeal 
cancer. 
Operation.—The patient, having been etherized, is placed on the back on 
a table, with the shoulders elevated and the head thrown back, in order to 
elongate the neck and render the laryngeal apparatus prominent. The in- 
cision is then made exactly in the median line, extending from the hyoid 
bone to the commencement of the supra-sternal fossa, and exposing from 
above downward the crico-thyroid membrane, the angle of the thyroid car- 
tilage, the thyro-hyoid membrane, the cricoid cartilage, and two or three of 
the upper rings of the trachea. The only vessels likely to require ligature 
at this stage of the operation will be the crico-thyroid arteries. The soft 
parts are next to be detached from the larynx and trachea as much as pos- 
sible by the handle of the scalpel, director, or finger: if the operator is com- 
pelled to use the blade of the knife, he should keep its edge, during the 
dissection, close against the cartilages of the tube. 
By observing this plan and thus keeping clear of the large branches of 
arteries, much bleeding will be avoided. During the process of uncovering 
the larynx, the vessels which may require the ligature will be those belonging 
to the superior and inferior thyroid arteries. If the isthmus of the thyroid 
gland is large, it should be tied on each side, and divided in the middle. The 
next step consists in isolating the upper part of the trachea from its faucial 
and oesophageal connections, in doing which care must be observed not to 
injure the gullet. The separation will be most safely effected by the director 
in place of the knife. Once completely disconnected from the surrounding 
parts, the trachea should be drawn forward by means of a blunt hook or the 
finger, and divided across, from behind forward, on a level with the second 
ring. A siphon-tube, formed of vulcanized rubber, is now introduced into 
the trachea, fitting its canal accurately above. Having provided for the 
maintenance of the respiration, the lower end of the larynx is drawn out- 
ward, and its posterior surface carefully dissected from the pharynx. The 
close adhesion between the two renders the task one of no small diffi- 
culty. The handle of the knife will again be found useful at this stage of 
the process. 
When the pharynx has been separated, it only remains to sever the con- 
nection between the thyro-hyoid membrane and the hyoid bone to complete 
the operation. After all bleeding has been controlled, a drainage-tube should 
be introduced into the wound, and the reflected flaps brought together and 
maintained by interrupted sutures. Should the patient survive until the 
wound cicatrizes, the siphon-tube can be substituted for the vocal apparatus 
of Gussenbauer. 
The following table, constructed from the cases collected by Dr. Baum and 
Dr. Mackenzie, contains, I believe, all the cases which have been recorded 
of extirpation of the larynx for malignant or other disease: EXTIRPATION OF THE LARYNX. 
73 
No. 
Operator. 
Date. 
Sex and 
Age. 
Disease. 
Primary Oper- 
ation. 
Parts Removed. 
Immediate Result. 
Final Result. 
Source of Information. 
P. H.Wat8on. 
1866. 
<d 
CO 
SS 
Syphilitic disease. 
Larynx and one ring of trachea. 
Recovery. 
Died in 3 weeks from pneu- 
monia. 
Dr. Fowlis’s paper before 
the International Med. 
Congress, 1881. 
2 
Billroth. 
1873. 
M., 36. 
Epithelioma of larynx. 
Larvngotomv. 
Entire larynx except one-third of 
tc 
Death in 7 months from re- 
New York Med. Jour., vol. 
glottis, also two rings of trachea. 
turn of the disease. 
xxi. p. 309. 
3 
Heine. 
1874. 
M., 50. 
Carcinoma of larynx. 
Entire larynx. 
U 
Lancet, Jan. 1878, p. 150. 
turn of disease. 
4 
M. Schmidt. 
1874. 
M., 56. 
U U 
U 
Death on 5th day, col- 
lapse. 
July, 1876, p. 280. 
5 
Maas. 
1874. 
M., 57. 
Tracheotomy. 
Death in 14 days from 
pneumonia. 
6 
fibroma. 
Epithelioma. 
it 
xxxii. p. 83. 
Dr. Fowlis’s paper. 
P. H.Watson. 
1874. 
M., 60. 
pneumonia. 
7 
Schiinborn. 
1875. 
M.,72. 
Carcinoma. 
Death in 2 days. 
Berliner Klinisclie Woch., 
No. xxxviii., 1875. 
8 
Bottini. 
1875. 
M., 24 
Sarcoma. 
Laryngotomy. 
U 
Recovered. 
Well in 1881. 
New York Med. Jour., vol. 
xxi. p. 83. 
9 
Laugenbeck. 
1875. 
M., 51. 
Carcinoma. 
Tracheotomy. 
Entire larynx, part of the tongue, 
“ 
Death in 4 months from re- 
Med. Times and Gaz., Aug. 
with hyoid bone, and a portion 
of pharynx and oesophagus. 
turn of disease. 
1875. 
10 
Billroth. 
1875. 
M., 50. 
Entire larynx. 
Death in 2 days. 
1875. 
11 
Maas. 
1876. 
M., 50. 
Epithelioma. 
Entire larynx except epiglottis. 
Recovered. 
Arcliiv fiir Klin. Chirurgie, 
Band xx. p. 535. 
months; death in 6 
months. 
12 
Gerdes. 
1876. 
M., 76. 
it 
» 
Tracheotomy. 
Entire larynx. 
Death in 4 days from 
New York Med. Jour., vol. 
collapse. 
xxviii. p. 200. 
13 
Reyher. 
1876. 
M., 60. 
Entire larynx except epiglottis. 
Death 11 days after 
from pneumonia. 
Archiv fiir Klin. Chirurgie, 
Band xxi. Heft ii. p. 473. 
14 
P.H.Watson. 
1876. 
F., 60. 
Larynx and enlarged glands of 
the neck. 
Death 11 days after. 
Dr. Fowlis’s paper. 
15 
Kosiuski. 
1877. 
F., 36. 
Tracheotomy. 
Entire larynx. 
Recovery. 
Died 9 months after from re- 
New York Med. Jour., vol. 
turn of disease. 
xxvii. p. 423, and Lancet, 
1877, Oct. 13, p. 530. 
16 
Fowlis. 
1877. 
M., 28. 
Papilloma and sarcoma. 
Thyrotomy. 
“ 
Died in 1879 from phthisis. 
Lancet, March 29, 1879. 
Ainer. Jour. Med. Sciences, 
17 
Wagner. 
1877. 
M., 52. 
Carcinoma. 
Tracheotomy. 
“ 
“ 
Living in 1878, 6 months 
18 
1877. 
M., 48. 
Epithelioma. 
Entire larynx and a portion of 
oesophagus. 
Death on 3d day from 
pneumonia. 
after operation. 
Oct. 1870, p. 562. 
Bottini. 
Died 10 months after op- 
eration ; disease returned. 
vol. xxviii. p. 427. 
19 
Bruns, Sr. 
1878. 
M., 54. 
Entire larynx. 
Recovery. 
Throat and Nose, etc., vol. 
i. p. 348. 
20 
Rubio. 
1878. 
M., 41. 
Necrosis of cartilages 
of larynx. 
n 
Death on 5th day. 
Throat and Nose, etc., vol. 
i. p. 348. 
# 
Extirpation of the Larynx. 74 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
No. 
Operator. 
Date. 
Sex and 
Age. 
Disease. 
Primary Oper- 
ation. 
Parts Bemoved. 
Immediate Besult. 
Final Besult. 
Source of Information. 
21 
Czerny. 
1878. 
M., 46. 
Sarcoma. 
Entire larynx. 
Becovery. 
Dr. Fowlis’s paper. 
currence of disease and 
other operation per- 
formed. 
22 
Billroth. 
1879. 
M., 50. 
Carcinoma. 
M 
M 
Mackenzie, Diseases of the 
Throat and Nose, etc., vol. 
Entire larynx and a portion of 
pharynx. 
Death in 3 days, from 
pneumonia. 
passage of a bougie into 
the mediastinum. 
23 
MacEwen. 
1879. 
M., 56. 
Carcinoma of larynx 
and upper part of 
i. p. 348. 
Dr. Fowlis’s paper. 
pharynx. 
24 
Caselli. 
1879. 
F., 19. 
Sarcoma of larynx, 
pharynx, tongue, pal- 
Entire larynx and a portion of 
pharynx and cervical glands. 
Becovery. 
operation. 
ate, and tonsils. 
25 
Lange. 
1879. 
M., 74. 
Sarcoma, adenofibroma. 
Thyrotomy. 
Larynx entire and portion of 
C< 
Death in 6 months and 24 
Archives of Laryngology, 
26 
1880. 
M., 48. 
Carcinoma. 
the oesophagus, and one horn of 
the hyoid bone. 
Entire larynx. 
Death on 7th day from 
broncho-pneumonia. 
days; return of disease. 
vol. i., No. 1, p. 30, 1880. 
Dr. Fowlis’s paper. 
Keyher. 
27 
Czerny. 
1880. 
M., 47. 
Epithelioma. 
Larynx and soft parts overlying. 
Becovery. 
turn of disease. 
i« It 
28 
Bircher. 
1880. 
F., 49. 
Carcinoma of the thy- 
roid gland, involving 
Thyroid removed, and 6 months 
later the larynx, with a portion 
Death in 16 days, from 
pneumonia and gan- 
larynx. 
of the oesophagus. 
grene of lung. 
29 
Thiersch. 
1880. 
M., 52. 
Epithelioma. 
Tracheotomy. 
Larynx. 
Becovery. 
Well Feb. 8, 1881. 
Boston Med. and Surg. 
Jour., June 2,1881. 
30 
Thiersch. 
1880. 
F., 40. 
U 
“ 
“ 
« 
Becurrence of disease and 
Boston Med. and Surg. 
31 
Pick. 
1881. 
M., 50. 
Papilloma and epithe- 
lioma. 
Entire larynx. 
Death on 5th day. 
death. 
Jour., June 2, 1881. 
Gaz., 1881, vol. i. p. 415. 
32 
Fowlis. 
1881. 
M., 50. 
Epithelioma, preceded 
by papilloma. 
<C 
Becovery. 
Well in the fall of 1S81; 
Dr. Fowlis’s paper. 
operation was done on 
30th April, 1881. 
33 
Bubio. 
1881. 
Epithelioma. 
Death. 
Siglo Medico, Madrid, 1881, 
vol. xxviii. pp. 101, 119, 
134. 
Dr. Fowlis’s paper. 
34 
Czerny. 
1881. 
M., 47. 
<« * 
Entire larynx and two upper rings 
of the trachea. 
Becovery. 
Well in the fall of 1881; 
Carcinoma. 
operation 12th May same 
year. 
35 
Beyher. 
1881. 
M., 57. 
Entire larynx. 
Death on 5th day, 
broncho-pneumonia. 
«l <4 
Tracheotomy. 
Boston Med. and Surg. 
Jour., June 2,1881. 
36 
Thiersch. 
1881. 
F., 67. 
Epithelioma. 
Larynx. 
Death on 4th day from 
pneumonia. 
Extirpation of the Larynx.—Continued. BRONCHOTOMY. 
75 
Though contemplated by Langenbeck, Heuter, and others, the operation 
of laryngectomy was tirst executed by Patrick Henry Watson, of Edinburgh, 
in 1866. Since those mentioned in the tables, there have been a large number 
of complete laryngectomies, the aggregate number, including those in the 
tables, amounting to 113, with 64 deaths; 36 of the latter are to be credited 
immediately to the operation, and 21 to recurrence of the disease, 1 after 
two years, 1 after eighteen months, and 19 after periods varying from two 
months to nine months. Of the remainder, only 7 have lived sufficiently 
long to be regarded as cured,—in one instance ten years, and in the others 
there having been no recurrence after two or three years. This is a doleful 
showing for excision of the larynx, and will compare badly with the result 
of temporizing resources, such as the use of the trachea-tube and general 
remedies, under which treatment patients may live three years. 
Partial or unilateral excision is a more promising operation. Of 16 such 
excisions, 10 recovered, 3 died, and 3 are undetermined, a death-rate of 23 
per cent. The operators were Fowlis, of Glasgow. Scotland, 1878; Billroth, 
of Berlin, 1878; Gerster, of Hew York, 1880; Reyher, of St. Petersburg, 
1880; Caselli, 1881; Wagner, of New York, Hahn, Schede, Winiwarter, and 
Kiister, 1883 ; and Fowler, of New York, 1888. 
The last-named operator adopted a method suggested by Dr. Cohen, of 
leaving the thyroid cartilage, except a narrow strip anterior, one-eighth of an 
inch in breadth. The diseases for which the operation was done were—car- 
cinoma in 9, sarcoma in 4, enehondroma in 1, stenosis in 1, with 1 undeter- 
mined. 
While the complete extirpation of the larynx for carcinoma may be re- 
garded as a striking proof of the manual skill of the surgeon, and a remark- 
able demonstration of the capacity of the human body to endure mutilation, 
I am for from admitting that it is a triumph of surgery, or even a justifiable 
procedure, except under very peculiar circumstances. Against partial removal 
of the organ, when the disease is limited, there can be no objections. 
Excisions of the Larynx. 
OPENING THE WINDPIPE. 
Bronchotomy. 
The different operations which are employed for the purpose of opening 
the larynx and the trachea are embraced under the general term of bronchot- 
omy. These operations are laryngotomy, tracheotomy, and laryngo-tracheotomy. 
Laryngotomy is divided into thyrotomy, or median laryngotomy, erico- 
thyro-laryngotomy, or inferior laryngotomy, and thyro-hyoid laryngotomy, 
or superior laryngotomy. 
Tracheotomy consists in opening the windpipe below the cricoid cartilage, 
and laryngo-tracheotomy in opening the larynx and the trachea by dividing 
the cricoid cartilage, together with the crico-thyroid membrane and the 
upper rings of the trachea. This operation is usually secondary either to 
tracheotomy or to inferior laryngotomy. 
These operations may be required on account of a foreign body in the 
air-passages; for the relief of dyspnoea arising from obstructive causes, as 
oedema of the glottis; for the removal of pseudo-membranous formations, 
malignant and other growths, either situated in the larynx, or pressing 
against the latter from adjacent parts; and from inflammatory swellings of 
the fauces and larynx, arising from burns, scalds, exanthematous disease, 
and fractures of the larynx. 
Surgical relations of the larynx and trachea.—The larynx and trachea occupy 
the middle line of the neck. In tracing the outline of this region from the 
chin down with the finger, the following topographical points will be observed, 76 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
—namely, the hyoid hone, the thyro-hyoid membrane, the thyroid cartilage, 
the projecting angle of which constitutes so prominent a feature of the neck, 
the crico-thyroid membrane, and the cricoid cartilage, at which point the 
larynx terminates. The trachea commences at the lower border of the 
cricoid cartilage, and as it descends recedes 
from the surface. Immediately above the 
sternum is a deep fossa, bounded on each 
side by the sternal origins of the sterno-cleido- 
mastoid muscles. 
The trachea is covered by the skin, super- 
ficial fascia, deep fascia, and sterno-hyoid and 
sterno-thyroid muscles, and is enveloped in a 
loose sheath of connective tissue. At the root 
of the neck it lies in the angle formed by the 
divergence of the innominate artery on the 
right and the primitive carotid on the left 
side, in front of which vessels, and necessarily 
in front of the trachea, crosses the great 
transverse vein of the left side. As the prim- 
itive carotids ascend the neck in a line run- 
ning from the sterno-clavicular articulation 
to a point between the angle of the lowTer 
jaw and the ear, these vessels become far- 
ther removed from the trachea as they go 
upward. A plexus of veins, the thyroid, lies 
in front of the trachea, and occasionally an 
artery, the middle thyroid, the size of which 
vessel renders it an object of great interest 
when the windpipe is to be opened. 
Passing across the crico-thyroid membrane 
from either side are two arteries (crico- 
thyroids) which are derived from the superior thyroids, and which are 
placed immediately along the under border of the thyroid cartilage and the 
upper border of the cricoid cartilage. By referring to Fig. 1735 the surgical 
relations of the trachea and larynx will be comprehended at a glance. 
Fig. 1735. 
A, trachea; B, innominate artery; C, 
left primitive carotid artery; D, transverse 
vein ; E, thyroid plexus of veins ; F, thyroid 
body; G, crico-tliyroid membrane; H, thy- 
roid cartilage membrane ; I, hyoid bone ; 
J, thyro-hyoid membrane; if, crico-tliyroid 
arteries. 
Thyrotomy, or Median Laryngotomy. 
The patient being placed on a table supine, with the shoulders raised and 
the head thrown hack, in order to make the larynx as prominent as possi- 
ble, the operator, standing on one side, makes an incision exactly in the 
median line, beginning over the thyro-hyoid space, and terminating at the 
top of the cricoid cartilage. By successive touches of the knife the skin and 
superficial and deep fascia are divided and the angle or prominence of the 
thyroid cartilage exposed. This done, the two halves, or the ala? of the car- 
tilage, are to be divided from below upward by a strong knife, observing 
not to deviate from the median line, and, when the case will admit, not 
cutting into the thyroid notch, but leaving the point corresponding to the 
upper junctions of the two halves undivided, thus preserving the attach- 
ments of the vocal cords intact. Should the cartilage be ossified, it may be 
impossible to effect the separation with a bistoury, and under these cir- 
cumstances I have used a pair of cutting pliers not unlike those employed 
in bone operations. A very fine, delicate saw will answer the same purpose, 
and has the advantage of enabling the operator to divide the junction of the 
cartilage its whole length before opening the cavity of the larynx, and thus 
to avoid any premature paroxysms of coughing. 
The disjunction being accomplished, and the mucous membrane divided, 
the two halves of the thyroid can be held asunder by retractors, exposing LARYNGOTOMY. 
77 
very perfectly the interior of the larynx. The operation is a wellnigh 
bloodless one, the upper branch of the crico-thyroid artery being the only 
one which will require to be ligated, and even this vessel often ceases to 
bleed spontaneously. 
The operation is almost always employed for the removal of laryngeal 
tumors which have resisted intra-laryngeal methods of extirpation. When 
the object for which thyrotomy is performed has been accomplished, the two 
cartilages should be brought together and retained in accurate contact by 
interrupted sutures passed through the soft parts, including, if possible, the 
perichondrium. 
History.—Median laryngotomy or thyrotomy was first suggested by De- 
sault, though the operation was not carried into effect until 1833, forty 
years afterward, when it was performed by Brauers, of Louvain. In 1843 
it was repeated by Ehrmann, of Strasburg, and again by Gurdon Buck, of 
New York, in 1851, since which time it has been frequently executed by 
different surgeons in this country and abroad. 
Inferior Laryngotomy. 
In this operation the larynx is opened between the thyroid and cricoid 
cartilages, or through the crico-thyroid membrane. The patient is to be 
placed in the same position as in thyrotomy. An incision, commencing over 
the middle of the thyroid cartilage, is carried down through the integuments, 
exactly in the median line, half an inch below the cricoid cartilage. The 
deep fascia is next divided, and the crico-thyroid membrane exposed between 
the two crico-thyroid muscles. Before dividing the membrane the branches 
of the crico-thyroid arteries, should they continue to bleed, must be secured. 
In a preparation of my own these branches are quite as large as the radial 
artery; this is exceptional, but the possibility of such irregularities teaches 
the importance of carefully examining the parts before opening the larynx. 
The superior thyroid artery sometimes crosses the crico-thyroid membrane. 
A fatal case of hemorrhage from the crico-thyroid vessels is recorded by Sir 
'William Fergusson, which in all probability was due to the abnormal size 
of these arteries. 
After all bleeding is arrested, the crico-thyroid membrane can be divided 
by a transverse or a crucial incision, when the lower portion of the interior 
of the larynx will be opened, the air rushing out of and into the tube during 
expiration and inspiration. If necessary, a flattened canula can now be in- 
troduced into the larynx, and conducted downward into the trachea. 
The operation is a very simple one, and can be done in a few moments by 
even an unpracticed hand : hence its value in cases of threatened suffocation 
from obstruction of the glottis. 
Even when it is desired to keep the orifice open for some time, inferior 
laryngotomy will admit of the canula being worn. Over thyrotomy it has 
the advantage of not interfering with the integrity of the vocal cords. When 
inferior laryngotomy is performed for the extirpation of infra-glottic growths, 
it will be necessary to cut out the crico-thyroid membrane in order to admit 
the mirror, and also the instrument for extraction. 
Inferior laryngotomy was first suggested in 1776, by Vicq d’Azyr, and 
has received the sanction of Fourcroy, Besault, Malgaigne, Holmes, and other 
surgeons. The operation, however, in my judgment, will never supplant 
tracheotomy when it is desirable to wear a canula for some time, as the mo- 
tion of the cricoid in deglutition is calculated to disturb or displace the tube, 
and to cause more irritation than when the latter is worn in the windpipe 
lower down. 
Superior Laryngotomy. 
In this operation it is not the larynx, but the pharynx, which is opened. 
The epiglottis is exposed to view, and access to the top of the larynx is 
gained. 78 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
The operation is done by making an incision transversely, while the 
shoulders are raised and the head extended, along the lower border of the 
hyoid bone, dividing, consecutively, the skin and the superficial and deep 
fascia. The sterno-hyoid muscles being now exposed, they should be raised 
on a director, and the anterior half of each severed from within outward. 
The thyro-hyoid membrane being now divided and the mucous membrane 
opened, the epiglottis will be brought into view. 
The operation has been done for the purpose of extracting morbid growths 
situated at the top of the larynx. 
History.—Superior laryngotomy was suggested by Malgaigne and by 
Vidal de Cassis about the same time. The surgeon who first performed the 
operation was Dr. Prat, of the French naval service. A second operation by 
Follin, in 1863, is, I believe, the only other that has been performed. 
Tracheotomy. 
In this operation the windpipe is opened below the cricoid cartilage in the 
median line. The facility with which tracheotomy can be performed will 
depend much upon the age of the patient and the shape of the neck. In 
persons with short, fat necks the operation is much more difficult than in 
those in whom the contrary conditions of form and bulk exist. In children, 
too, the great mobility of the trachea renders the procedure somewhat more 
difficult. Considering these facts, together with the close relation of the 
trachea to the great blood-vessels, and the size and number of the thyroid 
veins, in some of the conditions for which the operation becomes necessary, 
as, for example, in croup, tracheotomy is an operation which demands sound 
anatomical knowledge and operative skill for its execution. 
The instruments required in tracheotomy are a scalpel for dividing the 
soft parts, a dissecting forceps, a director, a sharp-pointed bistoury for opening 
the trachea, a probe-pointed bistoury for enlarging the opening if necessary, 
a tenaculum for the double purpose of raising vessels and of fixing the wind- 
pipe while being incised, a dilator, retractors, several canulae with pilots to 
guide them into the trachea, and a camel’s-hair brush, with which to keep 
the canula free from secretions, together with sponges, ligatures, and 
needles. 
The canula or tube should be double, and constructed of silver (Fig. 
1736), the external cylinder being the fixed or permanent one, and the in- 
ternal one movable, so as 
to admit of its being re- 
moved, cleansed, and re- 
placed. The shoulders of 
the permanent cylinder 
are supplied with eyelets 
for the attachment of 
tapes designed to keep 
the tube in place. 
The size of the canula 
will be determined by 
the age of the patient. 
Numerous measurements 
have been made to ascer- 
tain the relation existing 
between the lumen of the 
trachea and the age of its 
possessor. These observa- 
tions justify the use of a tube a quarter of an inch in diameter in children 
under four years of age; and in those from four to twelve years of age, of 
tubes varying from one-third to two-fifths of an inch. Adults require a tube 
three-fifths of an inch in diameter. 
Fig.1736. 
Tracheal Canute. TRACHEOTOMY. 
79 
In order to facilitate the introduction of the canula into the tracheal 
incision, a pilot can be passed through its canal (Fig. 1737), or, what will an- 
swer equally well, a gum catheter, the 
Eoint of which projects a short distance 
eyond the extremity of the canula. 
Unless some device of this kind is used, 
the end of the tube will be likely to 
strike against the sides of the trachea 
and prevent the introduction. 
Operation.—The operation of tra- 
cheotomy consists of three stages, 
—namely, uncovering the trachea, 
opening the trachea, and introducing 
the tube. 
Is? stage.—The patient should be 
placed on the back on a narrow table, 
in the position described for laryngotomy, with the shoulders raised on a firm 
pillow, and the head extended, in order to increase the length of the neck 
and to render the anatomical features of the larynx as prominent as possible. 
In the case of a child it will sometimes be found advantageous to pinion the 
arms to the sides by surrounding the body with a towel and securing its 
ends with a number of pins. 
The surgeon, standing on one side, and facing the patient, makes an incision 
in the middle line of the neck through the skin, commencing over the cricoid 
cartilage, and terminating a quarter or three-eighths of an inch above the 
top of the sternum. A few gentle touches with the scalpel will suffice to 
divide the superficial fascia. This layer is sometimes raised on the director 
previous to being incised. After the division of the superficial fascia the 
deep fascia will be exposed. The separation of this and of the two pairs of 
muscles—the sterno-hyoid and the sterno-thyroid—which the fascia unite 
should be effected as much as possible by the director or the handle of the 
scalpel, and should be carried to the same extent as the incision through the 
skin. By observing this rule, emphysema of the cellular tissue of the neck 
will be avoided. 
At this stage of the operation the thyroid veins will probably be exposed, 
and must be pushed aside; or, if this cannot be done, and the trunks are 
numerous, they may be raised in a mass with the forceps, and surrounded 
by a ligature. Single veins should be tied in two places and divided between 
the ligatures, a precaution necessary to prevent the entrance of air. 
Search should also be made for the middle thyroid artery, which is fre- 
quently present, resting on the anterior face of the trachea, the ligature of 
which, in the event of its being found, must be made before proceeding fur- 
ther. In a case which I recorded some years ago, the innominate artery 
passed up in front of the trachea some distance before inclining to the right 
side. 
The next step consists in breaking up, with the end of the director, the 
layer of cellulo-adipose tissue (tracheal fascia).which loosely envelops the 
trachea. This constitutes an important part of the operation, as only by 
effectually clearing the windpipe of this connective tissue can the tube be 
introduced with certainty. 
From the commencement of the operation an assistant must keep the 
wound clear of blood by the frequent use of sponge mops. 
2d stage.—The denudation of the trachea having been completed and all 
bleeding controlled, the next step is to open the cavity of the tube. In 
order to raise and at the same time to steady the trachea, the surgeon, 
while the sides of the wound are held asunder by retractors, hooks into 
the lower border of the cricoid cartilage a tenaculum. Holding it firmly so 
as to prevent any deflection, he pushes the sharp-pointed bistoury into the 
tube, with its back towards the sternum, and, cutting upward, divides 
Fig. 1737. 
Tube with pilot. 80 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
three rings of the trachea, making an opening about three-quarters of an 
inch in length. (Fig. 1738.) The incision should include the second, 
third, and fourth rings, being prefer- 
able to one made lower down in the 
tube. Care must be taken to enter 
the knife obliquely upward, and not 
to thrust it too far in, for fear of 
wounding the posterior wall of the 
tube. 
The opening of the trachea in cases 
where the latter is deeply situated is 
often facilitated by an assistant keeping 
the sides of the external wound widely 
asunder with retractors whilst the in- 
cision is made. 
Erichsen has found a sickle-shaped 
knife sometimes useful for opening the 
trachea, the hooked form of the instru- 
ment helping to keep the tube raised 
and steady while it was being incised. 
The opening of the trachea is an- 
nounced by the rush of air from the 
wound, accompanied by a convulsive 
cough and the expulsion of frothy 
mucus. 
3d stage.—The last stage consists in 
introducing the tube, in doing which, 
without relaxing his hold of the tenaculum, the surgeon, immediately on 
opening the trachea, lays aside the knife, and, taking the canula with its pilot, 
conducts it through the incision into the tube, after which the guide is with- 
drawn and the tenaculum detached. 
Various ingenious contrivances have at different times been devised to 
secure facility and certainty in the introduction of the canula. For this 
purpose dilators are occasionally employed, composed of two or three blades 
(Figs. 1739, 1740), which, being introduced, closed, through the incision in 
Fig.1738. 
Trachea fixed with the tenaculum preparatory to 
being opened with the bistoury. 
Fig. 1739. 
Fig. 1740. 
Two-bladed dilator. 
Three-bladed dilator. 
the trachea, are then separated, offering a dilated orifice for the reception of 
the tube. 
With the same ends in view, guides or trocars have been passed through 
the canula. Thus, we have the fenestrated trocar of Pean and the vertebrated 
one of Durham. These have no special advantages over tho plain, conical 
pilot of Gairdner, or the simple gum catheter. 
To prevent the tube from becoming displaced, the tapes which are attached 
to its shoulders are passed round the neck and tied. (Fig. 1741.) The 
tube, after being introduced into the trachea, for a time excites consider- 
able cough, which, however, subsides as the parts become accustomed to its 
presenco. Should the tenaculum become detached, or if it is held by an 
assistant, the operator will facilitate the introduction of the canula by using TRACHEOTOMY. 
81 
the tip of his index finger as a guide, passed into the lower angle of the 
wound in the trachea. The soft parts above and below the canula may next 
be brought together by a single stitch, when the 
operation will be completed. A fine piece of 
moistened gauze may now be laid over the open- 
ing of the tube, with a view to prevent foreign 
substances floating in the air from being drawn 
into the air-passages. 
Such are the steps of tracheotomy as done 
under ordinary circumstances. There are, how- 
ever, emergencies, when a patient is in imme- 
diate danger of perishing from suffocation, in 
which it is necessary that an opening be made 
into the windpipe in an instantaneous and in- 
formal manner. In such an event it may be 
necessary to lay open the superincumbent tissues 
by one or two rapid incisions, and immediately 
open the trachea without reference to bleeding. 
In a case requiring such prompt and decided 
action, and where the physician has had little 
operative experience, it will be more prudent to 
perform crico-thyroid or inferior laryngotomy. 
A rapid and comparatively safe exposure of the windpipe in cases of emer- 
gency can be made by adopting the method proposed by Durham, which 
consists in fixing the trachea between the thumb and index finger of one 
hand, thrust forcibly into the neck, while with the other hand the surgeon 
divides the superincumbent tissues in the median line, made tense by pressure. 
As the latter are being cut through, the wound gapes, and the trachea is 
made to approach the surface. Any vessel of importance can be felt with 
the finger introduced into the wound, and when, in this manner, the wind- 
pipe is denuded, it can be laid open before releasing it from the grasp of the 
fingers, and the tube introduced. 
The operation which consists in puncturing the soft parts and the trachea 
and laying both open at a single incision is a dangerous practice. All such 
stabs in the dark are reprehensible. 
The form of the opening into the trachea is regarded by some surgeons as a 
matter of importance. Some make a plain, straight incision, and of course 
a linear wound. Some prefer to excise an oval piece from the front of the 
tube, while others, as the late Professor Brainard, raise a crescent-shaped 
flap from the trachea by first passing a thread (a silver wire would be 
better) around one or two rings of the tube, and, after making a semi- 
elliptical incision through its wall, draw, by the thread, the divided portion 
back, as in opening the lid of a box. By this plan no tube is required. 
It may be necessary to dispense altogether with the canula, especially in 
cases of foreign bodies which do not promptly appear at the wound, and in 
such instances the orifice in the trachea 
can be maintained patulous by hooks 
inserted one on each side and secured 
by tapes passed round the neck. (Fig. 
1742.) 
Complications and difficulties. Hemor- 
rhage.—The operation of tracheotomy 
may be interrupted for a time by hem- 
orrhage. This may be either venous 
or arterial. As a rule, the windpipe 
should not be opened until the flow of 
blood is arrested. When the bleeding comes from an artery, as can gen- 
erally bo determined by the color of the blood and the manner in which it 
issues from the vessel, the wounded branch must be promptly tied. In croup, 
Fig. 1741. 
Tube introduced and secured by tapes. 
Fig. 1742. 
GEMRIG Br SOM 
Retractors. 82 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
in consequence of the great difficulty of dilating the chest, the veins of the 
neck become very much engorged, and consequently, when they are cut, the 
blood wells up profusely from the bottom of the wound. This kind of hemor- 
rhage is most promptly arrested by opening the trachea and introducing the 
canula, as the vessels are immediately unloaded by one or two full or easy 
inspirations. 
Free oozing can bo controlled by applying to the surface of the wound a 
piece of linen wrung out in water as hot as can be borne by the hand. Sec- 
ondary hemorrhage is uncommon, but, should it occur, the vessels must be 
searched for and tied. While the occasional occurrence of profuse bleeding 
in tracheotomy is admitted, the danger from this source is certainly not 
great. 
Misplaced canula.—This is no uncommon occurrence. The tube, instead 
of entering the trachea, passes between the latter and the loose connective 
tissue with which it is invested. The mistake can be readily detected by the 
mobility of the canula and the fact that no air passes through its canal. 
The respiration will also continue to be embarrassed. This failure is some- 
times attributable to the incision in the trachea being too small, sometimes 
to the oblique and ragged manner in which it is made, and often to the neg- 
lect of a very important part of the operation, that of denuding sufficiently 
the anterior wall of the windpipe. If due to the tracheal opening being too 
restricted, the error must be corrected by again fixing the tenaculum into 
the cricoid or into the upper ring of the trachea, and prolonging the incision 
upward, by means of the blunt-pointed bistoury, until it has been sufficiently 
enlarged to remedy the evil. If the incision in the trachea has deviated from 
the middle line, and inflicted a wound oblique to the longitudinal axis of the 
air-tube, it will be best to excise with the scissors a semi-elliptical piece from 
one side of the opening. If the error is referable to imperfect exposure of 
the trachea, the director must again be used to overcome the difficulty. 
Enlarged Isthmus of the Thyroid Gland.—The isthmus of the thyroid body 
may be enlarged so as to cover several of the upper rings of the trachea. 
When only encroaching slightly on that part of the windpipe to be incised, 
it may be detached and pushed up with the handle of the scalpel sufficiently 
far to admit of the required opening to be made for the canula. When, 
however, these limits are exceeded, the isthmus must be secured on each 
side and divided between the ligatures. This can be done without difficulty 
by passing a thread between the isthmus and the trachea. 
Suffocation.—During the progress of a tracheotomy, the air-passages may 
become so clogged with secretions or fragments of membrane that inspira- 
tion ceases, and death seems unavoidable. In such an event, the surgeon 
must act with great promptitude. The trachea, if not opened, should be 
immediately incised, and, if the breathing is not at once established, artificial 
respiration must be employed by introducing a catheter into the windpipe 
and alternately blowing air into the lungs and compressing the sides of the 
thorax for its expulsion, thus imitating the natural respiratory movements 
of the chest. 
Should these efforts at resuscitation not succeed after a few moments’ 
trial, the trachea must be unloaded by aspiration; and usually there is no 
resource left to the surgeon in such a strait but to apply his mouth to the 
catheter or to the wound, as was done with success on one occasion by Roux 
and on another by Erichsen, and thus dislodge the blood, mucus, and pus by 
suction. After this, should the patient not quickly revive, recourse must be 
had to artificial respiration, assisted, in unpromising cases, by faradism. 
Displacement of the Thymus Gland.—When the cellular tissue is broken away 
too far down, or at the lower part of the supra-sternal fossa, the thymus body 
will sometimes rise into the neck, overlap the trachea, and be in the way of 
the knife. This protrusion of the gland must be overcome by the pressure 
of a finger or a retractor in order to allow the operation to proceed safely. 
Emphysema.—The escape of air into the cellular tissue of the neck is due LA R YNG 0- Til A CHEO TO MY. 
83 
either to a want of correspondence between the openings in the trachea and 
in the soft parts, or to the improper manner in which the opening has been 
made, being on one side instead of the middle of the windpipe. The evil is 
not a serious one, and generally subsides spontaneously as the tissues become 
sealed together with lymph; but should it not do so, it will be necessary 
to draw one side of the external wound into line with the tracheal opening, 
and keep it in this position by adhesive strips until the difficulty is over- 
come. 
Cellulitis.—When the connective tissue has been rudely and extensively 
torn in exposing the trachea, a diffuse inflammation may spread through the 
neck. The local application of lead-water and laudanum, and free drainage, 
are proper means for controlling the disease. 
Erysipelas and diphtheria may also attack the tracheal wound, and must be 
treated on principles applicable to these affections when arising from other 
causes. 
Pneumonia has not unfrequently followed tracheotomy. It is a serious 
complication, and demands the same remedies as when the disease is idio- 
pathic. 
There are other evils following tracheotomy which appear at a much later 
period than those already considered, and which arc referable to the prolonged 
use of tho canula, as redundant granulations, stenosis, and fistula. 
Granulations.—These sometimes not only surround the canula, but project 
into the trachea, causing obstruction and difficult breathing. They require 
to be destroyed by caustics. 
Stenosis, if progressive, should be treated by dilatation. 
Fistula.—A canula being worn for a considerable time is liable, when re- 
moved, to bo followed by a fistula, which will prove very difficult to manage. 
When the opening is small, and the integument around it soft and movable, 
the simple operation of paring the edges of the fistula and bringing them 
together by sutures, and applying a compress secured by adhesive plaster, 
can be tried. The air, however, is liable to get between the soft parts and 
the trachea and infiltrate the cellular tissue, giving rise to emphysema and 
defeating union. 
The operation which has succeeded in my hands is the following. The 
edges of the fistula are first freshened, after which a flap of integument is 
raised from below sufficiently long to admit of being reverted on itself, and 
pressed into the abnormal opening in such a manner as to present the skin 
surface towards the cavity of the trachea, and the raw one towards the sur- 
face of the neck. After thus adjusting this fleshy obturator, it is fixed in 
position by passing two fine pins through the flap and the margins of the 
wound and keeping them together by the twisted suture. 
After-Treatment.—Generally, after the operation of tracheotomy is com- 
pleted and the tube introduced, the relief is so great that the patient falls into 
a quiet sleep, which may continue for two or three hours. This is the best 
restorer of exhausted nature, and should not be interrupted. A well-instructed 
nurse should be constantly at the bedside, watching the canula and keeping 
its canal free, with the brush, from any accumulations of mucus or other 
secretions. The room must be kept at a temperature of not less than 75°. 
As soon as the patient awakes, a cup of beef-essence or milk should be ad- 
ministered, and, if there exist any signs of collapse, a little brandy or whisky 
may be given. 
Laryngo-Tracheotomy. 
This is an operation not often performed. As the name implies, both the 
larynx and the trachea are opened. It may be effected in two ways,—either 
by prolonging the incision of tracheotomy upward through the cricoid car- 
tilage and into the crico-thyroid membrane, or by making a similar division 
of the cricoid cartilage from above downward, after having performed inferior 
laryngotomy. 84 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
In order to avoid the danger from hemorrhage, Amussat employed in 1870 
the galvano-cautery knife for opening the trachea, and this plan has been 
repeated a number of times by Yerneuil, Krishaber, Voltolini, Bruns, and 
other surgeons. Poinsot, of Bordeaux, in one case performed tracheotomy 
with the thermo-cautery knife of Paquelin. 
The dangers which are said to be thus avoided are of too rare occurrence 
to justify the adoption of these methods. A deep burn in the neck would 
jeopardize the life of the patient more than the evil which it is contemplated 
to prevent. 
History.—Tracheotomy, as may be learned from Galen, is a very ancient 
operation, dating back to a period long anterior to the Christian era. It has 
been carefully studied by Sprengel and by Mackenzie, from whom we learn 
that Asclepiades, of Bithynia, was the first to perform the operation. Under 
the impression that wounds of the cartilages do not heal, tracheotomy was 
condemned by Aretieus in the first century ; and the same opinion was enter- 
tained three centuries later by Coelius Aurelianus. Reference is frequently 
made to the operation in the writings of both Greek and Roman physicians 
until the period when letters were extinguished in the Dark Ages. The first 
name connected with tracheotomy after the revival of learning, in the four- 
teenth century, was that of Gui de Chauliac; and the operation was prac- 
ticed by Antonio Benivieni, a Florentine surgeon, in the sixteenth century. 
The canula appears to have been introduced first by Sanctorius, in the latter 
part of the same century. The addition of wings to render the tube more 
secure was made by Fabricius ab Acquapendente. The idea of changing 
the canula from a straight to a curved tube originated Avith Casserius. 
The double canula was devised by George Martin in the latter half of the 
eighteenth century. 
The favor with which tracheotomy has been received by the profession in 
this country, in Great Britain, and on the continent of Europe, is chiefly duo 
to the advocacy of the operation by Trousseau. 
Bronchotomy by Electro- and Thermo-Cautery. 
Suspended Animation. 
The terms asphyxia and apnoea have been employed to designate a con- 
dition of the body which results from imperfect arterialization of the blood. 
As the conversion of venous into arterial blood is effected in the lungs, it is 
through the medium of these organs that the agencies which suspend or de- 
stroy life operate. 
The term apnoea, from the Greek privative particle a, and “to breathe,” 
being properly restricted to the mechanical act of breathing, is too limited in 
its signification, the ulterior cause of death being often independent of the 
breathing. The term asphyxia, from a privative, and “I beat,” is 
open to still stronger objections, as it makes the cessation of the heart’s 
action the essential phenomenon of the condition under consideration, than 
which nothing can be further from the truth. As these terms, however, 
are generally understood in their applications, it is better to tolerate an 
etymological inaccuracy than to insist on any change likely to introduce 
confusion into the subject. Of the two, apnoea is the preferable term. To 
cease to breathe is to cease to live. The connection between the breath and 
the life is most intimate. “Breathed into his nostrils the breath of life, and 
man became a living soul,” was the Divine order. Apnoea, or suspended 
animation, results either from the absence in the blood of the oxygen of the 
air or from the respired air containing irrespirable or toxic gases, either 
condition being inimical to those chemico-vital interchanges of matter which 
normally take place in the elementary or cell forms of the tissues. While 
the essential cause, therefore, of apnoea is a chemical one, the affection may 
be produced in various ways. S USPENDED A NIMA TION. 
85 
It can be induced mechanically by both external and internal agencies. 
The external causes are hanging, grasping the neck with the hands, throt- 
tling,—or garroting,—holding over the mouth and nose some material imper- 
vious to air, as a feather pillow,—smothering,—or plugging the same cavities 
so as to exclude the atmosphere. The same effect may follow forcible com- 
pression of the chest-walls, either by falling timbers, by the caving in of sand- 
banks, or by being wedged in the midst of a panic-struck crowd of human 
beings. Traumatic causes are also to be included under this head, as frac- 
ture of the cervical vertebrae, injuring the medulla spinalis above the origin 
of the phrenic nerves, thus paralyzing the muscles of respiration; or a large 
penetrating wrnund of the chest may be followed by collapse of the lungs, 
the external pressure of the air predominating over that within the pulmo- 
nary organs. 
Morbid growths in the neck, as aneurism, enlargement of the thyroid 
glands, and other tumors, are capable of exerting a degree of pressure on 
the trachea which will prevent the entrance of air into the lungs. 
The internal causes are foreign bodies in the air-passages or in the oesoph- 
agus, supra- or infra-glottic tumors, false membranes in the larynx or trachea, 
oedema of the glottis, and spasm of the vocal cords. Drowning may also be 
enumerated among tbe mechanical causes of apnoea, as the liquid in which 
the body is immersed is not only unfavorable to the passage of air to the 
lungs, but also, by entering the air-passages, displaces that which may be 
present. 
Apnoea may also result from the inhalation of toxic gases. 
Symptoms.—Any one who will hold his breath for a short time will soon 
begin to experience a sense of uneasiness and fullness about the chest, which 
finally culminates in an irresistible desire to breathe, the succeeding respi- 
ratory movements being at first shallow and rapid, but gradually becoming 
deeper and less frequent, until at length the equilibrium is established, and 
the normal standard of sixteen or eighteen respirations per minute is attained. 
Accompanying this period of disturbed breathing there are experienced a 
sense of giddiness, indistinctness of vision, noise in the ears, and diminished 
sensibility to physical pain. 
When the impediment to the introduction of air is great and prolonged, 
the countenance becomes anxious, the veins of the temple, face, and neck 
turgid, the eyes prominent, the lips blue, and the face dark and dusky. 
Frothy mucus, occasionally tinged with blood, appears about the mouth, and 
as the suffocation deepens, and unconsciousness approaches, relaxation of the 
sphincters occurs, accompanied by the involuntary expulsion of the urine and 
fscces, and probably by erections and seminal emissions. The pulse, at first 
somewhat accelerated by the muscular struggles of the patient, soon becomes 
small, slow, and feeble, and finally disappears at the wrist. The circulation 
usually continues for three or four minutes after the respiration has ceased. 
Post-Mortem Appearances.—The appearances presented by persons who 
perish from apnoea differ according to the determining cause and also ac- 
cording to the time when the autopsy is made. -When the examination has 
been long delayed, many of the characteristic signs will be entirely lost. 
Generally speaking, when made early, the lips are found to be tumid and 
blue, the face pale, and the tongue swollen, livid, and sometimes bearing the 
evidence of having been wounded by the teeth. A blood-stained, frothy 
mucus is also seen about the mouth. 
Often, when death has been caused by external violence, as by throttling 
or by hanging, the marks of the hand or of the cord will be noticed, occasion- 
ing scratches, abrasions, or discolorations. The hyoid bone and the car- 
tilages of the larynx are also sometimes discovered to be bi’oken. Too much 
importance must not be attached to the traces of cord-marks on the neck, 
as, unless the constriction is very great and the violence considerable, as 
when the body falls some distance in hanging, no abrasion or discoloration 
may occur. This will be eminently true when the suspension is of short 86 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
duration, as when a body is cut down immediately after the extinction of 
life. 
There is a discoloration which is purely a post-mortem change, as has been 
shown by Harley, and which can be produced by suspending a body for half 
an hour by the neck with a rope shortly after death. The discoloration will 
remain permanent. This fact, in a medico-legal point of view, is one of some 
importance. 
The rigor mortis after drowning is not long delayed, and is hastened when 
the temperature of the medium in which immersion has occurred is low. 
The drowned are often taken from the water holding in the grasp some 
object which was seized in the act of sinking, and which can be detached from 
the hand only at the expense of considerable force in straightening the 
fingers. 
The vessels of the brain, generally described as being engorged with blood, 
are, according to Ackerman, comparatively empty, the engorgement being 
a post-mortem condition, and witnessed only when the head has been allowed 
to remain lower than the remaining part of the body after death. The pupils 
also are dilated, and the eyelids remain partly open. 
Heart and large blood-vessels.—The right side of the heart and its great 
vessels are filled with venous blood, while the left side is comparatively 
empty, as is also the arterial system of blood-vessels. All the abdominal 
viscera are engorged with venous blood. Where death has followed the 
inhalation of certain toxic gases, the effect on the color of the tissues is 
remarkable, sulphuretted hydrogen imparting a dark or black color, and 
carbonic oxide a scarlet, red, or vermilion hue. 
When from any mechanical obstruction the air is prevented from entering 
the lungs, respiration must necessarily cease, and the patient perishes from 
uncomplicated apneea. It has been shown by experiments on animals that 
the action of the heart continues from two to four minutes after the respira- 
tion ceases, or after all air is cut off from the lungs. It is, therefore, within 
the bounds of possibility that an animal may be recovered by the use of 
proper measures four minutes after it has ceased to breathe. When the 
heart ceases to beat, all hopes of resuscitation are vain. 
In many instances of death following mechanical obstniction, the event 
is due more to the accompanying violence than to the exclusion of air. This 
is constantly demonstrated in the public execution of criminals, whose necks 
are often broken and the spinal marrow lacerated by the fall from the drop; 
also in the case of persons who are buried under the ruins of a falling build- 
ing or sand-bank, and who perish not alone on account of the exclusion of 
air, but also from the effects of contusions. 
Death occurs in a much shorter time in drowning than when it follows the 
simple mechanical exclusion of air. This difference of time, which amounts 
to about one-half, is referred to the presence of water in the air-passages. 
The experiments performed by the committee of the Royal Medical and 
Chirurgical Society place this beyond a doubt. Animals which, before being 
immersed, had the windpipe plugged recovered after being under the water 
four minutes, while those submerged only two minutes without such pre- 
caution died. In the latter, one minute and a quarter was the longest 
period at which resuscitation was possible. 
In drowning, the air-passages are filled with frothy mucus mixed with 
water, and the air at the same time is expelled. Nor is the water confined to 
the air-tubes: it penetrates into the pai’encliyma of the pulmonary tissue, 
and even into the blood. How long a person can remain under water and 
yet recover after removal will depend on the completeness of the immersion, 
the temperature of the water, and the condition of the body at the time. 
When the immersion is complete, resuscitation is exceedingly uncertain after 
the lapse of two minutes, and perhaps impossible after the lapse of four 
minutes. Those cases which are related of persons having been resuscitated 
after remaining in the water fifteen minutes can be explained only by sup- SUSPENDED ANIMATION. 
87 
posing that they have risen several times to the surface, and thus have been 
enabled to expel the water and take in fresh air. 
During the winter season, when both the air and the water are cold, 
drowning will take place more quickly than in the summer, when the tem- 
perature is higher, in consequence of the rapid reduction of the animal heat 
and the benumbing influence of the cold disqualifying the person from putting 
forth those energetic efforts which would otherwise, by carrying the body to 
the surface, secure a new supply of air. 
On the other hand, wThen the water is hot, the extinction of life is hastened 
by the accelerated action of the heart and a more rapid waste of tissue. A 
person falling into the water in a state of syncope does not drown so quickly 
as one in the full possession of his consciousness, who exhausts his vitality 
in violent struggles and accelerates the metamorphosis of tissue. 
Apncea due to the influence of toxic gases, or of those in which carbonic 
oxide exists in large proportion, is produced by the displacement of the 
oxygen of the blood in consequence of the carbonic oxide uniting with its 
coloring-matter and thus rendering the sanguine fluid unfit for the supply 
of the nerve-centres, or for the molecular changes essential to the life of the 
tissues. Poisoning from this source is generally accidental, though it is said 
that in France suicide is very frequently committed by exposure to carbonic 
oxide gas. 
Treatment.—In adopting measures for the resuscitation of cases of sus- 
pended animation, though there will be some difference in the details of man- 
agement applicable to different eases, yet in the main there is one principle 
applicable to all,—namely, to establish at the earliest possible moment the 
function of respiration. If suicide has been attempted by hanging, the body 
must be immediately cut down and the cord detached from the neck. If a 
laborer is buried under a bank of sand or the debris of a falling building, 
efforts should first be made to open a way for the admission of air to the 
imprisoned victim, and afterwards directed to the removal of the rubbish 
which confines the body. In extricating bodies under such circumstances, 
there should always be some cool head to direct operations, for often life 
is sacrificed by the aimless and confused manner in which a number of 
persons, in their anxiety to rescue a comrade, interfere with one another. 
If the apncea is from immersion, the body should be taken from the water, 
and, after clearing the mouth, nose, and throat of all accumulations, car- 
ried with the face downwai’d, in order to favor the escape of liquids. When 
the apncea results from the toxic effect of deleterious gases, it is impera- 
tive that the person be first removed beyond the influence of the delete- 
rious agents; and, as the party who attempts the rescue is also exposed to 
the danger, the precaution should be observed to take a full inspiration 
of fresh air before entering the infected atmosphere, and to hold the breath 
until again beyond the poisonous influence of the gas. These immediate 
indications having been met, every article of clothing about the neck or 
thorax which can in any way restrict the movements of the chest or offer 
an obstacle to the entrance of air into the lungs must be removed. The 
attempt to remove the body any distance to a house or other shelter, unless 
close at hand, should the patient be in the open air, and before employing the 
means of resuscitation, is not to be thought of. I have, however, when the 
weather was inclement, in the case of the drowned, placed the body in a 
wagon and employed the means of resuscitation during the transportation. 
Wherever these may bo applied, particular attention must be given to secure 
a free access of air to the patient. These preliminaries being perfected, 
requiring only a few moments for their execution, the next step is to com- 
mence artificial respiration. This is accomplished in various ways. 
Mouth-inflation of the lungs.—There are emergencies in which the only 
resource left to the physician is to apply his mouth to that of the patient 
and blow into it the air from his own lungs. In several instances infants 
have been revived by this method under the most hopeless circumstances. 88 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
It is necessary, in this kind of respiration, to press the larynx firmly back 
towards the spinal column, in order to prevent the air from entering the 
oesophagus. This method can be modified so as to be less repugnant to the 
senses by introducing a metal or gum catheter into the trachea and inflating 
the lungs by blowing through the tube. By either plan the air forced into 
the lungs is loaded with carbonic acid, and, consequently, is not well suited 
for the purpose of respiration. 
Bellows-inflation. — An ordinary house-bellows may also be made avail- 
able for the purpose of artificial respiration. The nozzle is introduced into 
one nostril while the other is closed, and air is slowly forced into the lungs 
while the larynx is pressed back against the oesophagus. 
Manual pressure.—The natural movements of respiration can be imitated 
by placing the body on the back, and, with one hand on the sternum and the 
other over the abdomen, making alternate pressure. These movements, con- 
joined with the elasticity of the walls of the thorax, by which the latter, 
after being compressed, undergo spontaneous expansion, imitate those of 
natural respiration. 
There are three ways in which artificial respiration can be carried on 
under this plan, any one of which possesses advantages over all more 
complicated plans. They are the Marshall Ilall, Silvester, and Howard 
methods. 
Marshall Hall's method consists in placing the patient on the face and 
breast, with his right arm flexed under the side of the head, and so supported 
by an assistant as to keep the mouth free. This posture favors the escape of 
fluids from the windpipe, and also tends to keep the tongue forward. Should 
there be no breathing, let a hand be placed on the shoulder and the pelvis, 
and draw the body from the prone to the lateral position, or that on the side. 
If there is still no respiratory response, turn the patient to the original po- 
sition on the breast, roll a coat or other garment into a cylinder, place it 
under the lower extremity of the sternum, and again turn the body, quietly 
but fully, on the side, then roll it back on the face, where it is allowed to 
remain for two or three seconds, after which the same movements are re- 
peated, and in the same order, making in each minute about fifteen such 
semi-rotations of the trunk. As the body is rolled on the side, the thorax is 
relieved of pressure and expands, drawing air into the lungs, as in inspira- 
tion ; and when it is turned upon the breast, the walls of the chest are 
compressed, and the inspired air is expelled, as in expiration. 
Though this method has been practiced in many instances with success, 
it is not free from objections. For instance, the first position is that on 
the face and breast, which, though favorable to the escape of collections in 
the air-passages, is one producing expiration, and thus emptying the lungs of 
what little air they may contain. It has also been shown by the experi- 
ments of the committee of the Royal Medical and Chirurgical Society that 
by this method only a very small amount of air is exchanged by the two 
movements, never at any time over fifteen cubic inches. 
Silvester's method.—The plan formulated by Dr. Silvester has the advan- 
tage of being more in physiological harmony with the function of respira- 
tion than that of Marshall Hall, and is capable of exchanging from thirty to 
even fifty cubic inches of air at each respiratory movement. 
In carrying into effect the Silvester plan, the body is laid on the back, 
and a roll of clothing is placed under the chest. The physician, standing at 
the head of the patient, grasps his arms at the elbows and draws them up- 
ward on each side of the head until they almost touch each other. In this 
movement the walls of the chest are raised and expanded through the pec- 
toral muscles, and the air inspired. Retaining the extremities for two or 
three seconds in this state of traction, they are next brought downward and 
returned to the sides of the body, against which they are to be firmly pressed 
for two or three seconds (Figs. 1742, 1743), thus imitating expiration by di- 
minishing the diameters of the chest. These movements should be made S US PEND ED A NIMA TION. 
89 
with the same frequency as those practiced in the Marshall Hall plan,- 
about fifteen to the minute, or the same as in healthy respiration. 
Fig. 1743. 
Silvester plan of imitating respiration. 
Fig. 1744. 
Silvester plan of imitating respiration. 
Howard's method.—By this plan the patient is laid on his breast, with a 
roll of clothing under the chest and the upper part of the abdomen. While 
in this posture, forcible pressure is made on the back, in order to expel the 
water from the air-passages, after which the body is turned over upon the 
hack, with the roll beneath, and while the arms are carried up above the 
head, and by an assistant retained as in the Silvester method, the phj'sician 
keeps up the two movements of respiration by compressing, with his hands, 90 
SURGICAL DISEASES OF THE LARYNX AND TRACHEA. 
the walls of the chest, and again suddenly releasing them from his grasp, 
while artificial respiration is being practiced. 
There are other exciters of respiration, which must not bo neglected, as 
the application of volatile substances to the nares, dashing the surface of the 
chest with either hot or cold water, flagellation, and, in order to stimulate 
the circulation and maintain the temperature, the use of active frictions to 
the limbs with the hands or pieces of flannel, always rubbing from below 
upward, thus favoring the movement of the venous blood towards the heart. 
Warm, stimulating enemata of brandy and coffee occasionally thrown into 
the rectum are extremely serviceable. 
As there is frequently in the apnoea resulting from partial drowning or 
from strangulation great congestion of the right heart with its cavae, the 
cautious abstraction of a little blood from the jugular vein will serve to 
relieve the heart from over-distention and favor its contraction. 
The length of time during which it is proper to continue artificial respi- 
ration must be determined by circumstances. As soon as the natural respi- 
ratory movements are established, all others should be discontinued. The 
earliest signs of returning animation are a slight guttural groan, muscular 
twitchings, improved temperature, and the reappearance of color in the lips 
and cheeks. Should, however, none of these signs appear, it will not be 
proper to give over all efforts at resuscitation. They should be continued 
for four or five hours. Douglas gives an instance in which life was restored 
after eight hours’ persistent efforts. When, however, the eyelids are open, 
the eyes devoid of all expression and insensible to the touch, with the pupils 
widely dilated, and the surface of the body cold, accompanied by that serene 
countenance in which all wrinkles and lines of the face are smoothed out, 
with no respiratory movements of the chest, and no pulse felt at the wrist, 
and no beat of the heart discoverable by the ear,—when such a ghastly pic- 
ture is presented, there is no power which can call back the vital principle 
save that which first gave it existence. 
When respiration is established, the patient must be placed in bed with 
bottles of hot water rolled up in flannel and laid along the spine and to the 
extremities. Some warm coffee, beef-tea, or milk with a little brandy may 
be administered from time to time. 
Apnoea following oedema of the glottis, and membranous or other obstruc- 
tions of the windpipe, may demand laryngotomy or tracheotomy; and when 
produced by the arrest of some substance in the oesophagus, one or other of 
these operations may be required in the event of the gullet-forceps or the 
probang failing to clear the passage. 
A patient may be apparently entirely restored, and yet in the course of 
twenty-four or even twelve hours be seized by secondary apnoea: hence 
the necessity in all these cases of careful watching for several days. This 
condition bears some resemblance to secondary shock or collapse, and is 
probably to be attributed to defective nutrition of those nerve-centres which 
energize the lungs and heart, and which onty partly recover from the effects 
of carbonic acid or other gaseous poisoning. Should signs of returning 
apnoea make their appearance, they must be counteracted by the same meas- 
ures as were employed in the first instance. 
Precautions.—Apnoea may follow the presence of a foreign body in the 
larynx or trachea, or the impaction of a mass of aliment in the oesophagus; 
and whenever the practitioner is called to a case of this kind in which 
the cause is not known, he should at once explore the glottis and the 
pharynx with a finger. There is a preparation in the museum of the Uni- 
versity of Pennsylvania, taken from a patient who died suddenly, in which 
a large piece of meat is firmly wedged in the top of the oesophagus, the 
presence of which was probably never suspected until discovered by an 
autopsy. Harley mentions an instance in which a physician was misled in 
a case of apnoea resulting from an attempt to commit suicide by hanging. 
The patient was discovered before life became extinct, and was cut down, S USPENDED A NIMA TION. 
91 
the fact being carefully concealed from the medical attendant, who treated 
the case as one of apoplexy. 
Whenever, therefore, any mystery or doubt hangs over a case of apnoea, 
the surgeon must endeavor to elicit all the information possible by interroga- 
tories addressed to friends or by-standers, and also by such explorations, 
instrumental or otherwise, as will remove the case from the region of con- 
jecture. These inquiries, however, need not delay or interrupt the use of 
artificial respiration. The two must proceed together. 
Cases of successful resuscitation rarely recover without some evil effects 
remaining for some time, whatever may have been the cause which has im- 
periled life. If it was drowning, there remains some difficulty in the respira- 
tion, due, in all probability, to pulmonary oedema, the presence of which is 
indicated by a very fine crepitant rale defined over the chest. This gradually 
disappears as the circulation. and the respiratory movements of the lungs 
become properly established, and requires no treatment. When the patient 
has been saved from strangulation there will probably follow some obscuration 
of vision, vertigo, and headache,—the former depending on opacity of the 
vitreous humor and the optic disk, and the latter on temporary insufficiency 
of the vaso-motor nerves to regulate the lumen of the intra-cranial blood- 
vessels, thus favoring local congestion. It is doubtful, under these circum- 
stances, if any benefit is likely to accrue from the use of internal remedies. 
Theoretically, the tonicity of the vessels should be improved by the admin- 
istration of ergot and strychnia; the use of which, at all events, can do no 
harm, and may do good. 
Individuals who have suffered from the poisonous effects of irrespirable 
gases, such as carbonic oxide, or others equally destructive to life, are fre- 
quently left in a feeble state of health, with troublesome head-symptoms, 
pain, and dizziness. These symptoms, it is presumed, must result from the 
poisoned state of the blood, and from the effect of the latter on the cell- 
changes concerned in the nutrition of the tissues. Time and pure fresh air 
constitute the correctives for these conditions. 
There are other accidents, which admit of a mechanical explanation, some- 
times found associated with apncea, such as wounds of the tongue or of the 
lips, inflicted in the struggle and agony of suffocation, fractures of the hyoid 
bone or of some piece in the cartilaginous skeleton of the larynx after hang- 
ing or garroting, etc. The first injury is in itself comparatively unimportant, 
though it may have a value in a medico-legal point of view, as pointing, in 
connection with other evidence, to the fact of a probably violent death. 
The second lesion is one of vital moment, as it is likely to be followed by 
extravasation of air, blood, or inflammatory products in the submucous con- 
nective tissue of the larynx, which will necessitate the operation of tracheot- 
omy in order to save the patient from suffocation. CHAPTER XXVIII. 
DISEASES AND INJURIES OF THE NOSE, THE NASO-PHARYN- 
GEAL REGION, AND THE ASSOCIATE PARTS. 
The nose plays a very important part in respiration, olfaction, and vocali- 
zation. Ordinarily we speak of the organ as extending from the face to the 
pharynx, or from the anterior to the posterior nares, which is anatomically 
correct; but when we approach the consideration of the diseases of the 
organ it is impossible to disjoin it from the post-nasal portion or dome of the 
pharynx. The labyrinthic disposition of the nasal passages renders many of 
its affections most difficult of management. 
Congenital absence of the nose is very rarely seen. Holmes mentions a case 
of the kind, which was under the care of Maisonneuve. The only marks 
of the organ were two small apertures opening on the face and corresponding 
to the anterior nares. A similar defect is seen in some cases of monstrosity. 
Soemmering records a case in which there wras a complete absence of the 
organ, and also of the olfactory nerve, with malformation of the brain. Prof. 
Hamilton, of New York, mentions a case of absence of this organ, which 
occurred in the practice of Dr. McCready. Poederer gives the history of 
a similar imperfection, associated with malformed ears. There was no eleva- 
tion corresponding to the nose, and there were no nostrils, but in their place 
was a blind pouch. Vrolik,* who gives the above cases, speaks of one in 
which only the right half of the nose was present. Otto records a case in 
which there was an absence of the septum, and but one nostril present. The 
anatomist Ilildebrandt had a natural deficiency in the septum narium. 
Congenital closure of the anterior nares has occasionally come under the 
observation of the surgeon. Mason saw an example of the kind at King’s 
College Hospital, and he refers to another which was under the care of Mr. 
Thomas Smith, and which was benefited by making an opening with a bis- 
toury and maintaining it patulous with gum catheters introduced into the 
nasal fossa. 
Acquired contraction of one or both nares is a more common defect than 
the former. It may be produced by the cicatrices of lupus or rodent ulcer, 
or as a consequence of syphilitic ulceration, and also by burns and by warts. 
An occlusion of this nature interferes with free respiration, enfeebles the 
body, and modifies the quality of the voice, imparting to it a nasal tone. 
Incisions and the subsequent use of bougies constitute the means for cor- 
recting this evil. 
There is also a stenosis of the nares which is due to paralysis of the leva- 
tores alae nasi muscles. The sides of the nostrils close during inspiration, 
causing stridor, and compelling the patient to breathe through the mouth. 
Cohen met with a case of this nature which was followed by dry catarrh of 
the pharynx. 
When the obstruction is due to a collapse of the ala nasi, its inner surface 
resting against the septum or column of the nose, the nostril should be ex- 
panded by a piece of soft-rubber catheter, or by wearing a short hard-rubber 
tube in the opening. The same result can be attained by introducing, just 
within the nares, a ring made from a piece of watch-spring and covered 
with soft rubber. Such a device will, by its elasticity, be self-retaining. If 
there should exist bands of fibrous tissue, confining the cartilage in a bad 
* Handboek der Licktekundige Outleedkunde, ii. 70. DISEASES AND INJURIES OF THE NOSE. 
93 
position, they must be severed, and a hollow obturator worn until the cut 
surfaces have healed. 
Obstructions arising from papillomatous or warty growths are relieved 
by excision, and then touching the cut surface with a stick of nitrate of 
silver. 
Deformities of the nose of congenital origin are seen in those clefts which 
extend from the lip into one of the nostrils in hare-lip, causing flattening of 
the organ, the tip in some instances almost touching the upper lip; or, as 
sometimes happens, two clefts may exist, each 
running from the angle of the mouth towards 
the orbits, parallel with the nose, and isolating 
the latter from the lateral parts of the face 
(Fig. 1745); such a case, for example, as that 
given by M. Guersant. Vrolik has recorded 
four similar cases, and also one in which the 
extremity of the nose was bifid, the depression 
between the lateral cartilages, which always 
exists in the foetus, having failed to fill up from 
an arrest in development. 
The depression or flattening of the tip of the 
nose, which is so common in double hare-lip, is 
best corrected by using the middle or inter- 
maxillary piece of the lip as a column on which 
to raise the organ. Even in bad cases of a like 
deformity accompanying single hare-lip, the de- 
fect can in some measure be remedied by sepa- 
rating a small triangular piece from the larger 
half of the lip, and, after dissecting it loose from 
its alveolar attachments, pushing it upward along with the nose, where it 
can be held as a permanent support to the organ by the closure of the sides 
of the cleft. 
When the nose is disjoined from the sides of the face, as in Guersant’s 
case, a plastic operation will become necessary to close the chasm. 
Lateral deviations of the nose will be considered in connection with 
deformities of the septum. 
Fig. 1745. 
Double fissure separating nose from 
face.—Mason. 
Affections of the Soft Parts.—The skin covering the nose is frequently the 
seat of vascular and follicular disease, the acne rosacea of dermatologists. 
The morbid changes consist in congestive dilatation of the cutaneous capil- 
laries. The affection is sometimes hereditary, at other times it appears about 
the time of puberty, and frequently it is seen in persons who are free livers, 
indulging habitually in the pleasures of the table and in the use of alcoholic 
drinks. The red color may be confined to the tip of the nose, or it may spread 
over the whole of the skin, covering the cartilaginous portions of the nose. 
In the simplest variety, the skin at the extremity of the nose is very red, 
glossy, and oily, all of which appearances are intensified by exposure to 
either artificial or natural heat, and by atmospheric changes. 
In another and more pronounced degree of acne rosacea, there is not only 
the scarlet blush of the skin, but some of the vessels, both arterial and venous, 
are dilated so that their trunks are distinctly seen running in tortuous lines 
in different directions in the skin, giving a mingled red and purple appearance 
to the latter. Both of these varieties are connected with certain disturbances 
of the digestive organs, or with those perturbations of the system which 
belong to the period of puberty. Women suffer more frequently than men, 
and often about the climacteric time of life. Such a nose is by no means to 
be ascribed to the bottle and the table. Rosacea frequently is seen in persons 
most temperate in eating and drinking. 
The most marked examples of rosacea, however, are seen in the persons 
of those who indulge regularly in the use of spirituous liquors. Not only in 94 
DISEASES AND INJURIES OF THE NOSE. 
such are the vessels much dilated, and the nose enlarged and glossy, but the 
skin has a deep purple color, and the sebaceous follicles are thickened by 
inflammatory deposits, imparting to the surface a tuberculated or knotty 
appearance. Such noses belong only to persons who have passed the period 
of mature life and have long served at the shrine of Bacchus. 
Treatment.—In cases of hereditary rosacea no treatment will avail in 
removing the disease; but as the person advances in life the color fades, 
and may entirely disappear. Where the affection results from digestive or 
menstrual irregularities, the best constitutional remedies are aperients, fol- 
lowed by tonics, and a carefully-regulated diet, avoiding any excess of fatty 
substances, as well as all wines and other liquors. 
The local treatment is in most cases the most important. After bathing 
the nose in the evening with a suds of carbolic acid soap, made as hot as can 
be borne, tbe organ should be covered with a shield of lint having a piece of 
oiled silk basted on one side, the other side, or that next to the skin, being 
soaked with a solution of the bichloride of mercury (one grain to two fluid- 
ounces of water), and secured in place by one or two strips of adhesive 
plaster. This is allowed to remain during the night. The same process is 
repeated for several consecutive nights, or as long as any benefit is observed 
to follow. Should a change be indicated, an ointment of the iodide of lead 
maj7 be rubbed into the skin of the nose, after the use of the hot bath. Pul- 
verized acetate of lead or finely levigated calomel, thoroughly rubbed into 
the diseased surface, often causes a contraction of the vessels after some time, 
and a marked improvement in the appearance of the parts. 
In rebellious cases, those, for example, in which the noted color so conspic- 
uously advertises the habits of tbe patient, a more heroic plan of treatment 
will be demanded. Numerous incisions or free scarifications should be made 
in the long axis of the nose, dividing boldly the dilated vessels, and, after the 
hemorrhage subsides, the incisions should be wiped with a crayon of nitrate 
of silver, tincture of iodine, or Monsel’s solution of iron. A water-dressing 
should then be applied to the parts, followed in two or three days by the 
oxide of zinc ointment. 
Hypertrophy of the Nasal Integument is improperly called lipoma by 
some writers, and acne hypertrophica 
by others. 
In this affection, the integument 
covering the cartilaginous part of the 
nose is raised into tubcrculated or 
knotty elevations. Some of these pro- 
tuberances have a broad base, others 
a more narrow or somewhat peduncu- 
lated attachment. In typical cases, 
these outgrowths are prolonged into ir- 
regular, soft, fleshy, pendulous excres- 
cences, or lobulated masses, having a 
livid or purple discoloration, and being 
entirely painless: they may attain so 
great a bulk as to hang over the lip, 
or, in the event of their enlarging in 
an upward direction, to obstruct the 
vision to some extent. (Fig. 1746.) 
These growths are limited to the 
skin, never implicating the underlying 
cartilages. In rare instances ulcera- 
tion has occurred, also cystic degen- 
eration. 
The disease commences as a rosacea, 
resulting finally in an enlarged state of the sebaceous follicles, with dilated 
Fig. 174G. 
Hypertrophy of the nasal integument. GANGRENE. 
95 
veins and plastic infiltration of the skin and subcutaneous tissue, which at 
length becomes developed into fibrous tissue. 
Treatment.—Local applications are powerless to effect any good, unless 
it is in very slight cases of the diseaso, when the use of the tincture of iodine, 
freely brushed over the thickened skin, may arrest, or at least retard, the 
morbid process. The knife alone can effectually remove the disease, and was 
first used, it is believed, by Mr. Hey. When employed, it must be used with 
judgment, in order not to trench on the cartilages. This is best prevented 
either by expanding the nostrils over a plug of lint, or, what is better, by 
passing a finger into the nares, while the dissection is being made. The 
bleeding following the operation will be profuse. In a case of Sir William 
Blizzard’s, the patient perished from hemorrhage. The application of hot 
water or of the tincture of ergot can be used to stanch any unusual bleeding. 
Any vessel sufficiently large to admit of being ligated should be tied. The 
wound left after the excision, inasmuch as the skin is removed with the 
disease, will require to heal by granulation, during which period a 'water 
or carbolated oil dressing will answer best. 
Occasionally the hypertrophied tissue of the nose is permeated by numer- 
ous venous channels, imparting to the morbid mass some of the character- 
istics of an angeioma, the removal of which is followed by obstinate bleeding. 
After excision the disease rarely returns, though examples of its return 
have been recorded. 
Follicular Inflammation, or Furuncle.—The cartilaginous portion of the 
nasal integument is frequently the seat of small boils or circumscribed ab- 
scesses, the result of a follicular inflammation. These furuncles commence 
with redness of the skin and tenderness, followed by the appearance of an 
acuminated pimple, which finally opens and discharges a small amount of 
pus. In some cases, especially when the inflammation is located over the 
alae of the nose, where the skin is very firmly bound to the cartilages and 
the resistance is necessarily great, the pus, instead of finding its way to the 
surface, is discharged into the nasal cavity, not by perforation, but bypassing 
through a fissure between the cartilages. 
O o -l • i 
Furuncular inflammation occurs in both the young and the old, in males 
oftener than in females, and especially in persons who are gross feeders. 
Treatment.—Hot lotions of lead-water and laudanum, constantly applied 
over the nose, will often effect the resolution of the inflammation. When 
this does not follow, it will be best to favor the maturation of the abscess by 
frequent fomentations of hot water, or by laying upon the parts a little bag 
of pulverized slippery elm dipped in hot water. The pus should be liberated 
as soon as recognized, by puncturing the top of the swelling with a fine- 
pointed bistoury. 
There is an abscess which originates near the attachment of the upper 
lateral cartilage to the margin of the nasal bone, between this and the side 
of the face, in the loose connective tissue existing at this point. It is usually 
slow in its progress. It is attended by swelling>of the side of the face and 
the lower eyelid some time before the locality of the abscess is suspected. 
When allowed to progress without interruption, the pus finds its way down, 
and is almost invariably discharged at the outer angle of the corresponding 
naris and beneath the alar cartilage at this place. 
Steatoma.—Sebaceous tumors of the nose are occasionally seen. They 
never attain the bulk of similar growths elsewhere. They are painless, and 
usually increase very slowly. 
The remedy is extirpation, performed in the same way as in removing cysts 
of the scalp. 
Gangrene.—Several cases of gangrene of the nose have been recorded by- 
medical writers. One recorded by Dr. Bernard Henry, of this city, occurred 96 
DISEASES AND INJURIES OF THE NOSE. 
in a widow, 42 years of age, of abandoned habits, who was admitted into 
the Philadelphia Hospital, in which institution she died. The discolora- 
tion began on the tip of the nose. In this case the disease was not local, 
other portions of the body being affected in a similar manner, viz., the arms, 
feet, and legs, and the integument over both patellae. As in senile gangrene, 
the parts deepened into a black color, became dry, and shi-iveled up. A line 
of perfect demarkation followed in the upper extremities, after which the 
hand of one and the forearm of the other were amputated by cutting through 
the exposed bones. Granulations formed at the end of the bones, and the 
stump appeared disposed to heal. A similar line of demarkation formed upon 
the lower extremities, but the patient became comatose and died. The ap- 
pearances observed at the post-mortem scarcely explained the condition 
satisfactorily. There was adhesion of the brachial and femoral arteries to 
the bones, but no atheroma of these vessels was noticed. Incipient cirrhosis 
of the liver w as observed. 
A case of gangrene of the nose is given by Mr. Baymond, in the “Year- 
Book of Medicine and Surgery” for 18(52. This case also proved fatal. 
Mr. Begg* had charge of a woman, 21 years of age, who wras attacked by 
gangrene forty-six days after delivery. She had ahvays suffered from cold 
extremities, even in the hottest da}Ts of summer. Ergot was administered 
during the labor, after which improper nourishment was provided for her. 
The tip of the nose, the ears, and the four extremities were involved. Lines 
of demarkation formed, and forty days after the gangrene had set in, both 
legs were amputated; twenty-two days after this, a second doublo ampu- 
tation was performed at the left wrist and right foreaimi. The patient re- 
covered perfectly. 
Dr. H. C. Wood also had charge of a case of gangrene of the nose at the 
Philadelphia Hospital. 
All such cases of gangrene no doubt depend upon the same causes which 
produce senile mortification, and are incurable. 
Lupus frequently attacks the nose, appearing most frequently on the alae, 
tip, or column, though not limited to the external part of the organ. About 
ninety per cent, of all cases of lupus finally attack the nose, although the 
disease may begin on the cheek. It rarely occurs in mature life. It affects 
females oftener than males, and in time causes the most extensive devas- 
tation of the nose and face. The disease is not unfrequently confounded 
with epithelioma and with syphilitic ulceration, from both of which it differs 
in several important features, hereafter to be mentioned. 
Lupus begins by cell-infiltration into the superficial layers of the derm, form- 
ing papules, which in a short time assume the appearance of small nodules. 
The future history of these tuberculated masses is not always the same. 
Sometimes they become confluent, forming a single mass, the superincum- 
bent skin having a dark-red color, with an abundant epithelial desquamation 
(desquamatory lupus), or there may appear on the skin, over the tubercular 
patch, a number of small vesicles, the contents of which after a brief period 
of time become purulent. The pustules may run together. As soon as the 
cutis gives way, the pus, mingled with epithelium and disorganized con- 
nective tissue, desiccates into crusts of a light-yellow color. When these 
crusts are detached, an ulcerated surface is seen, the edges of -which, being 
somewhat irregular, are very slightly, if at all, elevated above the level of 
the surrounding skin. This constitutes that variety of the disease described 
by writers as lupus exedens, or noli me tangere. The ulcer once formed con- 
tinues to enlarge by a repetition of the primary morbid process, that is, by 
a new cell-infiltration around the margin of the original ulcer, forming new 
tubercles, which in turn ulcerate, and thus enlarge the boundaries of the 
primary sore. In this manner the destructive process extends, destroying 
the skin with its glands, but rarely going deeper than the subcutaneous 
* London Lancet, September 17, 1870, p. 397. LUPUS. 
97 
connective tissue. When not situated on the face, but in the nose, it some- 
times attacks the perichondrium of the cartilages and the septum. (Fig. 
1747.) It is remarkable that while the work of destruction continues at 
the periphery of the ulcer, in many 
cases, a process of repair commences 
in the centre, the two being simul- 
taneously in operation, the destruc- 
tive and reconstructive forces being 
nearly equally active. After a time, 
and from causes altogether unex- 
plained, the ulceration may cease at 
the circumference of the sore, when 
the ulcer will heal, granulation and 
cicatrization extending either from 
the centre to the circumference, or 
in a reverse direction. The result- 
ing cicatrix, at first red and shining, 
subsequently becomes paler, and 
finally white, somewhat depressed, 
and marked by’fine, radiating ridges. 
Like all inodular tissue, the cicatrix 
possesses the property of contraction 
to a degree that in time may occa- 
sion considerable deformity. 
Instead of lupus following the course just portrayed, it may commence 
with the initial tubercle, the skin being slightly yellow in color, and although 
the disease extends by the formation of new tubercles around the exterior 
of the first, yet no ulceration follows. With the enlargement of the area of 
the disease the deep layers of the derm, infiltrated with new connective-tissue 
cell-elements, soften and finally disappear, their place being occupied by 
cicatricial tissue. 
Lupus is so frequently found to occur in young persons who present the 
constitutional characteristics of struma, that there are well-grounded reasons 
for believing the disease to be one of the multiform manifestations of scrofu- 
losis. 
Diagnosis.—Lupus may be confounded with syphilitic, scrofulous, and 
epitheliomatous ulceration ; yet by carefully noting the following differential 
peculiarities a correct diagnosis can usually be attained. Contrasting it 
with syphilitic, tubercular, and ulcerative disease, the following differences 
may be detected: 
Fig. 1747. 
Lupus exedens of the nose. 
A disease of the young. 
The local papules, tubercles, and ulceration the 
only evidence of disease. 
Tubercles dark red. 
Commences in the skin of the nose. 
Rather slow in its progress. 
Ulcers exhibit a granular, red or pale yellow 
appearance; edges irregular and depressed, and 
the discharge not profuse; ulcer often covered with 
crusts. 
Constitutional treatment exercises little if any 
effect, causing at the best a slow improvement. 
LUPUS. 
A disease of more advanced life. 
Late manifestations in a syphilitic diathesis, 
and always preceded by other syphilides. 
Tubercles cqpper-colored. 
Follows ulceration of the mucous membrane of 
the nose. 
Usually rapid in its progress. 
Ulcers are gray, foul; their edges regular, 
sharply defined, everted, and the crater of the 
sore occupied by sloughy connective tissue. 
Constitutional treatment rapidly changes the 
unhealthy character of the ulcer and induces1 
cicatrization. 
SYPHILIS. 
There are several features common to struma and lupus; for example, in 
both there are scrofulous tendencies, in both there are papules and tubercles, 
and in both the disease is one of early life; yet, when carefully analyzed, 
there will be discovered a number of differential points which will serve to 
distinguish between the two affections: 98 
DISEASES AND INJURIES OF THE NOSE. 
LUPUS. 
SCROFULA. 
Rarely accompanied by enlargement or suppu- 
ration of the lymph-glands. 
Ulcer enlarges by a constant repetition of the 
first morbid process,—that is, the formation of new 
tubercles at the circumference of the sore. 
No burrowing or sinuses leading from the 
ulcer. 
Skin around the circumference of the ulcer 
slightly red. 
Edges not swollen. 
Such enlargement and suppuration very com- 
mon. 
Ulcer, whether in the first place succeeding the 
formation of tubercles or not, enlarges, not by 
the development of fresh tubercles, but by a tissue- 
disintegration corresponding to the process of 
ordinary ulceration. 
Burrowing very common. 
Skin around the ulcer purple or claret-colored. 
Edges usually swollen and thickened. 
Epithelioma is less common on the nose than is generally supposed. It be- 
gins sometimes as a wart-like excrescence, at other times as a tubercle, and 
more rarely in the form of a crack. Its 
progress is very irregular, requiring in 
some instances several years to destroy 
a surface as large as a quarter-dollar, 
while in other cases the march of the 
disease is exceedingly rapid, destroying 
not only the soft parts of the nose, but 
also the cartilages and bones, producing 
the most horrid mutilation of the face. 
(Fig. 1748.) I have observed that gen- 
erally, when the epithelial infiltrate 
masses the tumor into nodules, showing 
no very marked tendency to ulcerate, 
the progress is rapid and the morbid 
process singularly unmanageable. When 
ulceration occurs, the margin of the sore 
is more or less everted and indurated. 
In distinguishing epithelioma from 
lupus, this surrounding induration is 
a very important consideration, being 
uniformly present in the former, and 
not in the latter; neither does the ul- 
ceration undergo spontaneous cicatriza- 
tion in epithelioma, as is often the case 
in lupus. There often is, also, infection 
of the lymph-glands nearest to the epi- 
thelial ulcer, wThich does not occur in 
lupus. Moreover, epithelioma rarely appears before middle life, or after 
fifty, whereas lupus is a disease of the young. 
Fig. 1748. 
Epithelioma of the nose and face. 
Rodent Ulcer.—This destructive affection, though not commencing on the 
nose, soon extends to the organ from the upper part of the face or the lip. 
Beginning as a painless, colorless, and solitary nodule, notably hard, which 
cracks, scabs, and at length ulcerates, it becomes painful, extends rapidly 
in depth and circumference, always being preceded by the hard nodule of 
infiltrate, and destroys indiscriminately the skin, fascia, sebaceous glands, 
cartilages, and bones, producing the most frightful devastation of structures. 
(Fig. 1749.) 
This rodent ulcer differs from all other ulcerations in the depth and 
rapidity of tissue-destruction, and, as a rule, in the initial tubercle being 
single or solitary. In particular, it is differentiated from lupus in having 
no connection with a strumous organization, attacking the robust and those 
apparently sound in body, in developing late in life, and in exhibiting no 
tendency to cicatrization. 
Contrasted with epithelioma, the difficulty of distinguishing between the RODENT ULCER. 
99 
two affections is confessedly great, at least in their early history. The edges 
of the rodent ulcer are more regular and less indurated than in the epithelial 
sore. In the more advanced stages 
of the ulceration, should the lymph- 
glands become enlarged, the obscurity 
will be removed at once, as the rodent 
ulcer does not infect these bodies. 
There is another and rare variety of 
lupus, which affects the nose in com- 
mon with other portions of the face, 
—namely, lupus erythematosus. This 
affection, like the rodent ulcer, attacks 
persons in sound health. Its initial 
stage is not marked by the presence of 
either papule or tubercle, but merely by 
an indistinct red patch, followed by the 
appearance of thin scales, on the re- 
moval of which there is seen a circum- 
scribed and depressed cicatrix, the de- 
pression of the scar being due in a 
great measure to atrophy of the tissues 
underlying the red patch and to the 
contraction of the new-formed con- 
nective tissue. The connective tissue 
around the sebaceous fol licles is believed 
to be the primary seat of the disease. 
Treatment.—While in some cases lupus would seem to be defiant to all 
remedies, the disease is generally amenable to treatment. There is, indeed, 
a natural tendency in the morbid action to undergo spontaneous arrest. 
Such terminations are constantly witnessed, where cicatrization follows in 
the wake of ulceration, or where, after years, and when all remedies have 
failed, recovery takes place altogether independent of either the surgeon’s 
art or his drugs. 
Lupus is a constitutional disease, and demands constitutional remedies, 
which should always be administered before any radical local measures are 
adopted. Frequently, indeed, the affection disappears under the use of reme- 
dies addressed to the general system alone. It is, therefore, of the first im- 
portance to institute a careful examination of every patient thus affected, in 
order to discover any vice or constitutional defect which may be capable of 
explaining the local phenomena. 
A syphilitic diathesis exercises considerable influence over lupus, rendering 
it more destructive, a tendency which can be overcome only by the use of 
alteratives, as iodide of potassium, bichloride of mercury, or protiodide of 
mercury. The iodide of potassium is to be preferred in most instances, and 
should be given in full doses. 
Where no complication of a syphilitic nature‘exists, our remedies must be 
selected with a view to bring the nutrition of the body up to the highest 
possible standard: this would include the correction of any defect in the 
digestive apparatus, and the employment of a nutritious diet, with a proper 
amount of exercise and fresh air. When the digestion is feeble, pepsin, hy- 
drochloric acid, or the infusion of gentian or quassia will assist in imparting 
tone to the stomach. In amemic cases, iron will be indicated, with extract 
of malt. 
Two remedies which appear to exert a kind of specific control over the 
morbid action of the local disease are cod-liver oil and Fowler’s solution of 
arsenic. The oil must be given in small quantities at first, with a view to 
test the tolerance of the stomach, when, if it is well digested, the amount 
can be increased to the usual dose of one or two ounces, to be taken one 
hour after each meal. The arsenic must also be administered in the begin- 
Fig. 1749. 
Rodent ulcer. 100 
DISEASES AND INJURIES OF THE NOSE. 
ning with caution; three minims are sufficient at first, taken after each meal, 
the quantity being increased as it can be borne by the stomach, up to twenty 
or thirty minims, should none of the poisonous effects of the drug appear. 
Should the local conditions improve under the regimen thus outlined, the 
surgeon may rely on the constitutional medication for the eradication of the 
lupus, but, if not, the disease must be attacked by such agents as are capable 
of destroying not only the diseased surface, but also the tissues for some 
distance beyond. This may be done by the knife, caustics, or the cautery. 
The knife has never been successful in my hands, except when it has been 
followed by the actual, thermo-, or galvano-cautery. The sharp curette rec- 
ommended by Yolkmann in the removal of rodent ulcer 1 have many times 
employed with entire success. The scraping should be carried into the 
sound tissue, and when complete the cavity should be filled with iodoform. 
The caustics which have been used to destroy the diseased parts are caustic 
potash, Vienna paste, nitric acid, acid nitrate of mercury, chloride of zinc, 
nitrate of silver, and arsenic. The chloride of zinc, though exceedingly 
painful, I regard as far superior to all other caustics in this affection. One 
part of chloride of zinc with three parts of powdered gum arabic and a little 
morphia, made into a paste by adding a few drops of water or alcohol, and 
applied over and a little beyond the limits of the diseased part, will slowly 
effect its destruction. The amount applied must be carefully regulated by 
the depth of tissue to be destroyed: it is seldom that a stratum of the paste 
thicker than from half a line to a line will be required. A dossil of ab- 
sorbent cotton moistened wdth carbolated oil, laid over the escharotic and 
secured by two or three adhesive strips, will give sufficient protection to the 
parts. The separation of the slough, which commences in five or six days, 
will be facilitated by a warm water dressing or a flaxseed or slippery-elm 
poultice. After the dead mass has been detached, granulation and cicatriza- 
tion will be hastened by the use of resin ointment. 
In the management of epithelioma and ulcus ulcerans, or rodent ulcer, 
local treatment takes precedence of constitutional: indeed, I do not believe 
that internal medication possesses any value other than to counteract to some 
extent the effects of pain and general irritation. Nor can the local treatment 
be commenced too early: the smaller the diseased surface, the more encour- 
aging the prospect of relief. In the affection under consideration, excision, 
followed by the cautery, can be employed ; or if the former alone, and the 
surface is not too large, the cure is believed to be more certain if the wound 
is filled by a flap from the adjoining skin. Dr. Garretson, who has practiced 
this plan for some years, speaks encouragingly of its success ; and where I 
have adopted the procedure the result, on the whole, has been satisfactory. 
Among escharotics caustic potash acts most quickly, as the diseased tissue 
can be destroyed at a single sitting. The pain, though severe, is of short 
duration. The use of an anaesthetic will be proper when the surface to be 
attacked is extensive. The only objection to caustic potash is the bleeding 
which often follows its application. This is not likely to occur when the 
disease is superficial. 
Syphilitic Ulceration of the nose may commence either on the cutaneous or 
on the mucous surface of the organ. Its course is rapid, extending in a very 
short time to the cartilages, the cartilaginous septum, and the spongy turbi- 
nated bones, which are soon destroyed. The resulting deformity causes no 
small alteration in the expression of the face. 
Syphilitic ulceration is not difficult to diagnose. The fact of there having 
been a history of previous venereal accidents, the traces of which have not 
been entirely erased, and the rapid extension of the ulcer, are sufficient to 
reveal the origin of the affection and to suggest the treatment. 
Treatment.—In iodide of potassium we have a remedy possessing a 
marvelous power to arrest the progress of such a sore and restore the breach 
made in the part. This drug must, under the circumstances in question, be EPISTAXIS. 
101 
administered in full doses of fifteen or twenty grains three times a day, 
largely diluted with water, or in a smaller amount more frequently repeated. 
The local sore will require only to be cleansed with a solution of perman- 
ganate of potash and gently stimulated with dilute nitric acid, applied with 
a glass brush. Besin ointment may afterwards be used as a dressing during 
the progress of cicatrization. 
Wounds of the nose occur both accidentally and designedly. Those which 
are incised bleed very freely. The organ is often severely bitten by the 
teeth in brawls, and in such cases, the soft parts being more or less contused, 
the hemorrhage is less profuse than when a sharp implement has been used. 
Treatment.—In the treatment of wounds of the nose, the indications are 
to remove any foreign matters which may have been driven into the part, 
and afterwards to bring the sides together by interrupted sutures of fine sil- 
ver or silk thread, observing the utmost nicety in the adjustment. Except 
where the wound is located near the junction of the alse nasi with the 
face, where the lateralis nasi artery lies, ligatures are seldom required to 
control the bleeding. As the cartilages and the integument are closely ad- 
herent, the sutures, even when the cartilages are divided, do not require 
to be introduced deeper than through the integument. 
AFFECTIONS OF THE CAVITIES OF THE NOSE. 
Epistaxis.—Hemorrhage from the nasal cavities occurs at all periods of 
life, but is more common in the young, and particularly about the age of 
puberty. The amount of blood lost in the attacks varies from a few drops to 
many ounces, causing in some instances extreme pallor, vertigo, and fainting, 
and in some cases death. The blood usually issues from one of the nostrils, 
rarely from both at the same time, in a rapid succession of drops,—so rapid, 
indeed, in some instances as to form an unbroken stream. Generally the 
bleeding comes from one or two points. M. Mareschal examined eight cases of 
epistaxis occurring before death from other causes, and in all the source of the 
bleeding was found to be from a single spot of livid, congested, and abraded 
mucous membrane. Two of these spots were located near the junction of 
the septum and the floor of the nose, the others at the posterior part of the 
inferior turbinated bone. There are cases in which it would appear to ooze 
from an extended surface of the mucous membrane; and it is not difficult to 
understand the large and exhausting hemorrhages which often come from 
the nasal cavities, when the extent of the mucous membrane necessary to 
cover all the sinuous irregularities of these chambers is considered. The 
sources from which the nasal fossa? receive their supply of blood are chiefly 
the branches of the ophthalmic, internal maxillary, and facial arteries. 
Causes.—Among the causes which give rise to epistaxis are cerebral con- 
gestion, disturbances of the menstrual function, vascular perturbations inci- 
dent to the climacteric period in female life, and morbid growths, both nasal 
and pharyngeal. There are conditions of the* blood, also, such as exist in 
anaemia, typhoid fever, and scurvy, which predispose to nose-bleeding. 
Treatment.—The bleeding so common in the young, especially in those 
of sanguine temperament, may safely be left to nature, as long as the gen- 
eral constitutional vigor is not impaired by its frequent and profuse recur- 
rence. The depletion for the most part is salutary, relieving the overstrained 
vessels of the head from undue tension, and saving the contents of the cranium 
from inflammatory and other accidents. When it is desirable to interfere, the 
bleeding can be restrained within proper limits by directing that the bowels 
be kept soluble, urging the patient to avoid excessive exercise, the use of 
stimulants, and excess of animal food. During an attack the head should 
be kept elevated, and cold applied to the back of the neck, and to the nose, 
the forehead, and the face. When the bleeding begins to cease, the nose 
should not be blown, as is so often done. By doing so the coagula are ex- 102 
DISEASES AND INJURIES OF THE NOSE. 
polled and the hemorrhage is renewed. Douching the nape of the neck 
with cold water will, by exciting contraction of the vessels through reflex 
influence, often cause the bleeding suddenly to cease. Another popular plan 
for attaining the same object is the elevation of the arms for some time over 
the head, which frequently has the desired effect. The explanation of it 
appears to be in the diversion of the blood from the vessels of the nose to 
those of the muscles, rendered necessary by the effort to sustain the upper 
extremities in so unusual a position. 
Should these measures fail, astringents may be employed, the best being a 
weak solution of alum or of kino, MonseFs solution, persulphate of iron, 
largely diluted, gallic acid, antipyrin in four per cent, solution (llenocque), or, 
better, a similar solution of cocaine. Any of these agents can be snuffed up 
the nose until drawn into the pharynx. If still more energetic means are 
required, resort may be had to internal hasmostaties, as fluid extract of 
ergot, turpentine, acetate of lead and opium, and matico; and if the heart is 
acting with too much force or too great frequency, tincture of veratrum 
viride will be indicated, at the same time using cold to the head and a hot 
stimulating pediluvium. The haemostatic property of hot water is well 
established. It must be passed through the nasal cavity with the nasal 
douche. Coagulation will also be favored by compressing the sides of the 
nose between the thumb and the fingers, or by using a spring clamp. 
When the hemorrhage is due to a defect in the blood, tonics, especially 
iron, will be demanded, together with a nutritious and unstimulating diet. 
When all the usual means fail to arrest the hemorrhage, the nose must he 
tamponed; that is, the anterior and posterior nares of the affected side are 
to be occluded by the introduction of plugs of lint, fashioned so as to close 
with accuracy these two apertures. A cylindrical plug of fat bacon forced 
into the nasal cavity has often succeeded after other measures have failed. 
In two instances which I recall, and where all the usual remedies, both 
internal and external, including the ordinary tampons, proved unavailing, 
the use of this plug resulted in promptly controlling the hemorrhage. 
Tamponing.—This can readily be done by means of the Bellocq canula 
(Fig. 1750), an instrument which consists of a silver canula through which 
Fig. 1750. 
Bellocq canula. 
runs a piece of watch-spring having an eye at one end and a rod or stylet 
attached to the other extremity; or, in the absence of this instrument, the 
surgeon may use an ordinary gum catheter having an eye cut through its 
extremity for passing the thread. 
In depositing the plugs by the canula, a strong thread, twelve or fourteen 
inches in length, is first passed through the eye at the end of the spring. 
The patient being seated on a chair, or on the side of the bed, with the 
head thrown back, the surgeon takes the canula, previously armed with the 
thread, and passes it along the floor of the nose until it enters the pharynx, 
at the same time directing the patient to open the mouth. The stylet at- 
tached to the spring is now pushed in, when the latter will be seen coming 
forward beneath the soft palate. The thread is then seized and one ex- 
tremity of it brought out through the mouth ; the canula is next withdrawn, 
and with it the other extremitjT of the thread is brought out at the nostril. 
(Fig. 1751.) A compress of patent lint, three-eighths of an inch thick and EXAMINATION OF THE NASAL PASSAGES. 
103 
three-quarters of an inch long, is now secured at the middle to the part of the 
thread which hangs from the mouth, when, by drawing on the thread in the 
nose, the plug, followed by the finger of the surgeon, is conducted up behind 
the palate and fixed into the pos- 
terior naris. It only remains now 
to adjust a second plug of lint 
into the anterior naris, when 
all communication between the 
nasal fossa and the pharynx pos- 
teriorly and the face anteriorly 
will be closed. It is unfortunate 
when both nasal cavities have 
to be plugged, as the obstruc- 
tion to the breathing is so great 
that the patient soon shows signs 
of defective blood-aeration. I 
find, however, that I succeed 
perfectly in controlling cases of 
nasal hemorrhage by simply cut- 
ting a long narrow strip of lint 
and by means of a director push- 
ing one end to the back of the 
nasal fossa, and by installments 
filling the nose to the anterior naris. The lint may be moistened with weak 
Monsel’s solution, or dusted with gallic acid. When the piece becomes 
loosened by the secretions from the mucous membrane, it can be readily 
drawn away piecemeal without doing any violence to the parts. 
The tampon is usually worn two or three days, when it should be removed. 
If the posterior compress has been secured to the end of the cord, it can be 
dislodged only by conducting a director through the anterior meatus and 
pushing the roll of lint into the pharynx, from whence it can be drawn by 
the fingers. The director, when used for the purpose, is liable to wound the 
mucous membrane and renew the bleeding, and should therefore be employed 
with care and precision. By tying the posterior plug at the middle of the 
cord before drawing it into place the necessity for using any instrument to 
displace it will be obviated, as it can be dragged out of the naris by drawing 
on the thread which comes through the mouth. The objection which has 
been made to this mode of tamponing the nasal cavities, that the presence 
of a thread in the mouth keeps up a constant irritation of tho fauces, followed 
by gagging, is unfounded. 
Rhineurynters, or little bags which admit of being introduced into the 
nasal fossa and afterwards inflated, have been devised by Closset, Goodrich, 
and others as a means of tamponing the nose in cases of hemorrhage. 
Occasionally cases are encountered in which the bleeding is renewed as 
soon as the tampon is removed, and continues until the patient becomes ex- 
sanguine. Under such circumstances resort‘should be had to transfusion. 
In two patients who were under my care, and after all the usual measures 
had failed to arrest the bleeding, this procedure was adopted, with the effect 
of saving one; in the other the operation had been too long delayed. 
Fig. 1751. 
Plugging the nasal cavities. 
Examination of the Nasal Passages. 
There are two ways in which the nasal cavities may be examined,—namely, 
by the touch and by the eye. 
By the first method, the finger and the probe are the instruments employed. 
The finger can pass into the nose only for a short distance through the anterior 
nares; but by it a thorough exploration of the posterior nares, and indeed of 
the whole post-palatine region, can be made, thereby enabling the surgeon 
to detect the presence of growths which otherwise would evade discovery. 104 
DISEASES AND INJURIES OF THE NOSE. 
By the probe or director, introduced into the nose through the nares, por- 
tions of necrosed bone, and obstructions caused by various neoplasms, may 
be detected. 
A considerable portion of the nasal passages may be exposed to inspection 
by the eye. When the examination is conducted anteriorly, it is necessarj 
that the anterior nares shall be well expanded, the head thrown back, and 
that a favorable light—sunlight preferably—be allowed to fall into the cavity, 
while the tip of the nose is raised with the thumb. There are several specula 
which have been invented at different times to expand the nostrils. Among 
the best of these may be named that of Goodwillie, which has three self- 
expanding blades, that of Metz (Fig. 1752), and that of Fraenkel (Fig. 1753). 
Fig. 1752. 
Fig. 1753. 
Metz’s nasal speculum. 
Fraenkel’s nasal speculum. 
In many cases a pair of dressing forceps will answer quite well. Whatever 
insti'ument is used, it must not be introduced beyond the dilatable or disten- 
sible portion of the nose; that is, just within the naris. The view obtained, 
assuming that the nasal passages are normal, brings under notice the anterior 
extremity of the inferior turbinated bone; higher up and farther back, the 
middle turbinated bone, on the outer side of the nasal fossa; the septum 
narium on the inner side; part of the floor of the nose below and of the roof 
above. During the examination the color of the mucous membrane should 
be noticed; also the character of the secretions; any deviation of the septum 
which may exist; the capacity of the fissures; and whether any morbid 
growths are present, or other obstructions in the fossa. 
The posterior examination is made by the rhinoscopic mirror (Fig. 1754), 
requiring the illumination of the pharynx by focusing either sunlight or 
artificial light from a hand plano- 
convex lens or a brow-mirror. 
In order to enlarge the capacity 
of the fauces, the tongue must 
be depressed with a spatula or a 
tongue-depressor. As soon as 
the involuntary or spasmodic 
movements of the pharyngeal and 
faucial muscles, provoked by the manipulation, have subsided, the mirror is 
to be carried through the isthmus between the arches of the fauces into the 
pharynx, without touching the former or the uvula, the handle of the instru- 
ment being near the corner of the mouth, and its reflecting surface turned 
in order to receive the light, and held in such a manner that a small portion 
of its upper border shall be concealed behind the soft palate. Thus placed 
in position, it must be held with a steady hand, free from any contact with 
the surrounding parts, otherwise the muscular movements provoked will 
defeat the inspection. (Fig. 1755.) The palato-pharyngeal space can he 
further enlarged by requesting the patient to sound “ ah” with a forced 
nasal intonation. If the throat is particularly irritable, and the muscles are 
thrown into violent contraction at the close approach of the mirror, it may 
become necessary to adopt some preliminary handling of the parts with a 
spatula or the handle of a spoon until the requisite tolerance has been secured. 
Under favorable circumstances the observer should be able to see depicted 
in the mirror, by slight changes of its direction, the dome of the pharynx, 
the orifices of the Eustachian tubes, the posterior nares, the pharyngeal sur- 
Fig. 1754. 
Khinoscopic mirror. NASAL CALCULI, OR RHINOLITHS. 
105 
face of the septum narium, and the posterior extremity of the turbinated 
bones. 
In addition to the irritability of the throat, already described, the presence 
of hypertrophied ton- 
sils, elongated palate, or 
a rebellious tongue, may 
render the rhinoscopic 
examination unsatisfac- 
tory. The difficulty 
arising from the first 
can of course be over- 
come only by removal 
of the tonsil, which 
would, aside from all 
other inconveniences, 
scarcely be insisted 
upon ; and in regard to 
the latter, that of bow- 
ing up of the root of the 
tongue, repeated manip- 
ulation will in time sur- 
mount the difficulty. In 
cases where it is especially desirable to have an unusually ample palato- 
pharyngeal space, it may be obtained, after the plan of Dr. Wales, by passing 
a stout thread into the pharynx through each nasal fossa, bringing its ends 
out of the mouth, and, after carrying them over the ears, securing them 
together behind the head. By this method the soft palate is drawn forward 
and upward towards the roof of the mouth. The same contrivance serves to 
remove an enlarged and elongated uvula out of the axis of vision. The 
same object can be accomplished, though not in so satisfactory a manner, 
by lassoing the uvula with a cord and dragging it forward, or by a volsella 
forceps, which I have used for the purpose. 
Fig. 1755. 
Rhinoscopic examination of the naso-pharyngeal region. 
FOREIGN BODIES IN THE NASAL PASSAGES. 
Nasal Calculi, or Rhinoliths.—Calcareous concretions occasionally form in 
the nasal cavities. These bodies, according to the analyses of Demarquay, 
Bouchardat, and Wormley, consist of phosphates and carbonates of lime 
and magnesia and chloride of sodium, with inspissated secretions from the 
nasal mucous membrane. These concretions sometimes form around a foreign 
body which has been introduced into or has accidentally entered the nose. 
In the absence of such a body it is highly probable that a fragment of a scab 
or crust from the mucous membrane has acted as a nucleus in the formation 
of the stone. These concretions vary in size from a pin’s head to a good- 
sized marble, are of a dark-gray coloi*, and have a rough or irregular surface. 
From a patient in the hospital of the University of Pennsylvania, Professor 
Ashhurst removed a rhinolith the size of a shell-bark and weighing one 
ounce. In a majority of instances these calculi occupy the inferior meatus 
of the nose, and it is probable that when so placed the lachrymal secretion 
plays no small part in their formation. They also form in the cavities which 
communicate with the nose, as the antrum and the maxillary and frontal 
sinuses, subsequently finding their way into the nasal cavities. 
The causes which give rise to these concretions are usually of an ob- 
structive nature. Thus, any foreign substance, as a detached fragment 
of necrosed bone, or a bead or tack mischievously introduced into the nose 
in a childish freak, by the swelling and obstruction which it produces, will 
prevent the escape of nasal secretions, which under the modifying influences 
of irritation deposit their saline constituents in the same manner as does 
the urine in catarrhal states of the bladder or in the presence of some body DISEASES AND INJURIES OF THE NOSE. 
which plays the part of a nucleus. In one case reported by W. H. Brown,* 
in which the nostril was closed by a cicatricial contraction following variola, 
thus preventing the escape of the secretions from the nose and collateral 
passages, a large calcareous concretion formed in the corresponding nasal 
fossa, and was extracted after division of the obstructing tissue. Polypi are 
supposed in rare instances to be converted into nasal calculi by undergoing 
calcareous degeneration. A gouty state of the system has also been adduced 
(Yon Graefe) in explanation of the presence of rhinoliths. 
Symptoms.—The symptoms which indicate the presence of a calcareous 
concretion in the nose are obstruction, accompanied with a sense of fullness, 
diminution of smell, and frequently pain of an intermittent character, re- 
ferred to the frontal, orbital, nasal, or maxillary regions. The body may give 
rise to a rhinitis, with the discharge of a muco-purulent fluid. When the cal- 
culus occupies the inferior meatus, it may pi-oduce obstruction of the nasal 
duct and cause the tears to flow over the cheek. As these symptoms are 
not peculiar to rhinoliths, it will he necessary to resort to both ocular and 
instrumental exploration of the nasal fossa. By expanding the nostril the 
concretion may under favorable circumstances be detected by the eye. The 
diagnosis will be rendered more certain by sounding. A probe introduced 
into the nose will, when brought in contact with a calculus, communicate 
very definite information. The roughened surface which is felt, and the 
noise which may be heard, somewhat like that produced by touching a soft 
vesical calculus with the sound, are significant signs. It is true that the 
probe striking against a necrosed turbinated bone will also communicate a 
feeling of roughness; but there will be wanting the impression of a calcareous 
body. The calculus, moreover, is movable to some extent, and unless forcibly 
touched does not cause pain, neither of which peculiarities belongs to necrosed 
bone. If the suspected calculus is covered with the nasal secretions, the 
diagnosis will be aided by washing away the adherent matters with a stream 
of water thrown into the nose. 
Rhinoliths may bo confounded with polypi. Polypi, however, can gener- 
ally be distinguished by the eye, and, besides, the obstruction which they cause 
is subject to great variations, owing to the hygrometric properties of these 
growths. Touched by the probe, the quality of solidity is found wanting, 
and in polypi whose texture is firmer, and which occupy the posterior part 
of the nose, out of sight, the finger carried behind the palate will be able 
to distinguish between a fleshy mass and a stone. 
Treatment.—The remedy for nasal calculi is extraction. This can be ac- 
complished by the scoop or by a pair of delicate dressing forceps. When too 
largo to admit of being extracted entire, they should be crushed and removed 
by installments with the scoop or forceps; or, if the particles are numerous 
and small, they can be washed out by means of the nasal douche, passing 
the fluid through the unaffected nostril. Yerneuil removed in this way a 
nasal calculus of large size. When situated far back in the nasal fossa, the 
stone may be pushed through the posterior nares into the pharynx and 
received on the finger carried up behind the soft palate. 
Foreign Bodies which enter the Nasal Passages from without.—Children 
and insane persons are prone to introduce various substances into the nose, 
as beads, buttons, bits of sponge or paper, cherry-stones, carpet-tacks, grains 
of corn, and beans. The last two articles, if allowed to remain long, will ger- 
minate and sprout. These materials in time give rise to considerable inflam- 
matory swelling and offensive discharges, which seriously derange the health. 
I removed in one instance from the nose of a child, very feeble and emaciated, 
a carpet-tack, with the little disk of leather attached, which had been lodged 
in the cavity for eighteen months. The patient rapidly regained flesh and 
strength after getting rid of the offending substance. Portions of detached 
bone are liable to become impacted in the nasal cavity and create local irri- 
* Edinburgh Medical Journal, December, 1859. PARASITES. 
107 
tation. Balls also may lodge directly in the nasal fossa or may find their way 
there from adjacent regions. On one occasion I extracted from the nose a 
conoidal musket-ball, which several years previously had entered the frontal 
sinuses. 
Treatment.—Foreign bodies entering the nose should be extracted as soon 
as possible. Allowed to remain any great length of time, they are certain 
to excite inflammation and suppuration, which may eventuate in necrosis of 
the turbinated bones. Considerable tact is requisite in removing these sub- 
stances. Often they are by maladroit efforts forced farther into the cavities. 
When the foreign body is situated at the anterior part of the inferior or 
middle meatus and can be distinctly seen by the eye, it can often be readily 
extracted with forceps, or, if farther back, by means of a small scoop (Fig. 
1756) conducted dexterously beyond the body without striking it, and 
Fig. 1756. 
Scoop for removing foreign bodies from the nose. The instrument can be bent if desired. 
then withdrawn with a jerk. A small hair-pin, slightly bent at the closed 
extremity, can be used advantageously in the same manner. Beads and 
buttons can often be extracted by bending the extremity of a probe into a 
little hook and passing it through the eye of the foreign body. When the 
offending substance is not too firmly impacted, a forcible sneeze, provoked 
by the inhalation of a little snuff, will occasionally prove sufficient to 
dislodge it. The nasal douche can also be utilized for the same purpose, 
passing the stream of water through the unobstructed nostril. A body 
may be so far back in the fossa that it will be more convenient to push it 
into the pharynx and direct it into the mouth with a finger carried behind 
the soft palate. Balls will require to be seized with the bullet-forceps in 
order to dislodge them from their bed. All operations for the extraction of 
foreign bodies from the nasal passages of children will be greatly simplified 
by the exhibition of an anaesthetic. 
Parasites.—In the true sense, a parasite—that is, an animal finding a con- 
genial habitat and obtaining the pabulum for its sustenance in a part of the 
body—does not, I believe, belong to the nasal cavities. Yet there have been 
numerous instances in which maggots have been discovered in the nose, and 
in which they are believed to have reached the cavity by the ova of flies 
having been deposited either in the secretions adherent to the anterior 
nares or directly into the nasal cavity. Frantzius and Weber both mention 
instances. The latter writer states that soldiers belonging to the French 
army in Mexico were in some cases driven to suicide in order to escape the 
suffering resulting from the presence of the larvae of certain flies in the 
nasal cavities. 
The symptoms which have been described as characterizing the presence 
of the larvae of flies, such as Mu-sea carnaria and Lucilia hominivora, are 
sneezing, radiating pains along the branches of the fifth pair of nerves, pain 
in the neck, vomiting, insomnia, vertigo, delirium, sometimes the discharge 
of a bloody serum from the nose, oedema of the face, and accompanying 
fever. 
Centipedes, according to the observations of Tiedemann, are sometimes 
found in the frontal sinuses. Morgagni states that Caesar Magatus, a surgeon 
of Bologna, once laid open the frontal sinus and extracted a worm. Leeches 
may also enter the nasal passages unobserved. This has happened during 
the abstraction of blood from some part of the face. Among the many 108 
DISEASES AND INJURIES OF THE NOSE. 
misfortunes which befell the soldiers of Bonaparte during the campaign in 
Egypt, mentioned by Baron Larrey, was the introduction into the nasal 
cavities, while drinking water at Salahieh, of a species of leech, which from 
a slender filament grew to the magnitude of the Swedish animal. The pres- 
ence of these also in the air-passages and in the intestinal canal gave rise to 
coughs, hemorrhages, and diarrhoeas, from the effects of which not a few of 
the soldiers died. 
The treatment of parasitic animal irritation must be determined by the 
nature of the animal. Maggots, when visible, are to bo extracted with for- 
ceps, or, if they cannot be seen, and yet there are sufficient reasons for believ- 
ing them to be present, the injection of oil will, by entering the respiratory 
pores of the worms, thus interfering with their respiration, tend to secure 
their destruction. The inhalation of chloroform or ether would be likely to 
produce the same result. 
Leeches which accidentally enter the nasal cavities can readily be expelled 
by injections of tepid salt water. 
Vegetable parasites are also alluded to by writers as occasionally entering 
the nose. The existence of such organisms being determined, the remedy 
which would promise most certain success is carbolic acid. It could be most 
efficiently applied to the mucous membrane by means of the nasal douche, 
in a form sufficiently diluted not to do injury. 
Nasal Catarrh—Rhinitis. 
Catarrhal inflammation of the mucous membrane of the nose occurs in 
both the acute and the chronic form. It is the latter variety only which 
properly comes within the domain of the surgeon. This disease is un- 
doubtedly greatly on the increase in the middle and northern States of this 
country, and in its more severe forms is a very obstinate and disgusting 
affection. 
Chronic nasal catarrh gives rise to different structural alterations, on which 
have been based several distinct varieties of the disease,—namely, the simple, 
the hyperplastic or hypertrophic, and the atrophic : these, however, are 
merely degrees of the same affection. 
Simple Chronic Catarrh.—In the simplest form of chronic catarrh there 
exists an inflammation of the mucous membrane of the nasal passages, accom- 
panied by a free discharge of mucus or of a muco-purulent secretion. The 
sense of smell is but slightly, if at all, impaired ; the patency of the fossa 
is sufficient for nasal respiration; there is little disposition to sneeze, and 
there is no odor from the discharges. During mild and dry weather the 
symptoms subside, and may almost entirely disappear; but on the recur- 
rence of cold, damp, and changeable spells the inflammation, for a time 
latent, is rekindled, and the characteristic discharge reappears. Accordingly, 
we find that persons who are the subjects of this disease are rendered very 
uncomfortable during the cold, damp, and changeable seasons of the year, as 
the early spring and winter. 
The pathological changes in this variety of catarrh are not such as involve 
the deeper layers of the Schneiderian membrane. They consist of a rapid 
epithelial desquamation, and the exudation of large numbers of new cells, 
mixed with an abundant mucus. The fact that the smell and nasal respira- 
tion are not materially disturbed shows that the mucous membrane over 
the upper portions of the fossm is in a great measure exempt from the 
disease, and that there is little inflammatory infiltration or thickening of the 
membrane. An examination of the interior of the nose will reveal a deep- 
red congested condition of the mucous membrane, confined chiefly to the 
respiratory portions of the cavity, with considerable muco-pus adhering to 
its surface. This condition is not confined to the nasal membrane, but NASAL CATARRH. 
109 
extends into the pharynx, the surface of which, as regards both color and 
secretion, presents very much the same appearance, the mucus being a little 
more tenacious than that which is seen in the nasal passages. From both 
the nose and the pharynx the secretion trickles down behind the palate, 
creating a disposition to hawk it up into the mouth. The inconvenience 
experienced from this simple form of catarrh is with many persons so unim- 
portant that they are not disposed to seek medical advice; and yet these are 
the cases which, if allowed to go unchecked, finally terminate by insensible 
gradations in the more grave and unmanageable forms of the disease. This 
catarrh is sometimes induced by repeated attacks of coryza, though it is 
thought by many that there is in the majority of cases a determining influ- 
ence exerted by strumous or syphilitic parentage,—a causation, however, 
which I am not disposed to believe is so common as is asserted by some 
waiters. My opinion is based chiefly upon two considerations,—namely, first, 
a knowledge of antecedents in many cases in which no possible suspicion 
of hereditary taint existed; and, second, that these cases of simple catarrh 
are curable by local remedies alone, which scarcely could be expected if the 
inflammation were a symptom of a general condition. 
Treatment.—The indications in the treatment of this variety of catarrh are 
the removal of all adherent secretion from the nasal and pharyngeal mucous 
membranes, and the direct application of as- 
tringent and alterative remedies to the dis- 
eased surface. The first is no less important 
than the second, for unless the tenacious mu- 
cus is thoroughly disposed of, the agents em- 
ployed to remove the inflammation will be 
valueless. 
Cleansing away the secretions will be best 
effected by the Thudichum douche. This ap- 
paratus consists of a bottle, basin, pitcher, or 
other reservoir communicating with a long 
flexible-rubber tube at the end of which is 
fitted a hard-rubber nozzle. (Fig. 1757.) Any 
one of the following washes may be used,— 
namely, a solution of chlorate of potash (two 
drachms to one pint of tepid water), or of permanganate of potash (one grain 
to an ounce of water), or of bicarbonate of potash (one drachm and a half 
to a pint of water), or of common salt in the same proportions. A popular 
and efficient solution is that of Dobell, which can be used after the following 
formula: 
Fig. 1757. 
Thudichum douche. 
Acidi carbolici, gr. xvi; 
Sodas bicarb., 
Sodas biborat., aa gr. xxxii; 
Glycerines, 
Aquae, f^xvi. 
A douche consisting of one or two pints of tepid water should be passed 
through the nasal passages, first on one side and then on the other, which 
will suffice to remove the more detached or loosely adherent secretions, to 
he followed immediately by some one of the solutions mentioned above, 
which, by their solvent power over the mucus, cleanse the membrane more 
thoroughly. In using the douche, the nose-piece is to be introduced into one 
nostril, taking care not to raise the reservoir above the level of the root of 
the nose, by which precaution the liquid will not be likely to enter the Eusta- 
chian tube or the frontal sinuses, and as soon as the fluid is turned on the 
mouth must be opened. In a few moments the stream will issue from the 
opposite naris, as the soft palate shuts off the post-nasal portion from the 
other portions of the pharynx. (Fig. 1758.) 
In order more efficiently to cleanse the post-nasal region, the post-nasal 
syringe (Fig. 1759) can be employed to inject the upper part of the pharynx. 110 
DISEASES AND INJURIES OF THE NOSE. 
Atomizers, either the hand or the steam instrument, are used for the same 
purpose. For a long time I have employed for this purpose a swab with 
which to wipe out this 
part of the pharynx. 
The sponge attached to 
the extremity of the 
instrument, being well 
soaked in a solution of 
borax or soda, can be 
carried up behind the 
palate, and the space 
thoroughly cleansed. 
The nasal douche, by at- 
taching a curved nozzle 
to the gum tube and 
passing it up behind the 
soft palate, can be used 
very well for cleansing 
and spraying the phar- 
ynx. (Fig. 1760.) 
The mucous surface, 
having, by the means 
described, been freed 
from all adherent secre- 
tions, is now in a con- 
dition to receive the 
treatment necessary to 
remove the inflamma- 
tion on which the ca- 
tarrh depends. For this purpose both liquids and powders can be used. The 
post-nasal portion of the membrane can be most satisfactorily medicated by 
the swab. The article 
best adapted for the 
diseased surface is the 
nitrate of silver (gr. xl 
of the salt to distilled 
water to be used 
three times a week. The 
glycerole of tannin con- 
stitutes another valua- 
ble agent. Eight or ten 
parts of water with one 
of tannin can be used 
by the douche or by the 
atomizer. The insuffla- 
tion of powders is also 
beneficial. They are to 
be blown into the nasal 
cavities and also up be- 
hind the palate into the 
dome of the pharynx by the insufflator. The substances usually selected 
are vegetable or mineral astringents, as gallic acid, borax, rhatany, sub- 
nitrate of bismuth, and sulphate of iron: whichever article is selected should 
be mixed, before being used, with pulverized starch, gum arabic, white 
sugar, or lycopodium. In every instance the cleansing must precede the 
use of these remedies. 
Fig. 1758. 
use of the nasal douche. (The reservoir should be on a level with the nose.) 
Fig. 1759. 
Post-nasal syringe, with a nozzle for the anterior nares. 
Fig. 1760. 
Spray nozzle. 
Strumous Catarrh of Children.—A variety of catarrhal rhinitis is frequently 
seen in young children, confined to the mucous membrane of the nose, and HYPERTROPHIC CATARRH. 
never transcending the limits of the nasal fossae, unless allowed to go un- 
checked. It has always a strumous origin. 
Symptoms.—The symptoms consist of a muco-purulent discharge, issuing 
generally from both orifices, which are red, somewhat swollen, and after 
a time partly obstructed with dark scabs of inspissated muco-purulent 
matters. The discharges from the nose are very acrid, excoriating the 
upper lip and causing more or less swelling of the latter. There is frequently 
associated with the symptoms enumerated an inflamed state of the borders 
of the tarsal cartilages, their edges being often, especially in the morning, 
glued together with the altered Meibomian secretion. The lymphatic glands 
of the region may also be enlarged, and the appetite and nutrition of the 
child both be imperfect. 
Treatment.—Unlike most catarrhal affections of the nasal mucous mem- 
brane of a chronic nature, the one under consideration is amenable to 
treatment, yielding in a short time to the internal use of cod-liver oil, 
along with full doses of the syrup of the iodide of iron, reinforced by whole- 
some food, as milk, eggs, meat, animal broths, and sound vegetables, to which 
must be added tepid bathing, frictions of the surface of the body, sufficient 
clothing, and an out-door life, with good hygienic surroundings. Local ap- 
plications of weak citrine ointment or vaseline may also be employed with 
advantage. 
Hypertrophic Catarrh.—An inflammation of the naso-pharyngeal membrane 
allowed to proceed unchecked, under favoring constitutional conditions, will 
ultimately terminate in such structural alterations as to give rise to what is 
called hypertrophic catarrh, an exceedingly obstinate and distressing affection. 
It is both a constitutional and a local affection,—the former being in many 
respects more manageable than the latter. 
Symptoms.—In this variety of the disease there is considerable obstruction 
to nasal respiration in consequence of the thickened state of the mucous mem- 
brane. The obstruction is lessened or increased by atmospheric conditions. 
So sensitive, indeed, is the Schneiderian membrane to such influences, that a 
patient who at one moment is conscious of no unusual difficulty in breathing 
through the nose, may the next be compelled to inspire through the mouth. 
There is also a free, yellowish, muco-purulent discharge, which trickles down 
the pharynx and may be seen behind the soft palate. In order to get rid 
of this secretion in the pharynx the patient is compelled frequently to hawk 
it up. The discharge often descends into the larynx, producing an irritating, 
reflex cough, or by slow infection of the mucous membrane giving rise to a 
chronic laryngitis. In consequence of the extreme sensibility of the nasal 
lining membrane to atmospheric changes, the patient is strongly predisposed 
from such causes to acute attacks of coryza, in which for a time the discharge 
becomes thin and watery, is constantly running from the nose, and excoriates 
the skin of the upper lip and margins of the nares. The continuity of the 
mucous membrane of the nasal fossm with that of the pharynx, and in many 
respects their anatomical oneness, are such that both are implicated in the 
catarrh: indeed, nasal catarrh without a similar condition of the upper part 
of the pharynx is, I presume, rarely witnessed. 
When the cavity of the nose is examined in front, the mucous membrane 
covering the inferior and middle turbinated bones presents, as far as it can 
be seen, a tumid, deep-red, almost purple, congested appearance, and en- 
croaches so much upon the cavity of the nose as greatly to diminish the 
space between these bones and the septum: indeed, the membrane may have 
such a fleshy, pendulous appearance that I have known it to be mistaken for 
a polypoid growth. The membrane covering the septum is rarely very much 
thickened, though its naturally smooth surface is often roughened by localized 
infiltrations, and sometimes excavated by superficial ulcerations. 
When by the rhinoscopic mirror a view of the posterior nasal region is 
obtained, the same thickening is seen on the pharyngeal aspect of the tur- 112 
DISEASES AND INJURIES OF THE NOSE. 
binated bones. The mucous membrane covering the latter, in consequence 
of the anatomical disposition of the parts, is raised into longitudinal ridges 
or seams, which, with a swollen state of the same membrane at the free 
border of the septum, materially lessen the aperture of the posterior nares. 
The deep-red color which characterizes the mucous membrane covering the 
anterior extremities of the turbinated bones is on their pharyngeal surface 
exchanged for a much paler hue. Extending the examination into the 
pharynx, the same membrane will be found raised into groups of irregular 
nodulated eminences corresponding to the glands of the region, and traversed 
in different directions by ridges with intermediate depressions, the entire 
surface being red and congested and having tenacious masses of mucus 
adhering to it. In old cases of this catarrh the inflammation extends into 
the Eustachian tubes, and is followed by thickening of the lining membrane, 
causing dullness of hearing. 
Complications.—If chronic catarrh is allowed to go unchecked, it will, in 
the course of time, produce ulcerations of the Schneiderian membrane, peri- 
ostitis, perichondritis, caries, polypoid growths, and, extending into the 
accessory cavities, will involve the antrum and the sphenoidal and frontal 
sinuses. 
Pathology.—In hypertrophic catarrh the inflammation extends into the 
deeper layers of the mucous membrane. There is an active cell infiltration 
and proliferation, which results in a large increase of connective tissue, more 
or less mature. This is not limited to the exposed portion of the mucous 
membrane, but is equally active in its involuted or glandular part, so that 
the latter also becomes greatly hypertrophied, giving the granular and finally 
nodular appearance of the surface. This glandular hypertrophy is rendered 
still more prominent by an active formation of epithelial elements, which 
begins with the subepithelial connective-tissue forms. 
The secretion is made up of mucus, pus, and epithelial cells mingled together 
and suspended in a fibrinous transudation. 
As there is a scanty amount of submucous connective tissue attaching 
the mucous membrane to the walls of the nasal fossre, and as these walls are 
unyielding, the swelling and hypertrophy can be accommodated only at the 
expense of the free surface of the nasal passages: hence the obstacle to the 
entrance of air in respiration. 
Treatment.—When the evidences of a constitutional origin are present, 
whether strumous or syphilitic, the disease will demand constitutional reme- 
dies. Among the most valuable of these are cod-liver oil, iodide of iron, 
iodide of potassium, with or without the bichloride of mercury, and Lugol’s 
solution of iodine, and, when the circumstances of the patient will allow, a 
change of climate. Many cases of nasal catarrh which come under my ob- 
servation, and which obstinately resist treatment, quickly disappear upon 
the patient’s going South, only, however, to recur on his returning North. 
In the use of local remedies, the same preliminary measures of washing 
or cleansing the nasal passages as are requisite in the more simple forms of 
the disease will be necessary to prepare the way for therapeutical applica- 
tions ; and in the less pronounced degrees of hypertrophic catarrh, the reme- 
dial agents which are employed for the cure of the simple form of the disease 
will be found, if patiently persevered in, to prove effectual. When, however, 
the typical variety of this affection is encountered, remedies of a more de- 
cided character will be demanded. The great object is to get rid of the 
hypertrophy, or, what is equivalent, to effect the absorption of the new 
elements introduced into the structure of the mucous membrane. Various 
plans of accomplishing this have been recommended from time to time. 
Thus, we have pressure, the method of Wagner,—the use of sponge tents, 
or of bougies, passed into the nose,—avulsion, or the tearing away of 
circumscribed hyperplasise, which rise above the surface of the mucous 
membrane, caustics, galvano-cautery, sternutatories, and other local altera- 
tives. It is always best to employ first the milder remedies, and, if these fail HYPERTROPHIC CATARRH. 
113 
to produce the desired effect, to proceed to the use of those whose action 
is more potent. When the hypertrophy is of moderate extent, nitrate of 
silver (gr. i to xx to distilled water fgi) can be used with great advantage, 
beginning with a weak solution and increasing the strength gradually as the 
patient proves able to bear it. It can be applied very satisfactorily by a glass 
or hard-rubber syringe having a long flexible nozzle well rounded at the 
extremity and with a number of small apertures a short distance from the 
end, opening in a backward direction. (Fig. 1761.) The syringe, charged 
Fig. 1761. 
Syringe with flexible nozzle, for injecting fluid into the nasal cavities. 
with the liquid, is to be conducted along the middle meatus as far as the 
posterior nares, when its contents are to be gradually discharged by pushing 
the piston slowly down while the instrument is being gradually withdrawn. 
In this way the diseased surface is reached along the entire side of the nasal 
fossa, the redundant fluid thrown into the middle meatus falling over the 
inferior turbinated bone and the inferior meatus; or these spaces with their 
bony scrolls may be treated separately. The compound solution of iodine 
(gtt. xxx to water can be used in the same manner, also the sulphate 
of zinc (grs. v to water fji), or the chloride of zinc (gr. i to water f5i), or 
the nitrate of lead (grs. x to water The applications should always be 
preceded by some one of the cleansing washes, and in the intervals between 
their employment, which should be from two to three days, the patient can 
use with advantage a snuff consisting of equal parts of calomel and powdered 
liquorice root. The therapeutical solutions directed above can also be applied 
very neatly through the nasal speculum by means of a swab or piece of ab- 
sorbing cotton secured to a flexible probe. Acetic acid, from its resolving 
effect upon hyperplasias, enjoys a deservedly high reputation in the treat- 
ment of nasal catarrh. It is readily brought in contact with the thickened 
membrane by the nasal swab. Should the pain following its application 
continue long, it can be alleviated by injecting an alkali, as a solution of 
bicarbonate of soda, into the nasal cavity. In reaching the post-nasal hy- 
pertrophy, the pharyngeal swab will answer best for the application of 
remedies. 
Chromic acid possesses escharotic properties which render it both a man- 
ageable and efficient agent in the destruction of the thickened tissue. A 
probe with a little roll of cotton attached, to which the crystals of the acid 
adhere, will answer for nasal applications, and a delicate, curved probang 
similarly armed constitutes a convenient mode*of conveying the caustic to 
the vault of the pharynx. The crystals should be very sparingly used, and 
care taken not to allow them to come in contact with the sound parts. There 
are, however, cases in which the hyperplasia is so obstinate, in consequence 
of the amount of connective-tissue elements present, that nothing short of 
the most powerful agents will make any impression on the disease; and of 
these the gal vano-cautery, 
nitric acid, and chromic 
acid are most efficient. 
In applying the galvano- 
cautery to the hypertro- 
phied tissue of the turbi- 
nated bones, an electrode, designed either to resolve (Fig. 1762) or to incise 
(Fig. 1763) the thickened surface of the mucous membrane, is mounted 
Fig. 1762. 
Fig. 1763. 
Electrodes for use with galvano-cautery. 114 
DISEASES AND INJURIES OF THE NOSE. 
on a handle having the circuit-closer conveniently attached in order to 
be under the easy control of the thumb. The addition of a wheel to the 
handle or holder will also be valuable, as by it the ecraseur, in cases demand- 
ing its aid, can also be used. The electrode should be introduced into the 
nose through the nasal speculum. In treating the hyperplasia at the vault 
of the pharynx, the 
ingenious electrode of 
Dr. Lincoln, of New 
York (Fig. 1764), will 
be found both safe and 
convenient. The elec- 
trode is inclosed within 
a spiral coil, at the end 
of which is a hard- 
rubber hood contain- 
ing the platinum cone. 
When the electrode is passed into the pharynx and pressed against its dome, 
the cup retreats, thus exposing the cone, which on the removal of the 
pressure again recedes into its hood. When isolated masses of hypertro- 
phied tissue are discovered rising from the mucous membrane, they may be 
removed by the galvano-cautery ecraseur. In destroying the hypertrophied 
tissue at the dome of the pharynx, in addition to the means already de- 
scribed, the curette (Fig. 1765) and the avulsion forceps (Fig. 1766) are 
Fig. 1764. 
Dr. Lincoln’s pharyngeal electrode. 
Fig. 1765. 
Curette. The curette can be fixed at any desired angle. 
sometimes used. Other measures failing, the curette is best adapted to 
those cases where the surface of the mucous membrane is beset with small 
Fig. 1766. 
Avulsion forceps. 
wart like prominences of hypertrophied tissue, which admit of being scraped 
away. 
When the avulsion forceps is used, the instrument is carried up behind the 
soft palate to the dome of the pharynx, or to the posterior extremities of the 
turbinated bones, and the projecting masses of hypertrophied glandular tissue 
seized and torn away piecemeal. It is a rude kind of surgery, but it is 
wonderful how kindly the pharynx tolerates the barbarity. CATARRH OF THE ACCESSORY CAVITIES. 
115 
Atrophic, or Dry Nasal Catarrh.—This variety of catarrh maybe the result 
of the hyperplastic form of the disease, or it may be a sequel of any protracted 
inflammation of a chronic nature affecting the nasal passages. All occupations 
in which the air respired is loaded with irritating matters predispose to this 
form of catarrh. 
Symptoms.—Instead of a free muco-purulent discharge of moderate con- 
sistence, the secretions are scanty, and collect in the nasal foss® and pharynx 
in the form of thin, gray or dark crusts, which cling tenaciously to the mu- 
cous membrane. The latter membrane loses its moist and supple appearance, 
and becomes stiff, glazed, and shining. The nasal passages are very sensitive 
to atmospheric impressions. Though no particularly disagreeable odor belongs 
to the affection, yet in neglected cases where the crusts are permitted to ad- 
here for a long time to the walls of the nasal passages, preventing the escape 
and favoring the decomposition of the secretions which form between the 
two, a very offensive odor will be present. 
Pathology.—The structural changes observed in dry catarrh consist 
chiefly in atrophy of the glandular element, the result partly of pressure, 
from the great increase of cell elements in the deep layers of the membrane, 
and partly of contraction of the newly-formed connective tissue. In cases 
of marked chronicity, the atrophy is not confined to the components of 
the mucous membrane, but includes also the bones. The turbinated scrolls 
generally become thinner, and may almost entirely disappear by absorp- 
tion, giving to the nasal fossae a large, cavernous appearance. The agencies 
at work in producing this atrophy are twofold,—the presence of new cell 
forms in the bones, causing softening of the osseous tissue, and pressure made 
by the secretions pent in under the unyielding crusts, which cling to the 
mucous membrane. 
Treatment.—The permanent cure of atrophic catarrh presupposes the 
restoration of the glandular elements of the mucous membrane to a normal 
condition, which is never effected, and, consequently, the most that can 
be promised is palliation. The treatment is resolved into the preparatory 
and the therapeutic. 
The preparatory treatment consists in removing the closely adherent 
vitiated secretions and crusts from the nose and pharynx. This is not easily 
accomplished. The washes directed in hypertrophic catarrh will answer 
the purpose very well, and may be applied in the same manner, by douche, 
syringe, or mop. 
The chief therapeutical remedies which should subsequently be used are 
sanguinaria, iodoform, iodine, carbolic acid, salicylic acid, borax, chlorate of 
potash, bicarbonate of soda, myrrh, chlorinated lime, chlorinated soda, and 
charcoal. Astringents in this form of catarrh are entirely out of place. 
Most of the above-named remedies, admit of being applied in the form of 
powders, mixed in equal proportions with starch, sugar, lycopodium, or 
liquorice, and blown into the cavities by the insufflator, or introduced on 
pieces of cotton attached to a flexible probe. By daily cleansing the sin- 
uous passages of the nose and the irregular surface of the vault of the 
pharynx, and by the use of some one of the different powders already 
mentioned, the patient can be made quite comfortable, though he can never 
be entirely cured. 
Chronic inflammation located in the antrum, or in the frontal, sphenoidal, 
or ethmoidal sinuses, has been frequently confounded with nasal catarrh. 
The distinction has been very clearly set forth by Michel, of Cologne. 
Symptoms.—The symptoms which characterize chronic catarrh of the ac- 
cessory nasal cavities in some respects simulate those forms of catarrh which 
have been under consideration. There is a free discharge, which accumulates 
in the nose. There are masses of dark crusts, with more or less obstruction 
Catarrh of the Accessory Cavities communicating with the Nasal Fossae. 116 
DISEASES AND INJURIES OF THE NOSE. 
to the free passage of air. On closer inspection, however, the mueo-purulent 
secretions will be seen to have a green rather than a dark-yellow color, 
as in ordinary chronic catarrh, and to be more generally diffused over the 
surfaces of the nasal fossa;; the crusts also are more abundant, and appear 
to be more closely packed into the different recesses of the meatus, than 
in the ordinary varieties of catarrh. Still more distinctive will be the appear- 
ances presented by the mucous membrane when carefully cleansed from all 
the inspissated secretions and crusts: in catarrh of the communicating 
cavities it will be found to differ little in appearance from the same mem- 
brane in health ; the same can be affirmed of the pharynx. There are also 
in the affection under consideration peculiar and characteristic sensations, 
as a feeling of fullness, which is situated in the cheek when the antrum is 
affected, across the forehead when the frontal sinuses are implicated, and at 
the base of the skull when the sphenoidal sinuses suffer. To this sign may 
be added the very significant one of fetor, the breath, whether issuing from 
the nose or from the mouth, being loaded with a repulsive odor, often so 
disgusting that the unhappy patient is compelled to live in an atmosphere 
charged with fetid exhalations. It is this latter symptom wThich has secured 
for the disease in the nomenclature of some writers the designation ozaena. 
The antrum is the cavity usually attacked. 
Causes.—This form of catarrh is sometimes due to an extension of the 
disease from the mucous membrane of the nose in simple nasal catarrh, the 
inflammation remaining in these communicating cavities after it has dis- 
appeared from the former passages. In other instances it commences pre- 
viously in the accessory chambers, developed either from some local irritation, 
as the diseased root of a tooth (when the antrum is affected), or retained 
secretions in the other cavities, or from some pre-existing constitutional vice. 
The disease is generally met with in the young, and in girls oftener than in 
boys. 
Treatment.—The treatment is for the most part a palliative one, and 
consists in the employment of cleansing and deodorizing washes, as a solution 
of permanganate of potash, chlorinated lime (5i to of wrater), nitrate of 
lead (3i to f'Sviii of water), carbolic acid (gtt. vi to fjii of water), and chlo- 
rinated soda (5i to of water). Very many other agents have been 
recommended by writers, but those named embody all the qualities likely to 
do good. These cleansing washes require to be used in large quantities, less 
than a quart at each washing being of very little value. Should the accu- 
mulation of hardened crusts in the nasal cavities occasion abrasions of the 
mucous membrane leading to definite ulcerations, the ulcers will require to be 
touched with some iodoform mixed with balsam of Peru, or with a crayon 
of nitrate of silver or sulphate of copper. The gentle stimulus arising from 
the use of dilute nitric acid will also make a favorable impression on these 
sores. When a local irritant can be discovered, as the diseased root of a 
tooth trenching on the cavity of the antrum, the fragment of a necrosed 
bone, or some foreign body, as a shot or a ball lodged in the frontal sinus, 
its removal constitutes the initiatory step to all treatment. 
Nor must constitutional treatment he ignored when there can be dis- 
covered the evidences of a general dyscrasia. The iodide of potassium is 
best adapted to those cases in which a factor can be traced, and 
cod-liver oil with iodide of iron to such as develop in a strumous constitu- 
tion. Neither mercury nor arsenic possesses any therapeutic value in these 
catarrhal affections. 
Inflammation of the Frontal Sinuses having no specific character like that 
arising from struma, syphilis, or other causes ending in offensive catarrh, 
is occasionally witnessed, sometimes primarily as the result of cold, or sec- 
ondarily from the extension of inflammation in an ordinary rhinitis. In one 
instance where the inflammation occurred in the sinuses independent of any 
pre-existing affection of the nasal passages, it was brought on by the patient WOUNDS OF THE FRONTAL SINUS. 
117 
having ridden for many consecutive hours during a cold, stormy day with 
the apron of his carriage sufficiently high to expose merely the eyes and 
forehead. Traumatic causes, as blows and wounds over the brows, are also 
concerned in the production of this affection. 
Symptoms.—The symptoms of this inflammation are a sense of fullness, 
tension, and weight extending across the forehead from brow to brow, suf- 
fused watery eyes, headache, and the discharge of a thin mucus from the 
nose, differing from that which escapes in ordinai-y attacks of influenza in 
being more watery in consistence and having a straw color. Should there 
be any prolonged obstruction to the exit of the secretion, the suffering ex- 
perienced in the head becomes very great. 
Though generally under proper treatment the inflammation can be con- 
trolled and resolution established, yet it may end in suppuration, giving rise 
to abscess, a termination which will be announced by rigors, oedema, and a 
dusky discoloration of the integuments over the forehead. 
Treatment.—On the occurrence of the signs attending simple inflammation 
of the sinuses, a gentle purge or warm foot-bath, with a diaphoretic and 
anodyne mixture, will usually fulfill the indications. If the disease manifests 
no disposition to yield in a few hours, leeches should be applied over the 
sinuses, followed by the inhalation of hot vapor, or by steaming the head 
and face. 
When the inflammation ends in abscess, the pus will probably find its way 
into the nose; but should this not take place, operative interference will be 
demanded, otherwise necrosis of the bone may follow. The collection can 
be speedily evacuated by exposing the anterior wall of the sinus and making 
an opening through it with a small trephine. After the escape of the pus 
the cavities should be washed out with a solution of the permanganate of 
potassium. 
Foreign Bodies of different kinds may enter the frontal sinuses through the 
natural channel, or through the external walls of the frontal bone; others 
of a cei'tain kind are formed in the sinuses. Among those which gain ad- 
mission by the first-named route aro maggots, developed from the ova of 
flies deposited in the nose, leeches, etc. Hydatids have also been observed 
in these chambers. These, with the appropriate plans of treatment, have 
already been described. Balls, shot, the ends of knife-blades, etc., may enter 
the sinus by puncturing its wall. 
Calculi or concretions have, in rare instances, been found in the frontal 
sinus; they have been composed chiefly of lime. They were formed, doubt- 
less, in the same manner as rhinolitbs. The presence of such a body might 
be suspected from the existence of symptoms counterfeiting those of inflam- 
mation of the sinus, but it could not be positively determined. Its removal 
would require the surgeon to make an opening by a trephine through the 
anterior wall of the cavities. 
Wounds of the Frontal Sinus are punctured, incised, and gunshot. The 
cavities may also be opened by any kind of violence producing fracture. 
The existence of such an injury is readily determined by the probe. The 
escape of air from the nose through the external opening, or, when the com- 
munication between the sinus and the surface is indirect, its escape into the 
subcutaneous cellular tissue overlying the sinuses, giving rise to emphysema, 
will be further confirmatory of the nature of the injury. 
The treatment proper to wounds of the sinus must be regulated by the 
nature of the vulnerating body. In all cases the objects to be kept in view 
are the removal of the foreign body and the proper cicatrization of the wound. 
The first indication, particularly in shot injuries, may demand an enlarge- 
ment of the opening, in order to effect the extraction of the missile. When 
the air permeates the subcutaneous tissue in consequence of the indirect 
relations of the two openings (that in the bone and that in the soft parts), 118 
DISEASES AND INJURIES OF THE NOSE. 
an attempt should be made to obviate the difficulty by applying a compress 
and roller, which may abort the evil by making the two openings direct. 
It is possible for the wound in the integuments to heal, and for that in the 
anterior wall of the sinus to close imperfectly, and permit, as the conse- 
quence, the formation of a small emphysematous swelling over the brow. 
Under these circumstances, persistent pressure by a compress and bandage 
or by adhesive straps would be indicated. 
Tumors of the Frontal Sinus, though quite uncommon, are nevertheless 
sometimes seen, their nature being osseous or ivory-like, carcinomatous, poly- 
poid, and sarcomatous. The growth of these neoplasms, in some instances, 
gradually thins out the anterior wall of the sinuses, and causes the absorp- 
tion of its lime salts to an extent which permits the bone to crackle like 
parchment when pressed upon by the fingers; or the bone may be destroyed 
by necrosis, as in Mr. Hilton’s case given by Bryant. Excision of the super- 
incumbent bone alone renders the removal of such growths feasible; and 
where there are sufficient reasons for believing that the disease is circum- 
scribed by the walls of the sinus, such an operation will be perfectly 
proper. 
Affections involving the Septum.—The septum narium is made up of the 
vomer, perpendicular plate of the ethmoid bone, and cartilage. 
Deviations of the septum laterally are exceedingly common as a natural 
defect. Frequently the deformity is the result of traumatic or of patho- 
logical causes. It is very common after fracture of the nasal bones, and in 
cases where the nasal fossa of one side becomes filled with polj’poid or other 
growths. 
The deviation is readily detected by the eye after expanding the nares, 
when the septum will be seen encroaching on the cavity of the nose on one 
side, frequently to an extent which prevents the free entrance of air and 
compels the patient to breathe through the opposite nostril. The obstruc- 
tion imparts a nasal tone to the voice, and renders it necessary, in bad cases, 
to breathe to some extent through the mouth. 
The deviation may be confined to the cartilaginous septum, or it may in- 
clude both the latter and the bony partition. 
Treatment.—Various operations have been proposed and practiced at 
different times in order to correct or straighten these deviations of the septum, 
—namely, by making a number of incisions radiating from the centre to the 
circumference of the cartilage, b}7 excising one or more pieces from its struc- 
ture, and by subcutaneous and subperiosteal division. Except in a very few 
cases, these methods prove exti’emely unsatisfactory, particularly so when the 
bony septum as well as the cartilaginous is out of proper line. Very much, 
however, can be done by wedging, if perseveringly maintained. A piece of 
lint fashioned into a little wedge, from three-quarters of an inch to one inch 
in length, well smeared with vaseline or cold cream, is to be introduced, apex 
first, into the nose, and pressed well back into its cavity, where it must be 
Fig. 1767. 
Adams’s forceps for correcting deviations of the septum narium. 
allowed to remain from one to four hours. This process, repeated daily with 
wedges of increasing size, will in a few weeks correct much of the deviation 
and enlarge the capacity of the fossa. AFFECTIONS OF THE SEPTUM. 
119 
When the deviation is limited to the cartilaginous septum, or even affects 
the bony septum as well, the operation of Mr. Adams can be adopted with 
excellent prospect of success. This consists in introducing the blades of a 
strong pair of forceps (Fig. 1767) into the nose, the patient being etherized, 
and embracing the septum between their flat surfaces: as the latter are 
brought strongly together, the septum is immediately forced into place. 
After the removal of the forceps the advantage thus gained is maintained by 
introducing an instrument formed of two plates, which 
can be separated one from the other by a screw fixed 
in the handle. (Fig. 1768.) These appliances, used 
for three or four days, are afterwards followed for some 
time by the use of ivory wedges to prevent a relapse. 
When a case of lateral deviation, such, for example, 
as sometimes follows a severe fracture of the nose, is 
accompanied by much obstruction, and cannot be corrected by the forceps, 
it may become necessary, in order to overcome the difficulty, to resort to 
excision of the displaced portion of the septum, by cutting out from its centre 
an oval opening of sufficient size to admit the air from the unsound side to 
pass across to the nasal fossa of the sound side. This can be executed most 
satisfactorily by the use of the Blandin punch. (Fig. 1769.) A blade is in- 
troduced into each nostril, and by repeated applications of the instrume 
sufficient amount of the displaced septum can soon be cut out. 
Fig. 1768. 
Adams’s screw plates for 
keeping the septum straight. 
Fig. 1769. 
Blandin punch. 
The old method of obviating the difficulty arising from deviation of the 
septum was as follows: after detaching the middle of the upper lip from the 
jaw, and the column of the nose from its connections with the septum, and 
raising both together, the cartilaginous septum was exposed and excised by 
a pair of stout scissors, in whole or in part, either alone or with the bony 
septum; after which the lip and column were brought down and restored to 
their original positions without any scars or defects being produced. Such 
an operation can scarcely ever be required, in view of the means in our 
possession for correcting these deformities. 
Inflammation of the Septum may exist independently of any other disease 
of the nose, or may follow any injury inflicted on the nose. It may exist as 
part of a nasal catarrh, or it may appear as one of the late manifestations of 
syphilis, or possibly as an outcrop of struma. 
The mucous membrane presents a deep-red color, and is swollen on one or 
both sides. That part of the mucous membrane at the posterior border of 
the septum becomes more swollen from the inflammatory transudation than 
elsewhere, so much so, indeed, as to encroach upon the posterior nares, 
materially diminishing their size. The swelling also extends backward in 
the direction of the pharynx, so that in making post-palatine explorations 
with the finger or the rhinoscope the observer is often struck with the 
resemblance of the parts to the irregular broad-based tumors which appear 
in this region. 120 
DISEASES AND INJURIES OF THE NOSE. 
Treatment.—Inflammation of the septum, when not of a specific char- 
acter, as that from scrofula or syphilis, soon subsides under slightly astringent 
washes, as a weak solution of sulphate of zinc or hot water. A single leech 
applied on each side of the columna nasi exercises a capital influence in 
paling the membrane and relieving the overdistended blood-vessels. When 
the inflammation is only a symptom of a general dyscrasia, local measures 
alone will not suffice for the case : they must be supplemented by remedies 
suited to the diathesis. 
Blood Extravasations of the septum are sometimes seen, usually resulting 
from traumatism. The extravasation is seated between the mucous mem- 
brane and the cartilage, or between the former and the bony part of the 
partition. When the accumulation of blood is considerable, the Schneiderian 
membrane is detached from the cartilage or bone on w’hich it rests, forming 
a dark swelling which obstructs the nasal fossa. 
Treatment.—When the tumor or swelling is large and increasing, a free 
incision should be made into the swollen membrane and the blood allowed 
to escape. 
Abscess of the Septum.—There are two varieties of abscess met with in the 
septum narium, the acute and the chronic. 
The first, or acute form, occasionally provoked by an injury to the nose, 
is more commonly one of the developments of scrofula, or of that blood dete- 
rioration which is wrought by a low grade of fever. The abscess may be 
diffused or circumscribed, the former occupying both sides of the septum, 
and, unless promptly recognized and opened, is liable to cause no small 
damago to the parts by the extensive detachment of the pituitary membrane. 
Wherever situated, the entire cartilaginous portion of the nose sympathizes, 
becoming red, swollen, and tender to the touch. The upper lip frequently 
participates in the swelling, especially when the abscess is between the 
column and the septum of the nose. The mucous membrane covering the 
septum is also swollen, and has a red or purple color, and little if any secre- 
tion is discharged from the nasal passages. Febrile phenomena may accom- 
pany the local symptoms. The inflammatory swelling is not always confined 
to the parts named, but is likely to extend to the tear-duct and interfere tem- 
porarily with the flow of the lachrymal secretion into the nose, and to cause 
ulceration and necrosis of the components of the septum : indeed, instances 
are not wanting in which inflammation crept up the septum to the cribriform 
plate of the ethmoid bone, and thence to the membranes of the brain, event- 
ually destroying the life of the patient. 
The chronic abscess differs from the acute in being unilateral, in the faint 
redness of the mucous membrane, in there being much less pain, and in the 
absence of those signs which appear on the cutaneous surface of the nose. 
These abscesses must not be confounded wTith those which so often occur 
just within the nares, at the upper and lower extremities of those openings, 
in parts which are covered by the skin and beset with hair or vibrissa. 
Furuncles, or little boils, are very common in these localities, which, like 
similar abscesses in other parts of the body, are probably associated with 
disease of the follicular glands. 
Treatment.—In the acute abscess, if an early recognition of the precedent 
inflammation should be made, an antiphlogistic treatment may probably 
abort the abscess; but when this is not the case, and the disease advances to 
suppuration, the maturation of the abscess should be favored by the use of 
hot water, frequently drawn into the nose and applied to its outside; the 
pus should be liberated at the earliest moment by proper incisions. 
Perforating Ulcer of the Cartilaginous Septum.—This insidious form of 
ulceration, in a large proportion of cases, has a syphilitic origin. Its course 
is slow, and occasions very little local irritation. The presence of a sore of SOFT POLYPI. 
121 
this nature is readily discovered by expanding the nostrils before a good 
light and bringing the septum into view, when the opening through the 
cartilage, forming a communication between the nasal fosste, and usually 
perfectly round, with smooth edges, can be seen. 
The application, to the edges of the ulcer, of dilute nitrate of mercury 
ointment, or of iodoform mixed with balsam of Peru, will constitute tbe 
proper local treatment. Internally, iodide of potassium, iodide of iron, bi- 
chloride of mercury in a strong decoction of sarsaparilla, or with cod-liver 
oil, are the most appropriate therapeutic agents. 
Morbid Growths in the Nasal Passages. 
The neoplasms which develop in the nasal passages are benign and malig- 
nant. Among the former the most common growth is the polypus, of which 
there are two varieties, the soft, mucous or gelatinous, and the firm, or fibrous 
polypus. 
Soft, or Gelatinous Polypi constitute a very large proportion of all neoplasms 
found within the nasal fossae. They are nearly equally common in males and 
females, and seldom appear before puberty. The mucous polypus is grayish, 
sometimes of a pale yellow or a delicate green color, pyriform, lobulated, or 
flask-shaped, with a pedunculated attachment, in consistence soft, slightly 
elastic, having a tremulous appearance when detached from its connec- 
tions, and with long, straggling vessels sparsely scattered over the surface. 
Frequently these growths are multiple, occupying one or both fossae, and 
become moulded into all the sinuosities and recesses of the nasal passages. 
These polypi are usually suspended from one of the turbinated bones, ordi- 
narily the superior or middle, and very rarely 
from the septum. (Fig. 1770.) They vary 
in size from the dimensions of a pea to those 
of a small egg. When attached near the 
posterior part of the outer wall of the nasal 
fossa they frequently drop back into the 
pharynx, and when connected anteriorly 
will sometimes protrude even from the an- 
terior nares. The hygrometric property of 
the soft polypus is very characteristic, the 
growth absorbing moisture during damp 
weather, thus increasing the obstruction of 
the nose, and as promptly giving it up when 
the atmosphere is dry, when it shrivels up 
and recedes almost out of sight into the 
clefts of the meatus. When incised or 
crushed between the fingers they yield an 
unctuous, albuminoid fluid. Altogether, the gelatinoid polypus bears a strong 
resemblance to the oyster. 
Causes.—Catarrhal inflammations of the nasal passages play an important 
part in the causation of gelatinoid polypi. Other causes have been assigned, 
as syphilis, scrofula, disturbances of the menstrual functions, etc. 
Symptoms.—There are no signs in the very early formation of gelatinoid 
polypus to distinguish the effects of such tumors from those of any other irri- 
tation located witliin the nasal fossae. The patient will experience some degree 
of fullness in the nose, some mucous discharge from the pituitary membrane, 
and an inability to breathe with entire freedom through the affected fossa, 
particularly during damp or wet days. As these growths acquire bulk, 
however, the symptoms become more distinctive. Not only does the obstacle 
to nasal respiration increase, but the feeling of fullness in the nose becomes 
more pronounced. The patient is obliged to keep the mouth open, particu- 
larly when both fossae are involved. When an attempt is made to blow the 
Fig. 1770. 
Soft polypi attached to the turbinated bone. 122 
DISEASES AND INJURIES OF THE NOSE. 
nose, the air escapes with difficulty, and the same obstruction is experienced 
in making forcible efforts at inspiration. Sometimes the fossa opens for a 
moment, but on attempting to draw in the air it is suddenly closed by the 
pendent growth shutting off the cavity like a valve. A thin, watery mucus 
is discharged, sometimes blood; the sense of smell is more or less impaired, 
or even entirely lost, and the voice assumes a characteristic nasal tone. Irri- 
tation is often experienced behind the palate in consequence of the growth 
falling back into the pharynx. Carrying the examination into the interior 
of the nasal fossee, under a favorable light, the polypus can generally be dis- 
covered and recognized by its color, and may be moved about with the assist- 
ance of a director or probe, thus rendering its existence a matter of certainty. 
When the growth occupies the posterior portion of the nasal cavity, it may 
easily elude detection by an examination made from the front, but will be 
recognized by passing a finger up behind the palate. The rhinoscopic mirror 
can be brought into requisition for the same purpose. Among the rarer evils 
arising from nasal polypi is that of asthma, which, as has been shown by 
Yoltolini, does occasionally depend upon the presence of such growths in 
the nasal passages. Fraenkel and Haenisch have also observed the same con- 
nection. The explanation must be sought either in the reflex system of 
nerves or, possibly, in deficient aeration, the result of mechanical obstruction. 
Diagnosis.—The dissimilarity between the gelatinoid polypus and all other 
morbid growths of the nasal cavities is so striking that it is not likely to be 
confounded with any other. Its translucent appearance, gray color, soft, 
elastic, pulpy consistence, mobility, hygrometric variations, and indisposition 
to bleed on being touched, are so strikingly in contrast with the opacity, fixed- 
ness, density, tendency to bleed, and red. fleshy look of almost all other tumors 
—as fibroma, carcinoma, and sarcoma—of this region, that error of diagnosis 
is almost impossible. Bony and cartilaginous tumors may readily be dis- 
tinguished from polypi by their hardness and feel when they are touched 
with a probe. Even those soft polypi which become covered with a cal- 
careous incrustation, thus counterfeiting osseous growths, are unlike the 
latter in being still movable. Tho strumous hypertrophy of the mucous mem- 
brane covering the inferior turbinated bone, so frequently seen in children, 
has often been confounded with polypus, but its extent, form, and color 
should prevent any such mistake. And when it is considered that polypi 
rarely grow from the septum, and that they are not painful or accompanied 
by inflammatory phenomena, it is scarcely necessary to offer a caution 
against confounding them with abscess, or with blood-swellings of the 
septum narium. 
Pathology.—The histological elements of gelatinoid pol}rpi are not always 
the same. Though they are only localized hypertrophies of the normal con- 
stituents of the mucous membrane of the nose, the proportion which these 
constituents contribute to the formation of soft polypi varies greatly. In all 
the external layer or covering is formed of ciliated epithelium. The mass 
of the tumor, however, is sometimes made up of a reticulum of loose con- 
nective tissue, overspread by long, straggling, or tortuous blood-vessels, and 
its interspaces filled with mucus containing nuclei and cells of various forms, 
oval, fusiform, and caudate. In other instances the glandular element pre- 
ponderates, and the bulk of the growth consists of groups of hypertrophied 
and sacculated muciparous follicles. In a third variety the connective tissue 
constitutes a very considerable part of the neoplasm, imparting, in conse- 
quence, a firmness of structure which does not belong to the other form of 
the disease. 
Prognosis.—Though pure cases of gelatinoid polypi are free from any 
admixture of malignancy, recurrence after removal is very common. Even 
when the avulsion has been thorough, that is, when no part of the pedicle 
is left, the tumor is frequently reproduced. It does not necessarily follow, 
however, that the secondary growths spring from the identical surface or 
surfaces from which the first were removed. This is notably true when the SOFT POLYPI. 
123 
tumors are multiple; almost every portion of the outer wall of the nasal 
passages in such cases is rife for new developments of a like nature. 
Treatment.—Various agents for local application have been extolled at 
different times for the cure of soft polypi. Mr. Bryant speaks encouragingly 
of powdered tannin blown into the nose by an insufflator. The saffronized 
tincture of opium of the Prussian Pharmacopoeia is lauded by Primius. Per- 
sulphate of iron, perchloride of iron, tincture of chloride of iron, chloride of 
zinc, alum, pulverized sanguinaria Canadensis, nitrate of silver, bichromate 
of potash, and several other drugs have had their advocates. 
When the polypi are small, the persevering employment of astringents will 
occasionally shrivel and destroy them; but the process is a slow one, and 
is attended with uncertainty. 
Avulsion, or the tearing away of the growth by a properly-constructed 
forceps, in point of rapidity and thoroughness of execution is by far the 
most satisfactory and expeditious method of dealing with the form of polypus 
under consideration. The polypus forceps as made by some surgical cutlers 
is unsuited for the operation. The instrument is too large, and either too 
little or too much curved. The blades should be slender, slightly curved, 
and the extremity of each duck-billed in shape, having a concavity in the 
centre, with a serrated border. (Fig. 1771.) A favorable period, when 
Fig. 1771. 
Polypus forceps. 
choice is possible, should he selected for the extraction of polypi,—one when, 
in consequence of their hygrometric capacity, they are distended, and thus 
forced out of their lurking-place. On this account, a damp day is usually 
to be preferred to one that is dry. 
The patient is to be seated on a chair before a good light, with the head 
supported from behind, and with a piece of rubber cloth or sheet, or a large 
towel, secured about the neck and in front of the breast, in order to pro- 
tect the clothing. A basin containing a little water should be held in front 
of the neck, to receive the blood, which usually flows quite freely during 
this operation. Having ascertained the 
position of the tumor, either by the 
eye or by a director, the operator con- 
ducts the closed forceps into the nasal 
fossa, with a light hand, in the direction 
of the growth. When the latter is reached, 
whether seen directly with the eye or 
recognized by the sensation communicated 
to the hand, the blades of the instrument 
are to be separated, carried onward a little, 
and then firmly closed in such a manner as 
to embrace the pedicle of the polypus as 
near as possible to the pointof implantation 
upon the mucous membrane. (Fig. 1772.) 
The detachment is to be effected by the 
combined movements of torsion and trac- 
tion ; that is, by first turning the forceps 
two or three times on its axis, and then 
withdrawing it from the nose, thus twisting off the pedicle. The object of 
the torsion is twofold,—to prevent hemorrhage, and, by winding the pedicle 
Fig. 1772. 
Methods of removing polypus with the forceps 
and with the canula and wire. 124 
DISEASES AND INJURIES OF THE NOSE. 
around the blades, to detach more certainly the growth in its entirety. 
Should the first effort fail to extract the polypus, or should only a portion be 
removed, the instrument must be reinserted again and again until the fossa 
is entirely cleared, which may be known by the freedom with which the air 
can be drawn through the affected side of the nose, both in inspiration and in 
expiration. During the process of extraction the polypi frequently elude the 
grasp of the instrument by rolling into some retired part of the meatus. 
Forcibly blowing the nose will, under such circumstances, serve to dislodge 
the growths from their hiding-places and bring them again within reach of 
the forceps; it is useful in another way, by expelling fragments of polypi 
which may still cling to the pituitary membrane by a slender thread of un- 
broken tissue. Frequently the polypus, growing from the posterior part 
of the nasal cavity, and possessing a lengthy pedicle, falls back into the 
pharynx, in which location it is not easily caught by the instrument. The 
difficulty is surmounted by passing 
a finger up behind the soft palate to 
the growth, which can at the same 
time be seized with the forceps, car- 
ried through the nose. (Fig. 1773.) 
While the forceps are perfectly 
safe in judicious hands, they are 
capable of inflicting considerable 
damage when used in a careless 
or unskillful manner, the turbi- 
nated bones having been torn away 
and other injury done to the fossae. 
The bleeding which attends avul- 
sion is generally free, though rarely 
copious or of a character not to 
subside spontaneously. If too free 
or protracted, keeping the head ele- 
vated, applying cold water to the 
outside of the nose, and snuffing it 
up the nasal cavity will generally 
arrest the hemorrhage. These measures failing, hot water containing a little 
fluid extract of ergot may be passed through the nose. In obstinate cases, 
where the usual remedies fail, resort must be had to some of those plans for 
arresting hemorrhage which have been directed under the head of epistaxis. 
Snaring.—Placing a wire noose around the polypus, then strangulating it 
and removing it by traction, is perhaps the most ancient of all methods. It 
is certainly older than the Father of Medicine. Thirty years ago it was 
much practiced in this country; and in Great Britain at the present time it 
is in favor with Bryant, Hilton, and Durham. 
A double canula having passed through its barrels a fine, soft, well- 
annealed iron wire, one end of which is wrapped ai*ound the arm of the cross- 
piece at the upper extremity of the instrument, Avith a loop of the wire 
projecting some distance beyond the other extremity, constitutes the proper 
Fig. 1773. 
Extracting a polypus by the conjoined agency of the 
finger and forceps. 
Fig. 1774. 
Double canula and wire for snaring polypi. 
appliance for carrying into effect this method (Fig. 1774), and is quite as 
efficient as the more complicated mechanism of Hilton. 
In using the instrument, the loop of wire is pushed forward some distance FIBROUS POLYPI. 
125 
beyond the end of the canula and slightly bent. It is then passed into the 
nose with the canula, along the septum, and, directed by the eye, by a small 
fork, or by the hand, is made to slip over the growth; then, by pulling 
strongly upon the free end of the wire, the pedicle becomes snared and con- 
stricted by the noose; the detachment of the growth is effected by pulling 
upon the canula. (See Fig. 1772.) 
For removing a polypus which hangs into the pharynx the same appliance 
can be by using the finger behind the soft palate to adjust the 
noose about the growth. Waldenberg, in order to place a noose around the 
pedicle when the polypus was at the posterior part of the nasal fossa, advised 
passing a thread through the nose, pharynx, and mouth, as is done in tam- 
poning for epistaxis; the loop of the wire snare is then to be attached to 
the end of the cord banging from the nose, when, by drawing on the other 
extremity of the thread externally, the wire noose is pulled through the nasal 
fossa into the pharynx. By running the canula down the two branches of 
the wire, and then passing a finger behind the soft palate, so as to arrange 
the loop about the growth, the latter can be dragged away from its attach- 
ments. This plan will be found to work well when the canula and wire 
cannot be passed through the nasal cavity together. In whatever way the 
canula and wire are employed, the operator should not be content with 
merely strangulating the pedicle and allowing the mass to slough away: 
such a practice is unnecessary, and is attended by danger from the ab- 
sorption of septic matters. Immediately on snaring the polypus and con- 
stricting its base, the instrument must be used as a tractor, to tear away the 
growth. I have used an instrument for the removal of nasal polypi which 
combines the principles of the canula and the ecraseur, and by which the 
mass is crushed off at once, by turning the screw fixed in the handle. 
Galvano-cautery.—This, which is the plan of Thudichum, consists in snaring 
the polypus with a platinum wire, which, after being tightly screwed up in 
the canula, is connected by its extremities to a galvanic battery and brought 
to a red heat, by which the growth is burned off. This operation can be 
effected much more conveniently by the galvano-ecraseur, which accompanies 
several of the batteries in use. It is not probable, however, that a method 
which involves so large an expense and necessitates the transportation of a 
bulky mechanism is likely to come into general use, especially wThen it is 
much inferior to more simple and inexpensive means. 
Incision.—It is rarely necessary to resort to cutting operations with a view 
to enlarge the approaches to the nasal cavities or their outlets, in order to 
extract soft or gelatinoid polypi. Dionis, Manne, and Maisonneuve each 
have divided the soft palate for this purpose, the first two through the raphe, 
the latter by making a button-hole slit through the velum. JDieffenbach 
detached the cartilaginous portion of the nose and the septum from the 
nasal processes and the intermaxillary ridge of the superior maxillary bone, 
and turned them back, so as to expose the anterior portions of the nasal 
fossa), when the growths occupied the anterior parts of the nose. Thudichum, 
with a view to reach the same region, resorted to dilatation of the nostril 
by tents. 
While thus detailing the different plans which have been recommended for 
the radical treatment of gelatinous polypi, I have no hesitation in saying 
that, with few exceptions, the surgeon will find the simple polypus forceps 
fulfill all the requirements demanded for clearing the nasal fossa) of these 
growths. 
Fibrous Polypi, or Nasal Fibromata. 
Fibrous polypi are much more formidable growths than the variety of 
polypus just described. These neoplasms differ from the gelatinoid variety 
in appearance, locality, consistence, effects on surrounding parts, and struc- 
ture. In shape they are pyriform, lobulated, round or somewhat peduncu- 
lated (Fig. 1775), having not infrequently more than a single attachment. 126 
DISEASES AND INJURIES OF THE NOSE. 
When the attachments are multiple, it is thought that the growth com- 
menced by a single point, and that the other attachments are only adhesions 
which have followed ulcerations produced by the 
pressure of the fibroma. I am not convinced of the 
truth of this, but believe rather that the tumors 
are multiple, and become blended together by the 
adhesion of the surfaces of contact, which had pre- 
viously been in a state of ulceration. They have 
a red, fleshy look, and vary in size from that of a 
hickory-nut to that of an orange, their irregularity 
of form and surface increasing with their bulk. 
Females are slightly more liable to become the 
subjects of fibrous polypi than males; and while 
I have seen such a growth in a person over fifty, 
yet it is in the young more especially, or in per- 
sons under twenty-five, that we generally en- 
counter tumors of this nature. The nasal cavity 
is not the only locality in which the fibrous poly- 
pus arises. When this is its situation its attach- 
ment can be generally traced to the posterior ex- 
tremity of the floor of the nose, or to the upper 
portion of the lateral wall of the nasal fossa. They sometimes originate in the 
antrum, and make their way into the nose, or, beginning in the nose, pene- 
trate the antrum. Generally the favorite seat of these tumors is the naso- 
pharyngeal region, where they will be found attached to the posterior surface 
of the septum narium, the pterygoid processes of the sphenoid, the walls of the 
pterygo-palatine space, and the basilar process of the occipital bone; unlike 
the soft polypus, they do not grow from the corium and submucous tissue, but 
from the periosteum. In consistence they are dense, firm, and fleshy. Cases 
have been reported in which the surface of the growth was encrusted with a 
deposit of lime salts. Though the nasal chambers may be packed with gelati- 
noid polypi, it is uncommon to obsei’ve any marked deformity of the nose or 
face, or any material structural alteration of the walls of the cavities. Not so, 
however, with the nasal fibromata. Firm and unyielding in their structure 
and instinct with growth, they tolerate no restraint, but force their way 
first in the direction of least resistance, then into every nook and crevice 
of the cavity in which they originate, entering also the fissures or openings 
of communication between the nose, pharynx, and adjoining regions, dis- 
placing the bones, causing their absorption, and 
giving rise to a singular distortion of the coun- 
tenance. Thus, when growing within the nose 
and forcing the lateral walls of the nasal fossse 
into the antra, a great breadth between the 
orbits and a flattened appearance of the nose are 
produced, resulting in that peculiar visage to 
which the name “frog-face” has been given, 
and which is well represented in Fig. 1776, the 
original being a man of sixty years. Itoom 
for increase of growth in the polypus is some- 
times obtained at the expense of the mouth, the 
palatine plates of the palate and upper maxil- 
lary bones being forced downward, encroaching 
upon the oral cavity. In those fibrous polypi 
which commence in the naso-pharyngeal region, 
and which have their origin in the periosteum 
of the basilar process of the occipital, or the 
body of the sphenoid bone, the soft palate may 
be carried forward towards the mouth to accommodate the tumor as it grows 
downward in the pharynx; the growth may enter the sphenoidal sinuses, 
Fig. 1775. 
Fibrous polypus, or nasal fibroma. 
Fig. 1776. 
Frog-face. FIBROUS POLYPI. 
127 
destroying eventually the body of the bone, and entering the cavity of the 
skull. Indeed, there seems to be no limit to the aggressions of these neo- 
plasms, as they will grow forward and effectually plug up the nasal cavities, 
obstruct the lachrymal ducts and the escape of tears, perforate the septum 
narium, enter the antrum, and, after destroying its walls, invade the orbit, 
or extend between the upper maxillary bone and the integuments; or, in 
the demand for room, when the development of the polypus is more particu- 
larly limited to the post-nasal region, its prolongation may block the orifices 
of the Eustachian tubes, occasioning partial loss of hearing, may penetrate 
the spheno-palatine and spheno-maxillary orifices, and even enter the tem- 
poral region. 
Pathology.—As has been already stated, fibrous polypi have their begin- 
ning in the periosteal covering, or in the bone-forming walls of the nasal 
or naso-pharyngeal regions. Their density of structure is influenced very 
greatly by the rate of growth. Those which make tardy progress are very 
much firmer and tougher than those which increase rapidly. In both the 
tumors are composed of interlacing fibres of connective tissue more or less 
compactly packed together, with numerous fusiform cells and nuclei. The 
softer variety, being the more vascular, is well supplied with capillary vessels, 
the walls of which, in some cases, consist of embryonic cells,—a circumstance 
of no small practical import, as it is an intimation of a sarcomatous element 
being present, and foreshadows the probability of recurrence. Indeed, the 
frequent commingling of fibromatous and sarcomatous elements in these 
growths must have often attracted the attention of observers. 
Symptoms.—The symptoms which accompany fibrous polypus at first may 
not differ from those present in gelatinoid polypus,—namely, nasal obstruc- 
tion,'with imperfect nasal respiration. But as the growth increases in volume 
the dissimilarity of signs becomes manifest. The obstruction, when the nasal 
cavity is occupied by the fibroma, is constant,—not intermittent, as in soft 
polypus. When seen, the tumor presents a red or slightly gray color. When 
felt, either with the finger or with a director, its firm, compact structure will 
be recognized, as well as its fixedness of position. When occupying the naso- 
pharyngeal region, an examination can be made very satisfactorily with the 
finger carried up behind the soft palate. During this exploration the observer 
should ascertain not only the resistance of the growth, but its form, whether 
pedunculated or not, whether its attachments are single or multiple, and just 
where these are fixed. 
As the fibroma increases in size, the interruption to the venous circulation 
provokes frequent attacks of nose-bleeding. The surface of the tumor, from 
the pressure to which it is subjected, becomes ulcerated in places, from which 
is discharged thrdugh the nose and into the pharynx and mouth a sanious 
and purulent secretion. This discharge, together with the frequent attacks 
of epistaxis and difficult respiration, soon begins to undermine the health and 
strength. The patient, at first pale, becomes sallow, loses appetite and flesh, 
and, unless relieved by operation, at length perishes from septicaemia or from 
sheer exhaustion. 
Diagnosis.—The morbid growths with which fibrous polypi may be con- 
founded are gelatinoid polypi, carcinoma, and sarcoma. 
The differential features between fibrous and gelatinous polypus are striking 
and decisive, and are contrasted below: 
Opaque. 
Flesh-like in appearance. 
Firm and resistant on pressure. 
Rapid in growth. 
Uninfluenced by varying states of the atmos- 
phere. 
Great tendency to produce deformity of the 
nose and face. 
Hemorrhage, or epistaxis, common. 
FIBROUS POLYPUS. 
Semi-translucent. 
Oyster-like in appearance. 
Soft and yielding. 
Slow in growth. 
Influenced much by atmospheric conditions, in 
consequence of the hygrometric property of the 
growth. 
Little tendency to cause deformity. 
Epistaxis not common. 
GELATINOID POLYPUS. 128 
DISEASES AND INJURIES OF T1IE NOSE. 
The distinctive characteristics between fibrous polypus and sarcoma may 
be arranged as follows: 
FIBROUS POLYPUS. 
SARCOMA. 
Firm and dense in structure. 
Bather rapid in growth. 
Somewhat pedunculated. 
Epistaxis common. 
Most common under twenty years of age. 
Little tendency to create a dyscrasia. 
Moderately firm. 
Very rapid. 
But little tendency to such a form. 
Epistaxis not very common. 
Most common over twenty years of age. 
Marked tendency to do so. 
Carcinomatous tumors possess a strong tendency to implicate the lymph- 
glands, to cause loss of flesh, and to stamp on the face the cachectic hue so 
characteristic of malignant disease, and are thus recognized. 
A unilateral polypus which develops in the direction of the antrum might 
be mistaken for a tumor of the upper jaw. A careful inquiry into the history 
of the growth, showing that nasal obstruction antedated the swelling of the 
face, would remove the obscurity of such a case. 
Treatment.—Nothing short of the complete extirpation of the fibroma 
will avail for its radical cure. The facility with which this is accomplished 
varies with the situation, form, and extent of the tumor. When in the 
pharynx or in the nose, and pedunculated in shape, the task is not a difficult 
one; but when its base is sessile, or when it becomes wedged into the sinu- 
osities of the nasal or naso-palatine regions, or transcends the limits of these 
spaces, the operation becomes extensive and difficult. The remedies em- 
ployed by the ancients, as caustics and the actual cautery, have long since 
passed out of use. 
In dealing with fibrous polypi, assuming that the growth is located in 
the naso-pharyngeal region, a finger should be passed up behind the soft 
palate, determining at the same time the form of the tumor and the extent 
of its attachment. If the latter is limited, a second finger should be intro- 
duced alongside of the first, and the growth seized between the two and 
wrenched off at once from its connections with the bone. Although this 
practice is discountenanced by some writers, in my own experience I have 
found it not only practicable, but easy of execution. In this manner I 
have removed with permanent success very large fibrous polypi, not only 
where the connection with the bone was single, but also with equal facility 
where there existed a double attachment. 
When the throat is small, not admitting two fingers without difficulty, and 
when the tumor is small, pyriform, and distinctly pedunculated, its extirpation 
is readily effected by conducting a pair of strong polypus forceps through 
the nose into the pharynx, at the same time passing a fingbr behind the soft 
palate, with which the pedicle can be guided into the embrace of the instru- 
ment, when, by one or two forcible twists, the growth may be severed. When 
the base of the tumor is broader, and, on account of its toughness, cannot 
be thus torn away, the wire ecraseur or the galvano-cautery ecraseur, first 
employed for this purpose by Middeldorpf, can be used. The adjustment of 
the wire, before its connection with the ecraseur or the battery, can be accom- 
plished by the plan described for snaring the soft pol}’pus. In other cases 
the base of the tumor is very broad, and the growth so extensive as to fill up 
completely the entire post-nasal part of the pharynx, and then the wire cannot 
be applied, the posterior nares also being obstructed. These are cases where 
the plan first suggested by Professor Gross may be used with peculiar fitness; 
that is, the introduction, through the nasal channel, of a narrow chisel with 
a dull cutting edge, which, while the polypus, grasped in the throat by a 
volsellum forceps, is drawn upon, is made to shave away its attachment, 
when it can be extracted through the mouth. By this plan I succeeded 
in removing a fibroma which filled the posterior part of the nasal fossa? and 
the upper part of the pharynx, displacing the palate and extending forward 
into the mouth. The patient, a lad of thirteen years, in consequence of FIBROUS POLYPI. 
129 
repeated hemorrhages, was greatly reduced in strength. Six years later the 
same individual entered the University of Pennsylvania as a student of 
medicine, and he is at the present time successfully engaged in the practice 
of his profession. 
The bleeding after an operation of this kind is profuse, and, if the root 
of the growth has a nasal origin, may require the use of the tampon, as in 
epistaxis. Should the hemorrhage come from the denuded surface at the 
base of the skull, and not cease in a few moments during the use of a gargle 
of ice-water, a sponge fixed in the jaws of the post-palatine probang, and 
saturated with Monsel’s solution of iron, should be conducted up behind the 
soft palate and to the dome of the pharynx, which should be thoroughly 
swabbed. In one instance after an operation of this nature I drew up into 
the post-palatine space, by a cord passed through the nose, as in tamponing 
for nose-bleed, a large compress of lint moistened with Monsel’s solution, 
where it was allowed to remain for forty-eight hours: it promptly arrested 
the bleeding. 
In still another class of cases the growth enters the various recesses of the 
nasal cavities, displaces the bones and appropriates all the available space 
in the naso-pharyngeal region, and can be extirpated only by enlarging the 
outlets or approaches to these parts. This can be done by one of- three 
methods. The particular one to be decided upon must be determined by 
the position of the polypus. In one operation the exposure of the naso- 
pharyngeal space is made through the hard and the soft palate. This is 
the method of Nelaton. An incision is made completely through the soft 
palate, in the median line, from the palatine plates of the palate bones to 
the tip of the uvula. A longitudinal incision down to the bone is next 
carried forward along the raphe of the hard palate as far as its middle, and 
on either side an incision extending from the termination of, and at right 
angles with, the last to the alveolus. The soft parts are raised, including 
the periosteum, by an elevator, and turned to' the right and left. The ex- 
posed islands of bone on each side are now cut away with bone pliers, an 
opening having been previously made with a drill for the purpose of receiving 
the point of one of the blades of the cutting forceps. The exposed portions 
of the palatine plates of the maxillary and palate bones being disposed of, 
the mucous membrane of the nose, with the submucous tissues, requires next 
to be incised in the middle line and turned aside. It only remains now to re- 
move a sufficient portion of the vomer to expose the post-palatine region, thus 
giving access to the polypus. After the removal of the fibroma, the parts 
are to be brought together and retained by silver sutures. The closure can 
be made immediately after the operation, or, if it is thought best to keep 
the surface from which the polypus has been removed under observation for 
a few days, this may be done before making the apposition. I do not believe 
that this operation possesses any advantage over that with the chisel. 
Whately seems to have been the first to suggest the removal of the 
superior maxillary bone for the extirpation of post-nasal polypi, but the sug- 
gestion was first carried into effect by Syme in 1832. The operation has 
been variously modified since that time, chiefly by the Germans. 
Osteoplastic operations.—The ingenious idea of cutting the superior maxil- 
lary bone from all its surrounding connections, save one or two which are to 
play the part of a hinge, and thus displacing the bone in a direction which 
will expose the deep retired recesses occupied by the polypi, and after their 
extirpation of restoring it to its original position, was announced by Huguier, 
in 1852. 
Langenbeck, however, first carried the principle into effect by including 
the upper jaw in two incisions, one extending from the root of the nose along 
the lower border of the orbit across the orbital process of the frontal bone 
to the middle of the zygoma, and the other carried from the alse nasi out- 
ward and upward across the face to the termination of the first. The peri- 
osteum is next carefully divided in the tracks of the first incisions, and the 130 
DISEASES AND INJURIES OF THE NOSE. 
anterior origin of the masseter muscles separated from the malar bone. With 
a fine saw, following the course of the upper incision, the bone is cut through 
from behind forward, stopping short of the nasal process. The jaw is now 
separated from all its connections, save those of the nasal process with the 
frontal and nasal bones, and the palatine plate with its fellow. With a strong 
lever the isolated maxillary bone must next be pried away from the pterygoid 
process of the sphenoid bone, and slowly turned upward and forward, thus 
disclosing the space in front of the petrous part of the temporal bone and 
the pterygo-maxillary fossa, the regions which this operation contemplates 
bringing into view. After removing the polypus, the displaced jaw is to be 
brought down into its former place and secured by suturing the wound in the 
soft parts. 
Dr. Cheever, of Boston, repeated the operation of Langenbeek on three 
occasions, retaining only the palatine suture as the hinge in two of the 
cases; in the third, in consequence of the median position and extent of the 
growth, he pushed the method to an unprecedented extent by sawing through 
both upper maxillae from the tuberosity of each, along the lower borders of 
the orbits to the middle of the nose, the bones having been previously un- 
covered by an incision extending from the inner angle of the orbit, along 
the side of the nose and through the middle of the upper lip. After reflect- 
ing the flaps in an upward and outward direction, and dividing, with cutting 
pliers, the cartilaginous septum and the vomer, he forcibly depressed both 
maxillae, at the same time making the points of contact between the ptery- 
goid processes of the sphenoid bone and the tuberosities of the maxillary 
bones the hinges. Through the chasm thus exposed the operator was 
enabled to remove the growth, which was followed by the reposition of the 
bones; but the shock attending the operation exceeded the vital resources 
of the patient, who died a few days after its performance. Ollier extirpated 
a large polypus occupying the upper part of the nasal fossae by carrying an 
incision across the bridge of the nose a short distance in front of its root, 
and extending it down along both sides of the nose to the alae; then, sawing 
obliquely downward through the nasal bones, the nasal processes of the 
superior maxillae, and the septum, he turned the nose down over the mouth 
and exposed the tumor. 
Osteoplastic operations for the removal of polypi, with slight modifications, 
have been performed by Cooper, Foster, Weber, Billroth, Esmarch, McCormac, 
Van Bruns, Ashhurst, and other surgeons. Cutting operations on the jaw 
for the removal of fibroid polypi are not unattended with danger. Of 57 
cases collected from different sources, 42 recovered, 14 died; in one the result 
was not recorded. One-half of the fatal cases were those in which the 
method of Nelaton, or that of cutting through the soft and the hard palate, 
was employed. Of 26 cases operated on by Nelaton’s method, 13 were cured, 
7 died, and in 6 the result is not stated. The least fatal were those in 
which resection of the upper jaw in its totality was practiced,—2 deaths in 
14 cases. Of the osteoplastic ablations, 17 in number, 4 died. When the 
polypus is implanted in the upper portion of the nasal channel, even avulsion 
may be followed by fatal consequences, resulting from injury inflicted on the 
ethmoid bone and transmitted to tho brain or its membranes. 
The hemorrhage which is encountered in cutting operations for the extir- 
pation of naso-pharyngeal polypi, should it not cease spontaneously or under 
the application of st}7ptics, as Monsel’s solution of iron, alum, alcohol, or 
hot water, can be promptly arrested by the thermo-cautery, galvano-cautery, 
or actual cautery. 
Strangulation, either by cord or by wire, allowing the mass to slough away, 
has been frequently practiced. In one instance I removed a very large 
naso-pharyngeal polypus in this manner, but at so great a risk to the 
life of the patient from the horrid products of decomposition which accumu- 
lated in the pharynx, and which no doubt frequently found their way into 
the stomach and the vessels, that I should never be willing to repeat the OSSEOUS TUMORS. 
131 
operation. Nature in a number of cases has chosen this plan of success- 
fully getting rid of these growths, their vitality1" having been destroyed by 
surrounding pressure. 
Injections of caustic agents, as the chloride of zinc, have also been recom- 
mended, with a view to the decomposition of the tumor, but should be rejected 
for the same reasons as those urged against strangulation. 
Finally, the electrolytic treatment has been advocated. Although I have 
had no opportunity of personally witnessing a practical test of the method, 
the favorable reports given by Dr. Burns entitle it to a trial. The current 
is applied through two zinc or platinum needles, introduced into the tumor 
through the mouth and nose, guarded by rubber tubes, and connected with 
the poles of a Byrne or Storer battery. It should be continued from ten to 
twenty minutes at a time, and be repeated at intervals of from four to ten 
days. The advantage of using zinc needles is believed to be due to the 
caustic agency exerted on the tissues of the tumor by the chloride of zinc 
produced at the positive needle. 
Enchondromata.—Cartilaginous growths in the naso-pharyngeal region are 
very rarely seen. They occur chiefly in the young, and grow from the floor 
of the nasal channel, from the septum, from the frontal and ethmoid cells, 
and from the dome of the pharynx. Though hard in structure, and followed 
by marked deformity of the nose and face, they are particularly apt to 
cause absorption as well as displacement of the bones with which they are 
in contact. The form of these tumors is somewhat spherical, their attach- 
ment or base broad, and their growth rapid. The signs of a nasal enchondroma 
are nasal obstruction, embarrassed breathing, displacement of the septum, 
deformity of the nose, headache, altered voice, and the presence of catarrhal 
phenomena, as coryza, sneezing, etc. As these symptoms are common to 
other growths in the nasal fossa;, an exploration of the latter will be necessary 
in order to establish the diagnosis with certainty; and, as the peculiar char- 
acteristics of tumors are of surface, solidity of structure, and a 
spherical form, it is scarcely possible not to identify their presence. 
Treatment.—When small and attached to the septum, floor, or roof of the 
nose, they can be readily detached by a narrow chisel, and dislodged from 
the cavity by a tractor or forceps. When the bulk of the tumor does not 
admit of its being extracted through the natural outlet of the nose, the side 
of the latter must be opened so as to supply space for the use of the gouge 
and the extraction of the growth. The tendency of these cartilaginous 
neoplasms to cause absorption of the underlying bones will suggest the 
necessity for exercising great care in their removal when connected with the 
roof of the nose, as the membranes of the brain, or even the brain itself, 
may be damaged. When they spring from the base of the skull, these growths 
are much more serious than when in the nose. In such cases, operations, if 
undertaken at all, must be done early, and only when the base of the tumor 
is not extensive. The frequent combination of sarcomatous elements with 
those of enchondroma will require the surgeon to be cautious in his prog- 
nosis. 
Osseous Tumors.—The osseous growths mot with in the nasal fossae may 
he merely examples of exostoses w’hich grow from some portion of the bony 
w’alls of the nasal cavity: their structure is sometimes spongy, at other 
times hard, or like ivory. Their existence can often be traced to a constitu- 
tional vice. They may commence altogether outside of the nasal fossae, 
and by displacement and absorption of bone finally reach the cavity of the 
nose. 
Ossifying sarcomata also appear in the nasal channels, and occasion very 
great deformity of the countenance. The most remarkable instance of this 
kind is the one described by Mr. Durham,* occurring in an Irishwoman, 
* Holmes’s Surgery, yol. iy. p. 319. 132 
DISEASES AND INJURIES OF THE NOSE. 
admitted to Guy’s Hospital in 1835: in this case the tumor had involved 
both the bones of the nose and one side of the face, having attained in fifteen 
years the size of the patient’s head. It was successfully removed by Mr. 
Morgan, the patient recovering from the operation. 
The osseous tumors of the nasal fossfe, however, which have attracted the 
greatest interest are neither exostoses nor such as contain a diversity of 
elements, like bone, cartilage, and embryonic tissue, but tumors which appear 
to originate in the membranes of the nose or in its accessory cavities inde- 
pendently of the bony walls by which they are surrounded. Our knowledge 
of these singular neoplasms is derived chiefly from Dr. Paul Ollivier,* who, 
in 1869, published a treatise on the subject, in which are collected eleven 
cases. They do not necessarily commence in the nasal cavities, but oftener, 
it is believed, begin in the adjacent sinuses of the frontal bone. 
Between these growths and those to which reference has been made there 
are certain notable differences. Exostoses possess a structure in all respects 
similar to that of ordinary bone, and are fixed by their connection with some 
portion of the framework of the bony nose. The tumors under considera- 
tion appear to have no connection with bone, but originate either in the 
submucous tissue or in the periosteum of the nasal fossee or contiguous 
sinuses. 
They are often extremely hard, and even eburnated, and in minute structure 
are wanting in that orderly arrangement of osseous material which charac- 
terizes true bone. 
Symptoms.—In addition to obstruction, the symptom of nasal tumors 
generally, there are experienced pains of a sharp, neuralgic nature, headache, 
and epistaxis, which latter, as the disease progresses, disappears, doubtless 
from the obliteration of the vessels by pressure. There is deformity, in con- 
sequence of the displacement of the nasal bones to accommodate the increase 
in the growth of the tumor, which in time may encroach on the pharynx or 
upon the orbit, displacing the eye, and, by pressure on branches of the motor 
nerves of the eye, causing strabismus and drooping of the eyelid. The irri- 
tation developed by the pressure of the tumor causes a blood-stained, puru- 
lent discharge from the anterior naris. On expanding the nostril and looking 
into the nasal cavity, a tumor may be seen having a somewhat irregular but 
uniform surface, and when touched with a probe or a director it is found to be 
more or less movable, and probably as hard as a stone. In some of the cases 
described the tumor was of' unequal density, hard at one point and soft and 
friable at another; and in other cases it was spongy throughout. 
Treatment.—The treatment consists in extracting the growth from the 
cavity of the nose, a task the difficulty of accomplishing which will depend 
on the size of the tumor. When small, it can be taken out with a pair of 
dressing forceps. When large and soft in texture, Ollivier suggests the pro- 
priety of first crushing the mass and then removing it piecemeal. When 
this is not feasible, an opening of sufficient capacity must be made by re- 
secting the nasal bone, with a portion of the superior maxilla. Should the 
tumor attain any great size, it may, by destroying the surrounding walls, 
drop out spontaneously, as occurred in Mr. Hilton’s case. 
Papillomata.—Situated just within the nares of children are sometimes 
seen small, papillary, pointed or wart-like eminences, having a drab or a 
slightly yellow color, which are designated papillomata, and are composed of 
connective tissue arranged in club-shaped or pointed elevations, including 
numerous muciparous glands. These bodies create considerable irritation 
about the nostrils, causing the patient to be constantly picking at the nose 
until it becomes raw and throws otf a discharge which excoriates and 
thickens the lip. 
Treatment.—The parts, after being carefully cleansed with carbolated 
water, should be explored by expanding the nostril with the blades of the 
* Sur les Tumeurs osseuses des Fosses nasales. NEUROSES OF THE NASAL PASSAGES. 
133 
dressing forceps or with a nasal speculum. The hypertrophied papillae are 
then to be clipped off with scissors, and the raw surfaces which remain are 
to be touched with nitric acid, sulphate of copper, or nitrate of silver. If 
the operation is carefully done, the growths are not likely to return. 
Neuromata are unknown in the nasal fossa. The nearest approach to a 
neoplasm of this character was seen at the hospital at Pisa. The patient had 
a growth which occupied the nasal passage and was regarded as a polypus. 
After three unsuccessful attempts at extraction, cerebral symptoms set in, 
and soon after he died. The post-mortem examination showed that the nasal 
tumor had stai*ted from the sheath of the second branch of the fifth pair of 
nerves, and by dilating the spheno-palatine foramen had entered the nose. 
Malignant Growths.—The growths belonging to this class of neoplasms, 
which invade the nasal cavities and those lying adjacent thereto, are sar- 
coma and carcinoma. 
Sarcomata, though generally originating in the outer walls of the nasal 
fossa, are frequently found growing in the naso-pharyngeal region. They 
usually have a red, fleshy appearance; sometimes their color is gray. Their 
attachments are sessile rather than pedunculated. They penetrate into 
every accessible foramen and fissure, give rise to pain, to hemorrhages 
when touched, and to offensive discharges from the nose, and grow with great 
rapidity, especially in children. In other cases the sarcoma may begin as 
a polypus, or an enchondroma, the transformation taking place at a later 
stage in the history of the neoplasm. 
These tumors originate generally in the periosteum of the bones of the 
nose or at the back of the skull. Sarcoma of the nose, like the disease else- 
where, shows little tendency to invade the lymph-glands. 
Treatment.—Nothing short of removing the growth from every point 
where it may be found will avail. To do this will often demand ablation of 
the upper maxilla in part, so as to obtain access to the labyrinthic windings 
of the nasal fossa and thus enable the operator to dislodge every vestige 
of the disease. The application of a solution of chloride of zinc to the sur- 
face from which the sarcoma was detached will be a proper precaution to 
observe. When implanted broadly upon the base of the skull, all operative 
interference is harmful. Under any circumstances, recurrence of the disease 
is the rule after operation. Fortunately for the patient, as the disease moves 
on to a fatal termination the mind becomes oblivious to suffering, because of 
the stupor which results from brain-pressure. 
Carcinoma of the nasal fossa is much less common than sarcoma. Enceph- 
aloid, or epithelioma, is the form in which it appears. Scirrhus is un- 
common. Many of the cases regarded as carcinoma of the nasal fossa are 
only such secondarily, having originated in adjacent parts, as the pharynx 
or the maxillary sinuses, and having penetrated into the nose. The subjects 
are almost invariably children. The characteristics of carcinoma in the 
nasal passages are rapid increase and ulceration of the growth, severe pain, 
fetid discharges, frequent bleedings, invasion of the soft parts, of the bones, 
and of the adjoining cavities, as the pharynx, orbit, and antrum, infection 
of the lymph-glands, extreme exhaustion, and death. 
Treatment.—Operations are useless, or, rather, are injurious, by removing 
the very pressure which restrains the progress of the growTth. Nutrients and 
anodynes constitute our resources for palliation. 
The nasal passages are supplied with nerves from the olfactory (tlie nerve 
of smell) and from branches of the trigemini or fifth pair (nerves of common 
Neuroses of the Nasal Passages. 134 
DISEASES AND INJURIES UE THE NOSE. 
sensibility). Both those of special and those of general sensibility are subject 
to disturbances which are often difficult of explanation, and some of which 
are exceedingly distressing. 
Anosmia.—The loss of smell may be temporary or permanent; peripheral 
or central in its origin; idiopathic or traumatic. Those cases of anosmia 
which arise from intracranial disease, as aphasia and right hemiplegia, and 
which affect the olfactory tract of the left nasal fossa, depending as they do 
on organic changes of neurine, are beyond the reach of remedies. 
Those which so often attend coryza and other catarrhal attacks affecting 
the Schneiderian membrane, and which are to he attributed in large measure 
to pressure upon the nerve-filaments from congestive and inflammatory 
swellings, disappear as the disease which produced the loss of smell subsides, 
and are therefore best treated by using those measures which are commonly 
employed for the relief of nasal cold and of catarrh,—namely, stimulating 
Sjdiluvia, a gentle aperient, and the use of liquor ammonias acetatis and 
over’s powder at bedtime. 
Should the catarrh be of a chronic nature, the remedies required will be 
such as have been detailed in treating of the latter disease. 
Traumatic anosmia is common after blows upon or fractures of the 
nose. When thus developed, it is occasioned either by concussion of the 
olfactory bulbs, from the vibrations of the force being communicated to the 
cribriform plate of the ethmoid bone, or from tbe inflammatory swelling which 
follows the violence compressing the olfactory nerves as they are spread over 
the septum and the middle and superior turbinated bones. Traumatic anos- 
mia is generally temporary, the sense of smell returning as the transudations 
in the mucous membrane are removed,—the work of nature in time, together 
with the local use of anodyne and astringent lotions, as lead-water and 
laudanum. 
Pressure from the presence of intranasal tumors and from cerebral tumors 
constitutes another cause of anosmia. When it arises from growths within 
the nose, relief will be likely to follow their extraction. 
Caries attacking the ethmoid, or its lamina cribrosa, will induce alteration 
of structure in the olfactory nerves or their bulbs which is not likely to be 
corrected either by therapeutic or b}- operative plans of treatment. Hys- 
terical anosmia is generally of centric origin. 
In cases of anosmia induced by inflammatory states of tbe mucous mem- 
brane of the nose, in which, after all active disease has passed away, the 
smell, though slightly improved, is not completely restored, benefit may be 
expected from the use of sternutatories, the best being finely pulverized 
cubebs mingled with an equal quantity of powdered liquorice. The free 
flow of mucus excited by the snuff serves to deplete the vessels of the Schnei- 
derian membrane, and to secure the removal of any remaining infiltration 
which may compress the olfactory nerves. Electricity should also be em- 
ploy ed, either in the form of the faradic or the galvanic current,—one 
electrode being introduced into the nose and the other applied on the out- 
side. 
Sneezing is a reflex phenomenon, resulting from the action of an irritant 
upon the sensory nerves of some portion of the respiratory tract of the nasal 
fossa. It is frequently witnessed during the developing stage of colds, and 
can be controlled by placing the finger across the upper lip, close to the nose, 
and making firm pressure. With the subsidence of the catarrh the sneezing 
also disappears. There is, however, another form of the affection which is 
obstinate and distressing. The sneezing comes on in paroxysms, and when 
there is no evidence of cold being present, and continues without interrup- 
tion until the patient becomes exhausted. These paroxysms sometimes occur 
at short intervals for weeks, and either vanish suddenly or gradually wear 
away. Like hay asthma, of which sneezing is frequently a marked symp- 
tom, these attacks often observe a singular periodicity, coming on each year NEUROSES OF THE NASAL PASSAGES. 
135 
during a certain month. The inhalation of the pollen of certain plants or 
flowers has been regarded as a cause of excessive sneezing. 
Full doses of quinia, accompanied by the bromide of potassium, will occa- 
sionally control these attacks. Electricity may also have a like effect. But 
the remedy which, above all others, exerts a curative influence is a temporary 
change of residence. The particular place which is to work the cure can 
only bo determined by the personal experience of the patient. 
Sudden swelling of the mucous membrane of the nose is another curious 
phenomenon. A patient, breathing -with perfect freedom one minute, finds 
himself the next unable to pass air through one or both nasal fossae. In a few 
hours all obstruction disappears, or it may vanish suddenly, after the manner 
of its appearing. While atmospheric changes may sometimes provoke such 
attacks, yet the condition occurs in all seasons, and often arises from causes 
purely emotional. Persons laboring under catarrhal attacks are those who 
suffer most from these congestions. In examining the nasal cavity of persons 
suffering in this manner, it will be seen that the swelling is chiefly connected 
with the membrane covering the lowest turbinated bone. 
In order to understand the pathology of this form of nasal obstruction it 
is necessary to refer to the anatomical structure of the Schneiderian mem- 
brane, which in the localities referred to presents a mammillated appearance, 
and is supplied with a rich plexus of veins, resembling in some respects a 
cavernous tissue, which, through the agency of' the vaso-motor nerves, is 
subject to sudden congestions. It is not improbable that a certain degree 
of blood-aeration is normally effected in these vessels, which may in part 
account for the unsatisfactory character of the respiration when carried on 
wholly through the mouth, in cases where the nasal cavities have been 
plugged, either by the discharges of the disease or by the tampon. 
These congestive swellings can be relieved by tbe free use of hot water 
applied to the nose both internally and externally. Professor Harrison Allen 
employs for the same purpose a primary current of electricity, moderately 
strong, applying the cathode on the cheek a little below the orbit, and the 
anode upon the nape of the neck or over the mastoid fossa. This agent pos- 
sesses the value of being a differential test betwmen nasal obstructions arising 
from congestion and those due to inflammatory infiltration, the latter not 
being at all relieved by the electricity. 
Screatus.—I have given this name to a singular neurosis of the nasal pas- 
sages, which I have not seen described by any writer with whose work I am 
familiar. It is characterized by paroxysms of short, noisy inspirations or 
snortings, as though an effort was being made to draw into the pharynx some 
worrying secretion from the back of the nose. These efforts are continued 
with increasing rapidity and energy, sometimes for two or three minutes, 
until probably a small bolus of mucus is hawked up and spat out, or until the 
patient becomes utterly exhausted, and they cease from lack of muscular 
power to sustain them. These attacks are very frequent, often recurring 
every hour during the day, with longer intervals during the night, and are 
utterly independent of the patient’s volition, continuing until the climax has 
been reached, when the spasm becomes self-resolved. 
An eminent professional gentleman of this city was under nvy care for over 
two months suffering from this affection. lie lost flesh and strength, and 
caused very great anxiety to his friends, in consequence of the rapid deteri- 
oration of health attending the disease, which, it had been stated, was symp- 
tomatic of serious central trouble. After a careful examination of the nasal 
passages, I became satisfied that there existed an ulcer, seated at the pos- 
terior portion of the inferior turbinated bone of the right side. Applications 
of a strong solution of nitrate of silver were made to the spot, both through 
the nose and through the pharynx. Bromide of potassium and chloral were 
given at night to procure rest, the intestinal and other secretions were care- 
fully regulated, abstinence from wines was enforced, and finally a change of 136 
DISEASES AND INJURIES OF THE NOSE. 
residence was directed to the sea-side, under which treatment the affection 
slowly disappeared. 
Believing, therefore, that spasmodic screatus is a peripheral and not a 
central disease, it will be proper, in the management of a case of this kind, 
to subject the patient to a rigid examination, not only in regard to possible 
points of local irritation in the nose or pharynx, but also as to the digestive 
apparatus, habits, etc., all of which may play a part in the production of the 
eccentric phenomena. 
Rhinoplasty. 
The deformities and mutilations to which the nose is liable, either from'dis- 
ease or from accident, require for their relief, often, a remarkable combination 
of mechanical ingenuity with manual skill. As it is the nose which, more 
than any other part, gives character to the face, its loss is followed by the 
greatest deformity. On this account, and also because of the infamy often 
attending the loss of the organ,—cutting off the nose being one of the pun- 
ishments inflicted for crime in ancient times,—it is reasonable to suppose 
that the resources of surgery would be early taxed in order to repair the 
loss: hence we find that rhinoplasty is a very old operation. 
The observance of the following rules is necessary to the successful exe- 
cution of plastic operations: 
First. That the remains of the part or organ to be restored shall be soundly 
cicatrized before any operation is attempted. 
Second. That no operation shall be attempted when the patient is out of 
health, or during the prevalence of erysipelas. 
Third. That in planning a flap of the proper shape, to be used in restoring 
the lost part, due attention shall be given to secure for it a sufficient vascular 
supply, and at the same time to form it in such a way that in closing the 
subsequent wound no deformity of the eyelids or other parts will follow. 
Fourth. That in cutting the flap a proper allowance be made for its subse- 
quent shrinkage, say nearly a fourth larger than the place to be supplied. 
Fifth. That the thickness of the flap shall include all the components of the 
part down to the periosteum. 
Sixth. That the vivified surface, to which the flap is to be united, shall be 
sufficiently extensive to render the adhesion certain. 
Seventh. That the sutures shall be sufficiently numerous to make an accu- 
rate apposition of the parts. 
Eighth. That the adjustment shall not be made until all bleeding ceases, 
and that in order to obtain quick union the v-essels be secured either by 
torsion or by the animal ligature. 
The subject naturally divides itself into three methods, respectively desig- 
nated the Indian, the Taliacotian, and the French. 
By the first, or Indian plan, the lost organ is restored by taking a flap from 
the forehead ; by the Taliacotian, or Italian method, the integument over the 
inner face of the deltoid region is utilized; and by the French plan, the 
tissues of the face adjoining the ruins of the nose are used. 
1. The Indian plan.—This method, it is believed, wTas brought to the atten- 
tion of the profession in Europe by Mr. Lucas, and has met with marked 
success in the hands of American surgeons, among whom, especially, may 
be mentioned Mason Warren, of Boston, and Professor Joseph Pancoast, of 
Philadelphia. 
In performing this operation, the first step is to obtain an accurate pat- 
tern for the future nose. This is accomplished sometimes by building upon 
the remains of the lost organ an artificial nose out of potter’s clay or 
dough, and moulding a piece of soft leather or pasteboard over the model. At 
other times the surgeon follows the pattern of an ideal nose, which he has 
formed in his own mind, and proceeds at once to give material form to, 
by cutting a piece of pasteboard, paper, or adhesive plaster into the desired RHINOPLASTY. 
137 
shape, making this pattern always one-third larger than the contemplated 
nose, and outlining its form upon the forehead of the patient with iodine 
or nitrate of silver. (Fig. 1777.) In repairing a mu- 
tilation like the one represented in Fig. 1778, the 
patient being etherized and placed on the back, on 
a firm, narrow table, wdth the head and shoulders 
somewhat raised, the surgeon, taking his stand behind, 
follows the colored outline by an incision carried boldly 
down to the periosteum. (Fig. 1779.) These incisions, 
when approaching the root of the nose, must be of 
unequal lengths, one branch—the inner—being pro- 
longed down upon the organ, inclining to the orbit, 
and stopping a short distance above the inner ex- 
tremity of the bone, so as to preserve intact the an- 
gular artery, on which will depend the life of the new 
nose, and also to allow of the latter being readily 
twisted upon its pedicle during its transfer from the 
frontal to the facial region. (Fig. 1779.) Professor Pancoast, after cutting 
this flap, pares its edges into a triangular figure. As soon as the integument 
has been raised, the wound in the forehead should be approximated as much 
as possible without making too much tension, by the use of three figure- 
of-eight sutures. 
Fig. 1777. 
Pattern for flap with which to 
make a nose. 
Fig. 1779. 
Fig. 1778. 
Cartilaginous portion of the nose lost 
by disease. 
Flap raised and suspended by its pedicle, and 
the borders of the nose pared ready for its re- 
ception. 
The second step consists in preparing the margins of the lost nose for the 
reception of the new one. And here, again, it is proper to give due impor- 
tance to the incisions as modified by Professov Pancoast, which are either 
two oblique cuts made from without inward and joining each other a short 
distance from the surface, or are made by first freshening the edges of the 
nasal outlet, and then splitting them in two,—in either case forming a gutter 
of vivified tissue. Before carrying the above into effect, the nares should be 
plugged with lint, in order to prevent the blood from entering the pharynx. 
The third stage embraces the adjustment of the raw surfaces to each other. 
In doing this, provided the incisions have been executed after the plan of 
Professor Pancoast, in which case there is a tongue and a groove, it will be 
necessary to use a thread (silk or silver) armed at each end with a short, 
curved needle, and, after fitting the tongue into the groove, pass first one and 
then the other needle—a short distance apart—through the adjusted parts, 
thus forming a loop, the two ends of which, after being withdrawn from the 
needles, are to be secured by being tied over little rolls of lint. (Figs. 1780, 
1781.) 138 
DISEASES AND INJURIES OF THE NOSE. 
Though Professor Pancoast attaches much importance to this suture, 
I find in my own experience that the ordinary interrupted silver suture 
Fig. 1780. 
Fig. 1781. 
Suture of Professor Pancoast. 
answers eveiy purpose. It is certainly much less complicated, and admits of 
being introduced with less delay. Whatever sutures are selected, they should 
be sufficiently numerous to retain the denuded surfaces accurately in contact. 
In fixing the columna nasi, or the tail of the flap, a transverse incision must 
be made in the superior lip close to the nasal spine, and after paring for a 
short distance the surfaces of this process into the form of a wedge, it is 
to be inserted deeply into the slit and there held by sutures. The plugs 
having been taken out of the bony nares, it becomes necessary to support the 
newly-constructed nose by the introduction into each nostril of short pieces 
of a gum catheter, padded around with lint. (Fig. 1782.) Little more is 
now demanded than to give some additional support 
to the edges of the wound by strips of adhesive or 
isinglass plaster, and to cover the whole either with a 
water dressing or with a mask of lint moistened with 
carbolated oil. In four or five days the sutures can 
be removed and be replaced by strips of plaster. 
Various modifications of this operation have been 
introduced by different surgeons, to which reference 
may be briefly made. For example, Langenbeck ad- 
vocates raising the periosteum from the frontal bone 
along with the integuments in forming the nasal 
flap. The bone-generating property of this membrane 
he believes will, by the production of some osseous 
tissue, give a more stable form and better appearance 
to the organ. In forming the flap from the forehead, 
various modifications of form, according to surgical 
fancy, have been advocated. Dieffenbach preferred a lancet-shaped one; 
Charpue, a heart-shaped one. Dieffenbach also endeavored to effect a more 
complete closure of the chasm left on the forehead by lateral incisions in 
the temporal region, so as to admit of the integuments on each side of the 
frontal wound being slid near each other; and the same surgeon, as also 
Serre, introduced an important improvement, in cases where the hair came 
low down on the forehead, tendering it difficult to obtain the proper length 
of integument, by taking from the upper lip the material necessary for the 
construction of the columna nasi. 
2. Taliacotian, or Italian method.—This method was practiced by Taliaco- 
tius, of Venice, in 1597, although it appears that as early as 1495 the same 
plan had been described by another Italian, Alexander Benedictus, of Padua. 
In the operation of Taliacotius the same plan for obtaining the proper 
shape and size of the flap for the nose was adopted as in the Indian method, 
—that is, by forming a pattern from paper. This was placed upon the arm 
over the inner surface of the deltoid swell, and the circumscribed integument 
raised, though not detached at either extremity from its humeral connec- 
tions. After being raised, the sides of the wound were brought together 
beneath the flap by sutures, in which position the elevated integument was 
allowed to remain for two weeks, or until shrinkage was in some measure 
completed and the surface commenced granulating, when it was severed at 
Fig. 1782. 
Flap stitched in place and nose 
completed. RHINOPLASTY. 
139 
one extremity, and, after paring away the edges of the deformed nose, the 
arm was brought in front of the face by retaining bandages. (Fig. 1783.) 
In this position the arm was maintained 
for twelve days, at the expiration of which 
time the pedicle of the flap was severed and 
the extremity disengaged from its con- 
strained position. That the operation of 
Taliacotius may have succeeded in a few 
instances can scarcely be questioned, as 
a number of references are made to the 
procedure by Fallopius, Yesalius, Ambrose 
Pare, and other writers of the sixteenth cen- 
tury, and a case has been reported by Mr. 
MacCormac quite recently (1877). Yet there 
are few persons who could be induced, how- 
ever anxious to possess a nasal appendage, 
to endure the fatigue and distress of having 
the arm bound in the required position suffi- 
ciently long for the success of the operation. 
Yon Graefe has attempted to lessen the time 
required for the arm to be bound in the pain- 
ful position by immediately attaching to the 
freshened border of the nose a portion of 
the flap raised from the arm; and J. Mason 
Warren, of Boston, has repeated the same 
plan a number of times, it is said, with suc- 
cess, taking his flap in each instance from 
the anterior aspect of the forearm, a short 
distance above the wrist. 
Hardie, of Manchester, by a modification of the Taliacotian plan, in one 
case grafted upon the remains of a mutilated nose the last phalanx of the 
patient’s index finger, as a basis for the support of the nose which it was 
proposed to form. Post, of New York, made a similar attempt. 
3. The French method.—This differs from the methods already described in 
the fact of the reconstructing material being taken from the sides of the face 
and slid or twisted into position. The flaps may be formed either in a direc- 
Fig. 1783. 
Flap raised from the arm, and position of the 
latter, in the Taliacotian operation. 
Fig. 1784. 
Fig. 1785. 
Forming the nose by longitudinal flaps 
taken from each side. 
Flaps stitched in place. 
tion nearly parallel with, or at an angle more or less obtuse to, the lost organ. 
If the first plan is selected, it will be necessary to preserve the vessels at the 
inner angle of the orbit, and if the second method is adopted, those at the 
corner of the nose, in order to secure the proper vascular supply. 140 
DISEASES AND INJURIES OF THE NOSE. 
In the operation as performed by the longitudinal flaps, two diverging 
incisions are made in a direction from above downward on either side of 
the nose, and inclining somewhat towards the face. These incisions are 
to be joined at the lower extremities by a third or transverse one, and 
the flaps, including adipose and muscular tissue, raised towards their bases. 
These flaps are next brought towards each other and united in the median 
line by stitches, thus forming the dorsum and sides of the new nose. (Figs. 
1784, 1785.) The column is provided for by cutting a piece from the 
middle of the upper lip, turning it upward and securing it to the lower por- 
tions of the lateral flaps. 
When it becomes neces- 
sary to adopt the method 
of borrowing, for the res- 
toration of the lost nose, 
flaps more at right angles 
with the organ, the dif- 
ference between this and 
the former procedure 
consists chiefly in the di- 
rection of the incisions 
and the necessity for a 
more extensive twisting 
of the flaps; in doing 
which care must be ob- 
served not to cause de- 
formity of the eyelids. 
(Figs. 1786, 1787.) 
There are various deformities which arise from partial loss of the nose, as 
when one ala has been ruined in its totality or in part; where the tip is 
gone,—bitten off, perhaps, in a fight; where the column has disappeared, 
with probably a part of the upper lip; and where the septum has been de- 
stroyed, allowing the organ to flatten down upon the face. Only general rules 
can be laid down for remedying these mutilations. The ala is best restored 
by borrowing either from the upper 
lip or from the side of the face 
adjoining. 
If the first plan is selected, the 
lip must be divided by two inci- 
sions, one from its junction with 
the original position of the ala of 
the nose through to its free border, 
and the other from its free border 
upward and backward into the 
face, including between the two 
more than a sufficient amount of 
tissue to fill the chasm in the nose. 
The sides of the divided lip are 
next to be brought together by 
twisted sutures (Fig. 1788), after 
which the edges of the nasal car- 
tilage are to be pared and united 
with those of the labial flap by 
a number of interrupted stitches. (Fig. 1789.) When the material for res- 
toration is taken from the face, the incisions are to be carried upward and 
outward into the cheek, the flap having been previously outlined by tincture 
of iodine; when it is raised, it is to be twisted on its pedicle into the opening 
in the ala of the nose, the margins of which have been previously freshened 
for its reception, and it is then to be fastened by sutures. 
Fig. 1786. 
Fio. 1787. 
Flap taken from the face in order to 
repair a chasm in the nose made by 
syphilitic ulceration, a portion of the 
lower part of the cartilaginous septum 
having escaped. 
Flaps in place. 
Flap taken from the lip and 
twisted on its pedicle into its 
new position. 
Flap in position and 
stitched. CHAPTER XXIX. 
DISEASES AND INJURIES OF THE EYE AND ITS 
APPENDAGES. 
Ophthalmic surgery has become so amplified in the last thirty years that 
any attempt to treat the subject exhaustively in a work on general surgery 
would be out of place. I shall, therefore, in treating of this department of 
my subject, pursue as concise a course as may be consistent with an intel- 
ligent understanding of the various affections of the important organ in 
question. 
In the descriptive anatomy of the organ of vision it is common to divide 
the subject into the appendages, or tutamina oculi, and the eye proper; and in 
considering the surgical diseases and injuries of the organ a similar course 
will be adopted. 
GENERAL OBSERVATIONS BEARING ON THE EXAMINATION AND 
DIAGNOSIS OF DISEASES OF THE EYE. 
Blood-vessel Supply.—The arteries of the eye are derived primarily from 
the ophthalmic, a branch of the internal carotid. 
1. The arteria centralis retince enters the eye through the optic nerve, and 
is limited in its distribution almost entirely to that nerve and to the retina,— 
a fact which serves to explain the long persistence of inflammatory processes 
in the disk and retina without extending to the other tunics of the organ. 
2. The 'posterior and anterior ciliary arteries.—The former perforate the pos- 
terior part of the sclerotic, a short distance in front of the lamina cribrosa, 
and supply the choroid; the latter also penetrate the sclerotic, and, passing 
forward, one on each side, between the latter membrane and the choroid, 
reserve their branches of distribution for the iris and ciliary body, at the 
same time inosculating with the posterior or short ciliary vessels. This vas- 
cular oneness of the choroid, ciliary body, and retina explains the tendency 
of inflammation to travel from one of these structures to the others. 
3. The palpebral arteries, which enter the lids at the internal canthus, sup- 
ply, in addition to the conjunctiva,—the vessels of which are arranged in the 
form of a net-work,—other branches, which, at the junction of the cornea 
and sclera, communicate with those of the ciliary body, forming with the 
latter a remarkable vascular circle, which corresponds to the region where 
the sclerotic, cornea, iris, and ciliary body are located. It is this common 
point of inosculation which explains the red zone seen at the circumference 
of the cornea in cases of iritis, and it is the reticulate disposition of the con- 
junctival vessels which, in instances of conjunctivitis, imparts to the mem- 
brane the peculiar net-work-like arrangement of color. Notwithstanding 
the peculiarities which have been noticed and the influence of these on the 
morbid phenomena of the eye, their bearing on diagnosis, as relating to the 
localization of inflammation, may be greatly overestimated, as the general 
communication between the several vessels, except that of the central artery 
of the retina, may, when one part is inflamed, produce hypersemia of the 
others. 
There are certain significant phenomena, however, which possess diag- 
nostic value, based on the physiological functions of the components of the 
eye. Thus, the normal secretion of the conjunctiva, mucous in its character, 142 
DISEASES AND INJURIES OF THE EVE AND ITS APPENDAGES. 
and designed to facilitate the movements between the ball and the eyelids, 
becomes muco-purulent in some forms of conjunctivitis, gluing together the 
edges of the lids and the eyelashes. The little vascular eminences or papillae 
belonging to the palpebral conjunctiva, and designed to increase the extent 
of secreting surface, reveal, when inflamed and hypertrophied, by their fric- 
tion over the sensitive surface of the eye, the existence of granular lids. 
The cornea, which is non-vascular, and the brilliancy of which depends partly 
on the transparent contents of its surface cells, becomes opaque when inflamed. 
Extending the relation between structure, function, and disease, it may be 
observed that the iris, which is designed to regulate the degree of light as 
well as the place where it shall enter the eye, when inflamed becomes 
changed in color, and its pupil more or less immovable. 
Deportment of Patient.—Many diseases of the eye may be detected by the 
behavior of the patient. Thus, a patient who enters the office of the sur- 
geon with a cautious, uncertain, mechanical step, his eyes and head directed 
towards the floor, the corrugator muscles strongly contracted, and probably 
putting out a hand towards objects with which he apprehends coming in 
contact, is in all probability the subject of cataract. Another person ap- 
proaches without hesitation or timidity, walking firmly, with head erect, 
eyelids widely separated, and eyes looking directly forward and upward: 
such is the deportment of an individual who labors under amaurosis. 
Children suffering from strumous ophthalmia avoid the light, closing the 
eyelids more or less completely, twisting the head to one side, and con- 
torting the countenance, or perhaps burying the face in a cushion, or cover- 
ing the eyes with the hands. Adults who in examining any object turn 
the head to one side, or cover one eye with the hand, give evidence of 
having double vision, or deposits in certain parts of the visual field. 
Examination of Patient.—The first general survey of the eye should take 
in the direction of the eyeballs, and the condition of the cilia, cornea, and 
conjunctiva. A squint noticeable at a distance may entirely disappear on a 
nearer approach of the patient. The eyelashes may be found soiled with glu- 
tinous or muco-purulent crusts, indicating Meibomian disease, or they may, 
through a vicious direction or from inversion of the lids, be causing irrita- 
tion of the eye, or they may appear stunted and irregular in their curves, 
as when infested by parasitic disease. Any inflammation of the ocular con- 
junctiva will be easily detected by separating the lids with the fingers; and 
if disease of the palpebral or reflected portion is suspected, eversion of the 
lids will disclose it. The investigation in detail will also extend to the 
caruncles, the direction of the puncta?, the lachrymal canaliculi and sacs, 
pressing on the latter in order to see if any mucoid or purulent matter can 
be forced out. The mobility of the ball will be tested ; the form and curva- 
ture of the cornea, the depth of the anterior chamber, and the form, color, 
size, mobility, and symmetry of the iris, noted ; the sensibility of the eye de- 
termined by touching its surface with the point of a fine camel’s-hair brush, 
or with a silk thread ; the degree of tension of the globe under digital pressure 
learned, noting at the same time if pain is experienced over any part of the 
ciliary region, or if the ball is at all protruding. 
Having traversed this ground, attention may next be directed to the func- 
tions of the organ, which will include the acuity of vision, any defect in the 
refraction which may be present, and also, of consequence, the condition of 
the choroid, retina, optic nerve, crystalline lens, and vitreous body. 
In examining the surface of the cornea and other parts of the eye, it is 
important that the patient should be placed in a favorable light a short dis- 
tance from a window, preferably one with a northern exposure. The inspec- 
tion should be made both from the front and on the side, the patient being 
required to move the eye in different directions. A foreign body can scarcely 
escape detection if these precautions are observed. There is a decided advan- TENSION. 
143 
tage also, when narrowly scrutinizing the eye, in employing a double convex 
lens of two or two-and-a-half inch focus for oblique or focal illumination, 
equally applicable for sunlight or lamp-light. In using the lens with arti- 
ficial light, the room must be darkened, a lamp placed on a level with the 
eye and about two feet in front and to one side of the patient, and the light 
reflected by the lens on the cornea, iris, or crystalline body, while the ob- 
server occupies the opposite side. By thus concentrating the light on any 
part of the eye, superficially or deeply, the slightest trace of opacity may 
be detected. If it is desired to obtain a larger image, all that is necessary 
is to employ, in addi- 
tion to the illumination- 
lens, a magnifying-lens, 
which the observer 
holds in front of the 
patient’s eye. (Fig. 
1790.) 
The ordinary ophthal- 
moscopic mirror can be 
employed for the same 
purpose, using gas or a 
kerosene lamp placed, 
as is usual in ophthal- 
moscopic examinations, 
a few inches behind and 
to one side of the head 
of the patient. There 
is, however, a differ- 
ence in the appearance of opacities, according as one or the other of the two 
methods is employed: under oblique illumination they are of a grayish- 
white color, and dark under direct or transmitted light. 
Fig. 1790. 
Oblique illumination of the eye and magnifying the image by a magnifying- 
lens. 
Tension.—In ascertaining the tension of the eyeball, the patient is directed 
to close the eyelids, at the same time looking downward. The surgeon now 
applies the index-finger of one hand upon the eyelid over the sclerotic, in 
order to study the organ, while with the corresponding digit of the other 
hand he makes gentle pressure upon the ball, observing the degree of resist- 
ance which is encountered, and noticing whether the ball is hard and un- 
yielding or soft and inelastic. The normal tension will soon be learned by 
testing a number of eyes known to be free from disease. Different instru- 
ments have been devised (tonometers) by Yon Graefe and others with which 
to estimate intraocular tension, but they cannot be said to possess the value of 
the tactus erudiius. The important relation which exists between ocular ten- 
sion and ophthalmic disease has led to the construction of a formula for its 
estimation, very generally accepted by ophthalmologists, as follows: 
Tn = normal tension. 
Tj = slight increase of tension. 
T2 = considerable tension. 
T3 = extreme tension. 
When the tension is below normal, the sign — is placed before the letter T: 
thus, 
—Tj (?) = doubtful if tension is less than normal, and to convey this doubt 
an interrogation-point is placed after the numeral. 
—Tj = tension a trifle less than normal. 
—T2 = tension quite marked. 
—Ts = ball quite soft, permitting the finger to sink into the sclera. 
It may be thought that in these signs there is an unnecessary degree of 
refinement; but I am not disposed to criticise any methods which in scientific 
pursuits aim at mathematical accuracy: indeed, the tact which can be edu- 
cated up to the degree of perfection which is capable of communicating to 144 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
the mind these slight gradations of ocular resistance may possess the highest 
value, by revealing the stealthy approach of intracranial and intraocular 
disease long before it would be suspected by the less cultivated touch. 
Acuity of Vision.—To ascertain the acuteness of vision there are two sets 
of test-types in use, those of Jaeger and those of Snellen: the latter are 
generally regarded as preferable. The size of these letters increases in a 
regular ratio,—that is, the different numbers, running from 1 to 20, are seen 
each at an angle of five minutes. Thus, No. 1 is seen most distinctly by an 
eyo having a vision of normal acuity at one foot; No. 2, at two feet; No. 3, 
at three feet; and so on up to No. 20, at twenty feet. 
The greatest distance at which the types can be clearly recognized, indi- 
cated by the letter d, divided by the number of the type read, and expressed 
by the letter D, gives the formula for the acuteness of vision, V. For example, 
the formula for a person who at a distance of twenty feet can read a type 
(Snellen) marked No. XX. would have V = - ; or it maybe expressed in an- 
other way, as V = 20-; if No. X. is read at ten feet, the formula would be 
V = or it may be that No. XX. can only be read at the distance of ten 
feet, in which case the formula would be rendered V — = £, being only 
one-half of the normal acuity. There is also an acuity of vision over the 
normal: for instance, a person may be able to read distinctly type No. XX. 
at the distance of thirty feet, and then the formula would be stated as 
y 
XX* 
P’or testing the visual acuity of persons unable to read, test-dots have been 
prepared. In England these dots are frequently used in the examination of 
army recruits. 
It is important in testing the acuity of vision that the experiments made 
at different times should be conducted as nearly as possible under like degrees 
of illumination, whether made by natural or by artificial light. Some oph- 
thalmologists, in order to attain perfect accurac}7, insist on ascertaining the 
sensibility of the retina to light as preliminary to the trial of test-types,— 
a refinement, however, which is scarcely necessary in practice. 
Field of Vision.—In many instances it is important to ascertain the com- 
pass or extent of the field of vision. This can be done in various ways,—by 
the fingers, by the blackboard, and by an instrument called a perimeter. 
The first plan, though somewhat crude, will often answer the purpose in 
view. Each eye must be tested separately, the other being covered during 
the examination. 
By the first plan,—that by the fingers,—the patient is placed directly 
in front of the observer, at a distance of about sixteen feet, one eye being 
closed with the hand or a bandage, and the one under examination being 
steadily fixed on the opposite eye of the surgeon. Thus stationed, the band 
of the observer is raised and moved slowly in different directions from the 
centre of vision, in order to ascertain at what distance from the latter the 
fingers can be seen. Having determined the extent and form of peripheral 
vision (quantitative, as it is called), the next step is to learn the discriminating 
or qualitative degree of sight. A finger is now brought into the centre of 
the field of vision and then moved slowly towards its periphery, marking the 
exact point where it ceases to be visible to the eye of the patient. This trial 
is to be repeated in the different meridians until a fairly accurate idea of the 
visual horizon of the patient is obtained. A similar experiment may then 
be made on the other eye. 
If the blackboard is used, by which greater accuracy is obtained, let it be 
placed about one foot and a half in front of the patient, having a chalk-dot 
on its centre. On this dot let the eye to be examined be steadily fixed, the 
other eye being closed or covered with the hand. The observer now takes a FIELD OF VISION. 
piece of chalk, supported on a black holder, and, beginning at the outer side 
of the blackboard, brings it gradually towards the centre. The point where the 
chalk first becomes visible is then marked by a dot. This is to be repeated 
in the different meridians, and, when completed, all that is necessary to 
exhibit the form and extent of the field of vision is to join the different 
peripheral marks by a line. Proceeding next to learn the limits of the qual- 
itative field of vision, the patient, still keeping the eye fixed on the central 
point, is required to indicate the distance from the latter at which he can 
count fingers. 
It must be remembered, in all experiments of the above nature, that the 
peripheral extent ot normal vision varies in different directions in conse- 
quence of mechanical obstacles which themselves vary in different persons ; 
that is to say, on the inner and upper horizon the visual field is shortened 
according to the prominence of the nose and the eyebrows; it does not, on 
an average, exceed 50° in these directions, while on the outer side it will 
measure as much as 90°. 
Yarious modifications of the blackboard experiment have been made, only 
one of which I shall mention,—that of drawing through a common centre 
horizontal, vertical, and oblique lines, so as to divide the board into segments, 
by which the visual field can be more conveniently and accurately outlined. 
Unquestionably, when mathematical accuracy is desired, some one of the 
various modifications of the perimeter should be used. One of the best of these 
is that of Dr. Carmalt, of New Haven. (Fig. 1791.) This instrument consists 
145 
Fig. 1791. 
Carmalt’s perimeter: A, upright; B, arc; F I C, chin-rest; B A, view of the opposite side of 
the perimeter or arc, on which are marked the radii and the circle of 360°. 
of an upright stem, to the top of which is attached, transversely, an arc, laid 
off in graduated spaces of 10° each, and extending on one side to 90° and on 
the other to 50°, answering to the usual limit of temporal and nasal vision. 
This arc rotates on a pivot, corresponding in situation to its attachment to 
the upright, and marked by a prominent point, the spot on which the patient 
during the examination is to fix the eye. On the reverse of the arc are a 146 
DISEASES AND INJURIES OF THE EVE AND ITS APPENDAGES. 
number of radii, extending from zero to 360°, and running from left to right. 
An index points out the meridian at which the arc is fixed. Attached to 
the lower part of the stem is a horizontal rod, which supports an upright or 
chin-rest. The indications of the perimeter are noted on a chart. The pa- 
tient faces the instrument at a distance of fourteen inches. Areas where the 
visual field is defective or lost are highly significant, indicating the presence 
of damaged retinal tissue or scotomata. 
The invention of the ophthalmoscope by Helmholtz in 1854, by which the 
interior of the eye can be distinctly exposed and its deepest recess thoroughly 
explored, has enlarged immensely the field of ophthalmic medicine. Little 
did Brt'icke, and, still later, Professor von Erlach, suppose that, while engaged 
in their experiments on the illumination of the fundus of the eye, they were 
collecting a stock of optical facts which should furnish to the learned and 
ingenious Helmholtz the clue for the construction of an instrument which 
would enable the observer to traverse a hitherto unexplored region, and 
divulge all the pathological conditions of an organ which until that time 
had remained a profound secret. 
The difficulty which hitherto had barred the way to the study of the 
interior of the eye arose from the fact that there was no method known by 
which the eye could be strongly illuminated and at the same time the emer- 
gent rays of light be rendered divergent and reach directly the eye of the 
observer. In other words, it was necessary that the eye of the observer, the 
eye of the observed, and the source of light should all be in line. This dif- 
ficulty was surmounted when, in a dark room, the light from a lamp placed on 
one side of the person observed was received on a highly-polished surface or 
plane mirror and reflected into the fundus of the eye, the emergent rays 
reaching the retina of the observer 
through a small opening in the centre 
of the mirror (Fig. 1792) interposed 
between the examiner on one side and 
the examined and light on the other. 
The reflecting mirror first used by 
Helmholtz had a plane surface. This 
was changed subsequently for a con- 
cave one, which necessarily possessed 
greater illuminating power. 
The ophthalmoscopes most generally 
used are those of Liebreich, Loring, 
and Wolfe. 
The instrument of Wolfe has two 
disks placed behind the mirror, one of 
which is supplied with fourteen convex 
lenses, and the other with a similar number of concave lenses. 
The ophthalmoscope of Loring (Fig. 1793) has three disks, each containing 
eight lenses, one set being concave, another convex, by which the various de- 
grees of hypermetropia and myopia can be determined ; the third contains 
both forms of lenses, of much greater strength than the others, by which 
the highest degrees of error in refraction can be ascertained, and also in- 
equalities on the surface of the fundus measured with accuracy. One opening 
in the third disk is left unoccupied, designed to be used without an eye-piece 
in emmetropia and by the inverted image. With this instrument of Loring 
there is also a second mirror, which has in it a slit equal in length to the 
diameter of the openings in the cylinder. This plate with its polished sur- 
face is made to fit into the mirror-frame, in which it can be turned so as to 
make the slit answer to any meridian of the cornea. By this useful addition 
the degree of astigmatism in the different meridians of the eye can be quickly 
EXAMINATION OF THE INTERIOR OF THE EYE. 
Fig. 1792. 
Principle of ophthalmoscope shown: A, eye of ob- 
server; B, eye of observed; C, lamp; D, mirror for 
reflecting the light, with an opening in the centre, 
through which pass the emergent rays to the eye of 
the observer. EXAMINATION OF THE INTERIOR OF THE EYE. 
147 
•determined and its correction accomplished by turning the cylinder until the 
suitable glass is reached. There is a recent modification of the Loring oph- 
Fig. 1793. 
Loring’g ophthalmoscope. 
thalmoscope, having a single disk, containing sixteen glasses, the convex and 
concave ones being numbered in different colors, and having the segment of a 
second disk, containing four glasses. The numbers in one color exhibit the 148 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
strength of each glass alone, and those in the other the strength of any 
combination resulting from the addition of those in the segment. It is 
only necessary, to make this instrument a simple, single disk, to turn aside 
the segment or quadrant. 
There are also binocular ophthalmoscopes, which present a picture of the 
fundus of the eye in relief, much as photographic views are seen through a 
stereoscope. 
Examination of the Fundus of the Eye.—This examination is conducted in 
two ways,—viz., by the direct and the indirect method ; or by the upright or 
vertical, and the inverted or real image. 
Examination by the upright method.—The patient is seated in front of and a 
trifle lower than the observer, in a darkened room, with a gas or other lamp 
placed on the same side as the eye to be examined, and somewhat behind 
it. When the eye-ground is to be carefully studied, the pupil should be pre- 
viously dilated by atropia, unless, as is often the case, dilatation is present 
as a result of disease. The examiner, taking his seat and holding the oph- 
thalmoscopic mirror between his own face and that of the patient, and 
coming as close to the latter as possible, looks through the aperture in the 
eye of the same side as that under observation, and reflects the light into the 
fundus of the organ. (Fig. 1794.) A little practice will be necessary before 
Fig. 1794. 
the beginner can quickly catch the light and project it into the organ. 
When this is successfully accomplished, there will be seen a red reflection 
from the illuminated fundus. Both the observed and the observer must, as 
much as possible, suspend all efforts at accommodation. This can only be 
done after a little practice by dismissing from the mind the idea that specific or 
single objects are to be sought after,—in other words, by looking as one would 
take in a general view of a landscape,—after which the examiner may proceed 
to the study of the details of the ground. By this plan the pictures of the 
fundus are seen in the upright position, and the image is much larger than by 
the indirect or inverted method. The image seen in this examination is erect, 
simply because the rays of light which emerge from an eye of normal refrac- 
tion are parallel. Convergent rays are necessary to the formation of an in- 
verted image. Should the eyes both of the observer and of the observed not 
be emmetropic, it will be necessary to make the correction by the addition 
Examination by the direct method. EXAMINATION OF THE FUNDUS OF THE EYE. 
of such lenses as will neutralize the defect, whether it exists in the surgeon 
or in the one examined; for example, if the eye of the examiner is hyper- 
metropic, he must either, at the time of the examination, wear his convex 
glasses, or use a lens behind the mirror of the same form sufficient to correct 
the error of refraction; and in like manner if myopic, emmetropia must be 
restored by the addition of a concave lens. 
Examination by the indirect or inverted image.—The examiner, patient, 
and light occupy relatively the same positions as in the examination by the 
direct method, except that the surgeon now holds the mirror, resting against 
his brow, twelve or fourteen inches from the eye to be examined, at the same 
time placing in front of the latter a double convex lens having a focus of two 
and a half inches. (Fig. 1795.) Should the objects under examination be some- 
what indistinct, the head of the examiner may be moved away from or 
somewhat nearer to the mirror, as the case may be, until the defect in his 
refraction is corrected, which is probably the true explanation of the diffi- 
culty. The image of the fundus seen is an aerial and inverted one; that is, 
149 
Fig. 1795. 
Examination of the inverted image. 
it is not situated in the eye, as it appears to be, but between the double 
convex lens and the examiner. The image is an inverted one because by 
means of the bi-convex lens parallel rays are converted into convergent ones. 
The explanation of this will be made clear by studying Fig. 1796. 
Normal appearance of the fundus.—Having acquired the necessary tact in 
illuminating the eye, the observer may proceed to study the topographical 
features of the fundus. 
The optic nerve or disk.—If the eye of the person examined is the right one, 
and he is requested to direct it towards the left ear of the observer, without 
at the same time turning his head, the optic disk will come into view. It will 
at once be recognized by its transparent, pinkish-white color, mingled with a 
slight tint of blue. The color of the disk is influenced in no small degree 
by the color of the eye, being white and brilliant in dark eyes, and reddish 
in light ones. This admixture of colors will be better understood if the disk 
is enlarged somewhat by using a double convex lens of two and a half or three 
inches’ focus, which will enable the observer to discover, in what before ap- 150 
DISEASES AND INJURIES OF THE EVE AND ITS APPENDAGES. 
peared to be a homogeneous surface of color, connective, nerve, and vascular 
tissue, each reflecting its peculiar color of white, blue, and red. The form 
of the optic disk is oval, round, or slightly crescentic. Examining the cir- 
Fig. 1790. 
A is the bi-convex lens, by means of which an inverted image B C is formed of the fundus C B. 
eumference of the disk, it will be seen to be bounded, though well defined,, 
by two rings of color, one gray, the margin of the optic foramen in the 
sclerotic, and the other still more external, and darker in color, indicating tho 
margin of the opening in the choroid. Another noticeable feature of the 
optic disk is its blood-vessels, which appear on its surface, a little to the nasal 
side of the centre. These vary in number and distribution according as the 
division of their branches takes place within the optic nerve or after their 
emergence. Generally there will be seen with each artery two veins, running 
in an upward and a downward direction. The vessels multiply by division 
and follow a tortuous course. (Fig. 1797.) The arteries and veins can be dis- 
tinguished from one another, the former 
having a much redder color and being 
smaller and less tortuous than the lat- 
ter. In addition to the central artery 
the disk receives branches from the 
short ciliary, and also to some extent 
from the choroid vessels; these form a 
vascular net-work around the margin 
of the disk. Occasionally pulsation is 
seen in the veins of the retina. This 
phenomenon is not inconsistent with 
a healthy state of the eye. Pulsation 
in the arteries does not exist without 
there being some abnormal state of ten- 
sion within the ball. It is present also 
in cases where there is disease of the 
aortic valves. Another peculiarity pre- 
sented by the optic disk is a superficial 
central excavation, distinguished by its 
white appearance and surrounded by 
a pale pink zone. This excavation must not be mistaken for that of glau- 
coma. The presence of minute patches of pigment on the disk is also a 
physiological feature of this portion of the view. To the right of the optic 
disk and a short distance below it will be seen the macula lutea, a dark-red 
or 3mllow spot, with a central white spot, the fovea. The red color of the 
fundus of the eye is produced by reflection of light, chiefly from the blood- 
vessels of the choroid. 
Fig. 1797. 
Normal appearance of the fundus of the eye. 
Surgical Affections of the Appendages of the Eye. 
Included under the head of appendages are the eyebrows and eyelids, with, 
their muscles, and the lachrymal apparatus. SURGICAL AFFECTIONS OF THE EYEBROWS AND EYELIDS. 
151 
Eyebrows.—These fleshy masses, with their hairs, surrounding the supra- 
orbital portions of the frontal bone, must be included under the term tutamina. 
They not only shade the eyes from the superior rays of light, and in this way 
contribute to distinctness of vision when narrowly scanning objects, both 
near and remote, but also by their prominence defend the eyes against the 
violence of blows which otherwise might fall with disastrous effect on the 
ball beneath. The hairs likewise, which by their artistic curves add much to 
the beauty of the face, perform a protective part in catching and holding in 
their embrace foreign matters, such as dust, which might settle upon the eye. 
Wounds and contusions of the eyebrows, by knives, sabres, pieces of glass, 
bludgeons, or falls against projecting corners of stones, are common occur- 
rences. 
Treatment.—After thoroughly cleansing the wound of all foreign matters, 
and delaying its closure for a short time until the bleeding ceases,—a ligature 
being rarely required,—the edges are to be carefully approximated by fine 
carbolized silk or silver threads, including the muscular as well as the cuta- 
neous layers of the flap, and covered with a light pledget of lint moistened 
with carbolated oil and secured in place either by a narrow roller applied 
obliquely over the eye and head, or by an adhesive strap. The importance 
of making the adjustment accurate arises from the fact that unless such 
care is observed the corrugator muscle may cause a material alteration in the 
expression of this part of the face. When the wound is transverse or parallel 
with the fibres of the orbicularis palpebrarum muscle, severing the connection 
of the latter from the anterior belly of the occipito-frontalis muscle, the ne- 
cessity for observing the principle already emphasized, that of including the 
muscles in the suture, must not be forgotten, otherwise there may follow a 
drooping eyebrow. 
Contusions of the eyebrows are sometimes followed by a temporary loss 
both of motor and of sensory endowments, in consequence of the damage sus- 
tained by the branches of the facial and supraorbital nerves. 
Astringent lotions, and, if the power and sensibility are tardy in returning, 
faradic stimulation, constitute the remedies. 
Loss of hair from the eyebrows is almost invariably the effect of constitu- 
tional syphilis, and is remedied only by treatment addressed to the general 
system, mercurials being usually needed, as this form of alopecia commonly 
occurs in the early stages. 
Eyelids.—The affections of the eyelids are very numerous, as might be 
supposed from the variety of tissue which enters into their composition. 
Contusions of the eyelids are exceedingly common, arising from blows, ac- 
cidental or designed. In consequence of the very loose connection between 
the skin and the muscular and cartilaginous portions of the lid, from the 
abundance and elasticity of the connective tissue, furnishing little support to 
the large palpebral veins, contusions are followed by diffuse swelling and 
discoloration, very soon closing the eye: hence the familiar terms of the 
“ bunged” and the “ black eye.” 
Treatment.—Immediately after the reception of such an injury, pledgets 
wet with ice-cold water should be accurately adjusted to the lids and firmly 
bound in place by a bandage, in order to prevent the continued extravasation 
of blood. If this is done promptly and repeatedly, at intervals of a half- 
hour, or if the bandage is frequently wet with cold water without being re- 
moved, much both of the swelling and the discoloration may be prevented. 
Hot water can be used in the same manner and with equal efficiency. Various 
other articles besides water are used as local applications. Among these 
are tincture of arnica, lead-water, and alcohol. They possess no advantage 
over the water-dressing except in cases where the early use of remedies 
has been neglected and the swelling has reached its climax. Under these 
circumstances stimulating articles like those named, frequently applied, are 152 
DISEASES AND INJURIES OF THE EVE AND ITS APPENDAGES. 
to be preferred, so as to favor the absorption of the extravasation. When 
the accumulation of blood in the subcutaneous connective tissue is so great 
as to render suppuration probable, a puncture may be made at the outer ex- 
tremity of the lid with a lancet, and the extravasation pressed out, to he 
followed by water-dressing and compress. 
(Edema of the eyelids is usually a symptom of inflammatory disease in the 
adjacent parts, as in erysipelas, and requires no special notice. It is also 
among the phenomena following the poisonous effects of arsenic. 
Emphysema of the eyelids may follow fracture of the nose, or injury to the 
frontal sinuses, permitting the air from the former cavities to escape and to 
penetrate the spaces of the connective tissue of the lids. The condition is 
recognized without difficulty by the swelling present, and by the crackling 
sensation communicated to the finger on pressure. 
Treatment.—Nothing more is required for the removal of this affection 
than frequent cold lotions, aided, if necessary, by a few punctures made with 
the point of a fine tenotome. 
Wounds of the eyelids may extend only through the structures external to 
the cartilage, or they may include also the cartilage. 
Fine carbolized silk thread is to be preferred to silver wire for closing such 
wounds, as the latter, when applied to the yielding and extensible tissues of 
the palpebra, is apt, while being fastened, to twist the soft parts out of shape. 
Transverse wounds, when accurately adjusted, leave no visible cicatrix, as 
the lines of union are shaded by the concentric wrinkles of the lids. Wounds 
which are vortical, and which sever the cartilage through its free border, 
should be very accurately adjusted, the first stitch being introduced at the 
ciliary border of the flaps, in order to preserve the latter on the same plane, 
and should include the cartilage as well as the superincumbent tissues. 
When the wound is situated at the inner extremity of the lids, and involves 
the lachrymal canaliculus, additional caution will be required to prevent the 
latter canal from becoming obstructed in the adjustment; and to avoid this 
a director should be introduced and the canaliculus slit up. Transverse 
wounds of the cartilage do not require the sutures to extend deeper than 
the muscular la}rer. 
Lacerated wounds of the lids, though liable to slough and heal by open 
granulation, should always be closed by sutures, in the hope of at least lessen- 
ing the resulting chasm. The notch which follows a sloughing wound of 
the cartilage can only be removed, after the healing is complete, by paring 
the edges and bringing them together with sutures. When gaping is too 
great to permit of an easy approximation, it ma}r be necessary to make, on 
each side, vertical incisions of the fibres of the skin and orbicular muscle, 
in order to favor the adjustment, as practiced by Knapp, of New York. 
When the loss of substance is so great as to make this treatment improper, 
the deficiency can be supplied only by borrowing tissue from the adjoining 
parts and transplanting it into the gap, previously prepared for its reception. 
Burns or Scalds of the eyelids must be treated as similar accidents else- 
where are; and where the injury is followed by sloughing, the lids must be 
closed, and kept upon the stretch by a compress and bandage applied over 
the dressing during cicatrization, in order to prevent, as far as possible, an 
ectropion. 
Stings.—Few lads in the country familiar with the adventures of school- 
boy days have escaped having their eyes closed by the stings of bees, received 
in the act of gratifying their melliphagous instincts. These wounds are 
very painful, and are quickly followed by great swelling of the eyelids. 
Similar symptoms attend the bite of the mosquito and the sting of the gnat. HORDEOLUM, OR STYE. 
153 
The constant application of a lotion of cold lead-water will give the neces- 
sary relief. 
Hordeolum, or Stye, is a circumscribed phlegmon, boil, or abscess, which 
appears at or near the edge of the lids, and is accompanied by swelling, 
redness, heat, pain, and itching. These inflammatory swellings vary in size 
from that of a mustard-seed to that of a pea, and are sometimes multiple. 
The young, especially females of delicate or strumous constitution, are par- 
ticularly liable to attacks of this nature. They are often among the results 
of old cases of catarrhal conjunctivitis. Persons of either sex, and at any 
time of life, with disordered digestion, also patients convalescing from asthenic 
fevers, are often the subjects of tarsal boils. 
These styes occur in two different localities,—first, in the glandular acinus 
of a cilia; secondly, in one of the inner tarsal glands. 
When originating in a ciliary gland, the swelling is seen near the edge 
of the lid, effacing for the time the sharp definition of the external margin 
of the palpebra, and being very tense from the resistance offered by the over- 
lying parts at this portion of the lid. When the stye begins in an internal 
tarsal gland, the tumor, appearing as a red pimple, obliterates the internal 
sharp margin of the palpebral cartilage alone, pushing before it the mucous 
and submucous tissue of the lid, and never attaining the size of external 
hordeolum. 
Styes generally run an acute course, terminating, after the lapse of two 
or three days, in the formation of pus, which is announced by the appearance 
of a yellow point at the summit of the swelling. When the constitution 
has been seriously impaired, styes are apt to follow a chronic course, several 
appearing at the same time, and some slowly undergoing resolution without 
reaching the stage of suppuration, or they may be converted into what oph- 
thalmologists term chalazion, which is simply a swelling or thickening, con- 
sisting of inflammatory neoplasia, a portion of which, under a retrograde 
metamorphosis, is converted into a fatty pulp, mingled with cholesterin, 
lime-salts, and epithelial debris, a condition not unlike that seen in residual 
abscess. 
Occasionally, by a similar process the stye is transformed into a cyst. 
When styes are frequently repeated they are liable to induce, by the produc- 
tion of so much cicatricial tissue, deformity of the lid. 
Treatment.—It is sometimes possible at the very commencement of an 
hordeolum to abort the disease by introducing into the orifice of the in- 
volved gland a very fine bristle-pointed probe and liberating thereby the 
contents of the follicle. The removal of tension exerts a decidedly anti- 
phlogistic effect. Iodine applied early to the swelling, especially when asso- 
ciated with tincture of belladonna, will in some instances arrest the progress 
of an hordeolum. 
Generally, however, when the attention of the surgeon is called to a case 
of stye, the inflammation has passed the point where resolution is possible, 
and it is better to encourage suppuration as rapidly as possible. For this 
object, frequently renewed pledgets of lint wet with warm water, laid over 
the closed lids and covered with oiled silk, will often suffice; or the same 
effect can be obtained from the use of a little bag of powdered slippery- 
elm bark dipped in hot water and applied to the palpebra. As soon as the 
presence of pus is discovered, a puncture should made with the point of a 
delicate bistoury or a Beer’s cataract-knife, and the contents of the abscess 
discharged. Nothing more is necessary, except occasionally to bathe the 
lid with a lotion of warm water, as the swelling rapidly disappears. 
In cases of chronic hordeolum or recurring hordeolum, both constitutional 
and local measures are demanded. After correcting any derangement of the 
digestive apparatus which may exist, quinia and iron, or cod-liver oil and the 
iodide of iron, are among the most valuable general remedies to be adminis- 
tered, while the application to the edge of the lids of dilute citrine ointment, 154 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
or an ointment of the red oxide of mercury, will have a decidedly correcting 
influence upon the local morbid action. 
Acne Tarsi.—Closely allied to hordeolum is acne tarsi, characterized by in- 
flammatory swellings, or red nodules, connected with the sebaceous glands 
of the eyelashes, and seated on the outer edge of the lid, surmounted by one 
or several cilia. They sometimes cause the entire lid to swell, and give rise 
to considerable heat and irritation. Along the surface of the lids, between 
the little conical masses of acne, the epithelium rapidly desquamates, leaving 
the palpebral border somewhat abraded and covered with thin crusts. 
Acne of the lid advances in a few days to suppuration, or it may undergo 
resolution, or reabsorption. 
Treatment.—The lids should be frequently bathed wfith warm mucilagi- 
nous liquids of slippery elm or the pith of sassafras, to which has been 
added a very little acetate of lead. If the yellow point appears on the sum- 
mit of the nodule, indicating the formation of pus, an opening must be made 
with the point of a needle. To prevent the recurrence of the pimples, the 
border of the lids should be treated every night with very dilute mer- 
curial, citrine, iodine, or iodoform ointment. When the subject of acne is 
obese, a gross feeder, and one whose sebaceous glands are over-active, much 
can be done towards effecting a cure by the exhibition of an occasional 
aperient, frequent bathing, and the use of farinaceous diet. 
Palpebral Abscess.—The difference between abscess and hordeolum of the 
eyelid consists only in location, the former being seated in the subcutaneous 
connective tissue of the palpebrae. 
The upper lid is most commonly affected. The abscess is the result of 
blows, burns, erysipelas, etc. It appears as a diffuse swelling, a form result- 
ing from the loose and abundant character of the superficial fascia of the 
palpebrae. The swelling is red, shining, tense, and painful, bounded by a 
line of induration not sharply defined, and causing the eye to be closed. 
There is an abscess of the lid which I shall designate as submuscular. The 
purulent matter forms in the connective tissue between the palpebral portions 
of the orbicularis palpebrarum muscle and the cartilage. 
This abscess differs from that described above chiefly in the swelling 
of the submuscular one being much less prominent and more oblong than 
in the subcutaneous abscess, in its being preceded by oedema, and resulting 
in an earlier closure of the eyelids. 
Treatment.—The treatment does not differ from that required for horde- 
olum,—namely, the use of hot fomentations, or poultices of slippery elm or 
flaxseed-meal, and opening the abscess at the first appearance of suppuration. 
Unless this course is adopted, there will follow", especially if the abscess is 
the result of erysipelas, extensive sloughing of the connective tissue of the 
lid. Early evacuation of the pus is equally important in the submuscular 
abscess. 
Blepharitis Ciliaris.—This is a pustular disease of the border of the lids, 
sometimes described as tarsal-ophthalmia. The commencement of the affection 
usually escapes observation. There is first an inflammatory redness, followed 
by slight tumefaction, along the upper edge of the free border of the lid. fol- 
lowed by minute pustules, which soon break and discharge their contents, 
leaving a raw, moist surface, the discharges from w'hich, mixed with epi- 
thelial cells and glandular secretions, dry into crusts upon the eyelashes, 
and, accumulating through the night, glue together the eyelids so tenaciously 
that considerable force is required to effect their separation. When the 
disease is allowed to go unchecked, very considerable structural alterations 
follow. The ulcerations along the lid deepen, run together, and their edges 
become ragged. Granulation-tissue forms. The sharp-cut lines which sepa- 
rate the cutaneous and the mucous surfaces from the free border of the MALPOSITION OR MALDIRECTION OF THE CILIA. 
155 
tarsal cartilage gradually disappear, giving a rounded appearance to the 
edge of the lid. The proliferation of connective-tissue elements about the 
follicles of the cilia imparts a sensible thickening and induration to the 
edge of the lid, often changing the direction of the eyelashes. In conse- 
quence of the formation of cicatricial tissue, the cilia may be lost, and the 
traces of the glandular elements of the palpebrse be obliterated, leaving the 
lids perfectly bald. Thelachrymal punctaj may also participate in these inflam- 
matory changes, so as to become either impervious to the tears, or so changed 
in direction as to prevent the admission of the latter, thus allowing the secre- 
tion to flow over upon the cheek,—constituting lippitudo, or blear-eye. A mong 
other deformities resulting from the production of cicatricial tissue is ectro- 
pion. The ametropic eye, it is thought by Roosa, is predisposed to inflam- 
matory disturbances like those enumerated; but the latter are certainly 
exceedingly rare effects of such an imperfection in the refractory media of the 
eye. Blepharitis ciliaris, though generally a symptom of a constitutional 
state, is often the result of local ii-ritation arising from habits of uncleanliness. 
Once established in the eyelid, its dispossession is a most difficult and often 
impossible task. It is essentially a chronic affection, clinging to the patient 
through all the changes of life, from adolescence to old age. 
Treatment.—The importance of early treatment cannot be overestimated. 
The indications are to keep the lids free from hardened secretions or crusts, 
and by the use of stimulating and alterative remedies to secure the cicatri- 
zation of the ulcerated surface. 
The first object is to be accomplished by frequent ablutions of the lids with 
warm milk-and-water, or with alkaline and mucilaginous liquids, as slippery- 
elm or marsh-mallow tea containing a small quantity of bicarbonate of soda 
or a weak solution of biborate of soda or boracie acid. This cleansing must 
be attended to at least three times a day, and should be done with a camel’s-hair 
brush, carefully working in between the individual eyelashes, and always 
followed by touching the washed surfaces with a little spermaceti, oxide of 
zinc ointment, or vaseline. In the morning when the patient arises, the lids 
are often found firmly glued together by the discharges and secretions of the 
night, and much harm may be occasioned by suddenly tearing the adherent 
surfaces apart. No attempt to separate the lids should ever be made until the 
bond of agglutination has been softened by a protracted bathing with one of 
the lotions given above, or by using warm water alone. Cutting off the eye- 
lashes will serve in some measure to lessen this tendency to adhesion, and 
renders the cleansing an easier task. 
The second indication, that of favoring cicatrization, requires the use of 
alterative ointments, the best being dilute citrine or red oxide of mercury 
ointment, blue ointment, the ointment of ammoniated mercury, nitrate of 
silver, and particularly a mixture of iodoform and balsam of Peru (iodoform, 
grs. v; balsam of Peru, 5ss). Depilation of the cilia, recommended by some 
writers, is, so far as my own observation extends, rarely necessary, the vio- 
lence of the procedure rather aggravating than mitigating the inflammation. 
When the ciliary inflammation extends to the conjunctiva, giving rise to 
catarrhal thickening, the nitrate of silver becomes an important agent in 
controlling the inflammation of the mucojis membrane. 
Malposition or Maldirection of the Cilia.—Under this head are included 
two diffei'ent peculiarities of the cilia,—one in which the eyelashes, either in 
consequence of a change in the direction of the lid, or from some vice in 
the nutrition of the cilia, are turned so as to come in contact with the Bur- 
face of the eye (trichiasis) (Fig. 1798); the other, in which a second row 
of hairs, more or less complete, or a few scattering hairs,—popularly, “ wild 
hairs,”—grow from the inner edge of the lid, and cause a similar irritation 
of the eye (districhiasis). The latter condition may be congenital, or it may 
appear at puberty. The evil effects of such irritation continued for a length 
of time are severe itching of the edge of the lids, spasmodic contraction of 156 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
the orbicularis palpebrarum muscle, conjunctivitis, keratitis, and opacity of 
the cornea. 
Trichiasis is often due to malposition of the lid alone, as in some cases 
of entropion. It is also among the evils 
of blepharitis ciliaris, and may follow 
injudicious cauterization of granular lids. 
Treatment.—When the trouble de- 
pends exclusively on a vicious direction 
or position of the cilia, the offending 
hairs, with their bulbs, should be pulled 
out fi*om the follicles. This may require 
to be repeated every day or two. Be- 
peated depilation tends to bring about 
atrophy of the follicles, and even ulti- 
mately to destroy them altogether. At 
all events, frequent extraction delays the 
growth of the cilia, so that after a time 
their removal is required only at inter- 
vals of two or three weeks. Some skill 
is required to perform this minor oper- 
ation judiciously. It is not to be accom- 
plished by seizing the hair at the middle 
or by a sudden jerk, a procedure which almost certainly breaks off the stem 
without disturbing the root of the cilia, leaving a stump or bristle, which 
serves only to add to the irritation. The hair is to be grasped by the cilia 
forceps (Fig. 1799) close to the cartilage, 
and to be extracted by a steady pull. 
An elliptical portion of the redun- 
dant integument of the palpebra may 
also be removed, as practiced in entro- 
pion, and in extreme cases the affected 
cilia may be permanently destroyed by excision of the follicles along with 
the hairs. (See Entropion.') Before, however, a measure so radical is adopted, 
it will be better to try the method of Arlt, that of setting the cilia back, or, 
as it has been termed, their transplantation. This operation is done in the 
following manner. 
Passing a bone spatula between the eyeball and the palpebra, and raising 
the latter from the eye so as to make it somewhat tense, a Graefe’s cataract- 
knife is introduced into the free border of the tarsal cartilage, midway be- 
tween its mucous and cutaneous lips, and, pushing it onward and upward, 
the point is caused to emerge on the ex- 
ternal surface of the lid about one-sixth of 
an inch above the eyelashes. The knife 
is now carried by a sawing motion first 
towards one and then towards the other 
extremity of the lid. By this incision the 
cilia with their follicles are detached from 
the other structures of the lid, except at 
the extremities of the cut, where the con- 
nection between the two is left undisturbed. 
(Fig. 1800.) A semilunar portion of the 
tarsal integument above the upper incision 
is next dissected away, after which the 
ribbon-like strip of tissue connecting the 
eyelashes is stitched by three or four in- 
terrupted sutures to the margin of the cut 
above. In closing the wound the cilia are 
drawn upward and thus removed from contact with the eye. 
Should the portion of the lid bearing the cilia slough, no evil can follow : 
Fig. 1798. 
Trichiasis. 
Fig. 1799. 
Cilia forceps. 
Fig. 1800. 
Cilia separated from the lid, except at the ex- 
tremities, and a semilunar portion of the integu- 
ment of the lid outlined for removal. ENTROPION. 
157 
what may be lost in appearance will be more than compensated for by the 
relief from irritation. 
Two other plans have been resorted to for getting rid of the cilia,—namely, 
by suppuration and by sloughing. The first, known as the method of Iler- 
zenstein, consists in passing subcutaneously a thread across the lid, im- 
mediately above the roots of the cilia, bringing its ends out at the free 
border of the palpebra, sufficiently far apart to include the affected hairs, and 
attaching this to the forehead with adhesive plaster. 
Hayes, of Dublin, effects the destruction of the hair-follicles by slough- 
ing, introducing for this purpose the perchloride of iron into the hair-bulbs 
with a hypodermic syringe. Mackenzie accomplishes the same result by 
passing a straight cataract-needle along the shaft of the hair to its root; a 
probe dipped in liquid caustic potash is, after the withdrawal of the needle, 
passed to the bottom of the wound. The galvano-cautery may also be em- 
ployed for the destruction of the hair-follicle, by introducing a fine platinum 
needle along the shaft of the hair to its root and connecting it with the 
battery. Snellen, where the trichiasis was limited, attempted to change the 
direction of the hairs by using a thread to retract them under the skin of 
the eyelid. 
Lice.—The eyelids are subject to an irritation produced by a species of louse, 
the pediculus pubis or crab-louse. These vermin burrow along the roots of the 
hair, and may readily be overlooked by a careless observer. Their presence 
is to be suspected when the eyelashes are covered with a gray dust and 
filled with brown crusts. These accumulations are made up of the exuvia> 
of the lice, mingled with bloody serum from the wounds which they inflict. 
The remedy is an ointment of ammoniated mercury, or blue ointment, 
rubbed into the roots of the eyelashes, either of which quickly destroys these 
creatures. 
Fissure of the Lids.—At the external palpebral commissure a linear ulcer 
sometimes exists, and occasions considerable irritation of the eyelids, along 
with a local conjunctivitis and more or less spasm of the orbicularis palpe- 
brarum muscle. When the lids are separated at the external can thus, a drop 
of blood may be discharged. 
Treatment.—Touching the diseased surface with a particle of iodoform 
or a crayon of nitrate of silver (fifty per cent.), and placing over the closed 
lids a compress of charpie, secured with a roller bandage, will generally be 
all that is required to effect a cure. The bandage should not be removed for 
three days. In the event of failure, the external commissure of the lids 
should be severed through the ulcer, along with the corresponding fibres of 
the orbicular muscle, and the wound allowed to heal by granulation. The 
division is to be done subcutaneously. A water-dressing is to follow the 
operation. 
Entropion.—By this term is meant the inversion of the eyelid. The lower 
lid suffers more frequently than the upper. There 
are several degrees of this deformity, from a 
slight turning in of the ciliary border of the lid 
to its complete inversion. The evil effects re- 
sulting from entropion are similar to those 
which follow trichiasis and districhiasis, in which 
the cilia, coming in contact with the surface of 
the eye (Fig. 1801), create irritation and inflam- 
mation. 
Yarious causes are concerned in producing 
the inversion, chief among which is muscular 
spasm of the orbicularis palpebrarum: hence 
all those forms of inflammation of the eye which tend to excite reflex 
Fig. 1801. 
Entropion of both eyelids. 158 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
action of this muscle are strong predisposing causes, among which may be 
mentioned strumous and granular ophthalmia and keratitis. Cicatricial 
tissue, the result of the application of too potent caustics in the treatment 
of certain forms of ophthalmia, constitutes another cause of the deformity; 
so also does relaxation of the lids, owing to redundant tissue, so often wit- 
nessed in old people. 
Treatment.—In very slight cases of entropion, those, for example, which 
occur in strumous children and are due to blepharospasm, a judicious con- 
stitutional and local treatment, consisting of cod-liver oil, iodide of iron, and 
the occasional instillation of atropia into the eye, with the use of astringent 
collyria, will, as the general health improves, resolve the muscular spasm, at 
the same time allowing the border of the lid to resume the normal direction. 
There is a muscular inversion of the lid not depending on general spasm 
of the orbicularis palpebrarum, but only on that of a pale strip of fibres 
which lie close to the ciliary border of the lid, and which is relieved by a 
subcutaneous division of this portion of the muscle at each tarsal commissure. 
There are, however, a large number of cases which can be corrected only by 
more extensive operative measures, of which there are a great variety. 
Where there is redundancy of tissue, a very good result is obtained by ex- 
cising an elliptical portion of integument, along with the underlying muscular 
fibres, from the surface of the lid, and uniting the cut surfaces with sutures. 
The success of this operation will depend chiefly on the amount of tissue 
removed and on the close proximity of the lower part of the ellipse to the 
border of the lid, where, on examination of the palpebra, the skin will be 
found pretty firmly connected with the cartilage. 
In executing this operation, the redundant tissues on the cutaneous surface 
of the lid are to be pinched up and secured in the grasp of the entropion 
or crutch forceps (Fig. 1802). The 
amount to be included must be de- 
termined by observing the effect 
produced on the ciliary border of 
the lid. When satisfied on this 
point, three silk sutures are to be 
passed through the base of the fold, 
and the redundant portion excised 
by carrying the knife between the 
forceps and the sutures. (Fig. 1803.) 
The large raw surface exposed is next closed by bringing the edges of the 
wound together with the three interrupted sutures. (Fig. 1804.) The trac- 
Fig. 1802. 
Entropion forceps. 
Fig. 1804. 
Fold raised and held in the grasp of the for- 
ceps; the sutures passed, and the knife applied 
preparatory to making the excision. 
Wound, witli sutures introduced. 
tion thus made on the free margin of the lid will serve to raise and evert the 
eyelashes. A very ingenious instrument has been devised by Dr. Thomas G-. Morton, which combines two instruments in one, the forceps and the knife, 
and renders the operation for entropion very simple and easy of execution. 
(Fig. 1805.) 
In cases where the cartilage has become obstinately incurved, the resist- 
ance will sometimes be so great that sufficient traction cannot be made, even 
after the excision of a 
large amount of integu- 
ment, to correct the in- 
version. In such an 
event, the difficulty can 
be overcome, after re- 
moving a portion of the 
skin from the lid, by ex- 
cising a wedge-shaped slip from the whole transverse extent of the tarsal 
cartilage and stitching together the sides of the wound in the skin. This is 
the operation of Streatfield, though it differs very little from that of Graefe. 
The removal of an ellipse from the cartilage will answer quite as well as 
that of the wedge-shaped piece. There are inveterate cases of entropion, in 
which, from cicatricial deformation of the palpebra, no operation based on 
the principle of traction will remedy the evil, and under these circumstances 
it becomes necessary to attack the eyelashes directly, either by transplanta- 
tion, as described under the head of trichiasis, or by their entire excision. 
ECTROPION. 
159 
Fig. 1805. 
Morton forceps and knife. 
Ectropion, or eversion of the lids, like inversion, is met with of all degrees. 
The most marked cases are those which follow burns of the face, the result- 
ing cicatrices often evei'ting the lids in such a manner as to expose the 
conjunctiva. Similar exposure of the latter membrane is seen in the oph- 
thalmia of strumous children, produced by muscular spasm, the mucous 
membrane forming a red, turgid fold, which to some extent conceals the eye 
and the lid. Various other causes, as wounds, ulcers, chronic inflammation, 
especially papillary trachoma, and tumors, are concerned in primary ectropion. 
Eversion of the lower lid frequently follows obstruction of the laehrjunal 
passages, from the excoriation and cicatricial shortening induced by the tears 
overflowing the lids. In a fewT instances the affection has been congenital. 
The prolapsed or exposed conjunctiva is necessarily subjected to various 
irritations, and if the palpebral deviation is not rectified it becomes greatly 
thickened by inflammatory infiltrations and the formation of new connective- 
tissue elements, which render the correction a matter of increased difficulty. 
With the abnormal deviation of the lids in this affection the direction of the 
lachrymal puncta may be so changed as to prevent the entrance of the 
tears. 
Treatment.—Ectropion dependent on inflammatory conditions of the con- 
junctiva will often disappear with the cure of the ophthalmia, and to this 
our remedies must be first addressed. When the eversion is caused by 
lachrymal obstruction, it can be relieved by defending the skin beneath 
the lower lid from the action of the tears by frequently applying to its sur- 
face a little vaseline or rose ointment. The radical relief of course requires 
that the primary cause, or the lachrymal obstruction, be removed; and so 
in the ectropion arising from morbid growths, the affection can be corrected 
only by taking away tbe cause. 
In certain varieties of ectropion which have had a chronic course, the car- 
tilage is liable to become thinned and elongated,—changes which allow the lid 
to leave the surface of the eye. These alterations are sometimes a part of 
those structural degenerations of tissue so often observed in old age. When 
not very marked, no interference will be required, but if a different course is 
demanded it will be sufficient to diminish the palpebral fissure by vivifying 
for a short distance the free borders of the lids at their external commissural 
extremities and bringing them together with sutures. In bad cases of ec- 
tropion of the lower lid, in which the cartilage is chiefly at fault, a V-shaped 160 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
piece should be removed from all the structures of the lid, as practiced by 
Adams and Dieffenbach, and the wound closed by twisted sutures. (Figs. 
1806, 1807.) When the displacement of the lids is the result of old cica- 
Fig. 1806. 
Fig. 1807. 
Correcting ectropion of the lower lid by removing a V-shaped piece. 
trices, the remedy consists in dissecting away the cicatrix and supplying its 
place by transplantation from the adjacent parts. The details of such opera- 
tions will depend upon the position, size, 
and direction of the cicatrix, as well as 
upon the lid affected. When ectropion 
implicates the lower lid, an operation 
similar to that of Dieffenbach can be 
performed with excellent results. The 
cicatrix is included in a triangular in- 
cision and dissected out, and the lid 
pushed up to its natural position. The 
chasm is then filled by a rectangular 
flap taken from the sound integument 
adjoining. (Fig. 1808.) When the upper 
lid is the subject of cicatricial displace- 
ment (Fig. 1809), after dissecting away 
the modular tissue the gap can be sup- 
plied by a flap brought from the temple. 
(Fig. 1810.) In old cases of ectropion, 
where the mucous membrane has become 
thickened by interstitial deposit, inca- 
pable of being disposed of by natural 
processes, the hypertrophied tissue must be removed before the restoration 
of the lid is possible. This can be done by clipping off the redundant mass 
with the scissors and bringing the cut edges together with very fine silk 
sutures, after which the lid can be replaced. I have cured an aggravated 
case of ectropion by the ingenious operation of Snellen, of Utrecht, in which 
a loop of silk thread is passed, by two needles, through the mucous surface 
of the lid, near the base of its cartilage, and out on the cheek nearly an inch 
below the orbit, where the two ends, emerging, as they enter, a short distance 
apart, are to be tightly tied together, and are allowed slowly to ulcerate their 
way through. The resulting cicatrix corrects the deviation. 
To prevent displacements from the cicatricial contraction following burns 
and scalds, the edges of the lids during healing should be kept together 
by a collodion dressing, which, by gluing the hairs of the eyelashes to one 
another, constitutes a very good ligature. Some recommend, under similar 
conditions,—unnecessarily, I think,—stitching together the free borders of the 
lids. The bond of union, after the injury of the latter has been repaired, can 
easily be severed by a probe passed between the lids. When this method is 
Dieffenbach’s operation for cicatricial ectropion of 
the lower lid. SYMBLEPHARON. 
161 
selected, I would advise limiting the operation to the middle of the palpebrse 
alone, trusting to the collodion for supporting the inner and outer portions. 
Fig. 1810. 
Fig. 1809. 
Ectropion of the upper eyelid. 
Operation for cicatricial ectropion of the 
upper eyelid. 
In all these operations for cure of ectropion the lids should always have the 
benefit of external support, by means of charpie or lint moistened with water 
and confined in place by a roller bandage. 
Adhesions of the Lids. 
Ankyloblepharon.—The lids, in consequence of inflammation resulting from 
burns, scalds, cauterization from quick-lime and acids, and from ulceration 
following blepharitis ciliaris, are liable to become adherent to each other 
by their free borders, thus diminishing the palpebral fissure. The adhesion 
has been noticed as a congenital affection. The term ankyloblepharon is used 
to express this condition. The false bands which unite the lids do not always 
occupy their free borders, but may arise from either the cutaneous or the mu- 
cous surface. The union may be at the angles of the palpebral commissures 
or throughout a larger extent of their free borders. 
Treatment.—When the adhesion is located at the outer eanthus, mere 
division of the bond will prove valueless, as the subsequent granulations will 
invariably extend from the commissure 
inward and reproduce the adhesion as it 
existed before the operation. It will be 
necessary, after dividing the lids at the 
commissure, and also the adjoining mucous 
membrane, to bring the latter into the 
angle and fasten it in place by two or 
three interrupted sutures. (Fig. 1811.) 
Adhesions or bands along the free borders, 
some distance from the angles of the lids, 
after being cut away with the bistoury 
or the scissors, require to be carefully 
watched, as the tendency to reunite will 
continue until the surfaces have cicatrized. 
This can be prevented only by separating 
the lids and touching their borders with 
oxide of zinc ointment, or with a solution of rubber dissolved in chloroform, 
once or twice a day, until cicatrization has been completed. 
Fig. 1811. 
Ankyloblepharon treated by a conjunctival flap. 
Symblepharon, or adhesion of the lids to the ball of the eye, is the result of 
sloughing of the conjunctiva, induced by injuries to the eye from blasting, 
by molten metal or quick-lime coming in contact with the membrane,—acci- 
dents common to foundrymen and mason-tenders,—and by mineral acids acci- 
dentally or maliciously thrown into the face. After the detachment of the 162 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
devitalized parts of the conjunctiva, granulations arise and become organized 
into connective tissue, which unites the lids to the ball of the eye, and which, 
after a time, by the motions of the ball, assumes the form of bands of various 
degrees of length and density. These connections exist sometimes as threads, 
single or interlacing; at other times as bands, and again in the form of a 
membrane. These bands often reach from the conjunctiva along the sclera 
to the cornea, and are in almost all instances confined to the lower half of 
the conjunctival sac: the comparative exemption of the upper half of the 
pouch from these adhesions has been attributed to the effect of the lachrymal 
secretion. 
Treatment.—Various plans have at different times been devised for the 
cure of symblepharon,—namely, by conjunctival approximation, by trans- 
plantation, by reduplication, and by mechanical pressure. 
First, by conjunctival approximation, in which, after cutting away the band 
or membrane, the raw surfaces are covered by stitching together the sides of 
the conjunctival membrane with threads of fine silk. 
Second, by transplantation, in which a flap of conjunctiva, or of skin from 
the eyelids, temple, brow, or face, is turned into the place where the adhesion 
was divided. 
In using the conjunctiva it will be necessary to raise a flap of the mem- 
brane proportioned to the extent of denuded surface and twist it into place, 
where it is to be retained by sutures, bringing together the sides of the 
space from which it was taken with a few stitches, after the manner practiced 
by Teale. 
When the mucous membrane cannot be made available, it may be substi- 
tuted by a skin flap, taken from the nearest part, as the temple, face, or brow, 
and twisted on its pedicle into the desired place, with the cutaneous surface 
towards the eye,—an operation successfully executed by Dr. Post, of Beirut. 
Taylor, in utilizing the skin to prevent the reunion of a divided adhesion, 
conducted the flap into its new position through a slit which he made in the 
lid. 
Third, by reduplication.—In a case of my own, a band, starting from the 
conjunctiva of the lower lid, extended over the sclera and a part of the 
cornea. The tongue-like membrane was closely shaven away from the cor- 
nea and the sclerotic, but not detached from the conjunctiva, after which it 
was turned in between the lid and the ball 
of the eye and stitched, the conjunctiva 
having been slit for its reception. (Fig. 
1812.) 
Arlt performed a similar operation in a 
case of symblepharon of the upper lid. He 
passed a thread through the anterior ex- 
tremity of the band, and, while it was ren- 
dered tense by traction on the ligature, 
shaved it away from the ball of the eye 
by a knife carried from behind forward. 
Having thus detached the anterior ex- 
tremity of the band, he next dissected its 
posterior and broader part from before 
backward from the sclera, as far as the 
tarso-ocular reflection of the conjunctiva, 
after which, arming each extremity of the 
thread with a needle, the band was turned inward upon itself, and fastened 
by passing the needles through the upper part of the lid and securing the 
ends of the ligatures on its cutaneous surface. 
Fourth, mechanical means.—These are well adapted to cases where the ad- 
hesions are broad. The late Dr. Hayes employed for the purpose tin or silver, 
in form resembling an artificial eye, which, after separating the false bands, 
he inserted between the ball of the eye and the lids, securing the latter 
Fig. 1812. 
Band after being raised and turned down be- 
tween the eye and the lid, with sutures passed 
in order to retain it in place. LAGOPHTHALMUS, OR HARE-EYE. 
163 
together by strips of isinglass plaster. The appliance was removed daily 
in order to cleanse the parts, and again replaced as at first. 
In a number of cases I have succeeded in obtaining good cures by a similar 
plan, using lead in place of silver or tin for the artificial eye, and observing 
the same precautions as to cleanliness. In a case recently operated on for Dr. 
D. Crouse of this city, I used an ordinary artificial eye for this purpose: it 
was not disturbed for several days together, the parts being washed without 
removing the appliance. The time required for complete cicatrization is 
seldom less than from twenty to twenty-five days, before which term it 
would be unsafe to dispense with the mechanism. 
Excurvation of the lids is a deformity affecting almost exclusively the upper 
palpebra, and one in which the tarsal cartilage becomes turned outward. It 
is occasionally seen to follow protracted cases of granular conjunctivitis, in 
which the nutrition of the cartilage has been disturbed by the cicatricial 
transformation of the palpebral conjunctiva: this is frequently brought 
about by the injudicious use of continued cauterizations. 
The remedy consists in slitting the external canthus and permanently en- 
larging the palpebral fissure, by bringing the divided mucous membrane 
through the slit and stitching it to the skin of each lid. 
Muscular Defects of the Eyelids. 
Two very different conditions of the eyelids are met with, referable to 
causes affecting the muscles of the lids : one in which the palpebrse cannot 
be voluntarily closed,—lagophthalmus; and the other in which the upper lid 
cannot be raised,—ptosis. 
Lagophthalmiis, or Hare-Eye {kayos,“ a hare,” and 6<p0akfj.6s,“ the eye”).—In 
this affection the palpebral fissure is greatly enlarged by the inability of the 
patient to close the lids. The increased exposure of the eyeball which follows 
imparts to the countenance an unpleasant stare. The defect lies, in most in- 
stances, in paralysis of the orbicularis palpebrarum muscle. This may arise 
from a central lesion, or from inflammatory or mechanical pressure on the 
facial nerve, caused by cold, syphilis, or morbid growths. In rare cases of 
this affection, the inability is due to spasm of the levator palpebrse. 
The eye, deprived of the protection of the lids, is rendered defenseless 
against dust and other foreign matters floating in the air, and hence conjunc- 
tivitis and opacity of the cornea result. Those movements also of the pal- 
pebrse, as in winking, which are concerned in conducting the lachrymal secre- 
tion to the canaliculi, being suspended, the tears flow over the cheek, causing 
excoriation, cicatricial thickening, and eversion of the lower lid, all of which 
sequels aggravate the suffering of the patient. 
Treatment.—When the lagophthalmus is due to intracranial lesion, the 
prospect of recovery is very unpromising, though we sometimes see this 
symptom in paralytic attacks gradually disappear as the internal pressure is 
removed. The remedies proper in such cases are those employed to hasten 
the absorption of extravasations, if there are reasonable grounds for believing 
that such exist, as iodide of potassium. This agent, exhibited in doses as 
large as will be tolerated by the stomach of the patient, is the most valu- 
able of all remedies when the affection has a syphilitic origin; and so in in- 
flammatory deposits about the portio dura, followed by paresis or paralysis 
of the orbicular muscle of the lids, this drug, after the acute symptoms have 
been subdued by local blood-letting and blistering, constitutes our most potent 
means for relief. 
When the lagophthalmus is the result of a morbid growth in the parotid 
region, relief is possible only by the extirpation of the tumor. 
In cases of hopeless paralysis of the orbicular muscle, the eye will be 
greatly protected by bringing the lids together and keeping them in juxta- 164 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
position by the skin-plaster, and placing a light bandage over the eye. This 
dressing should be removed every two days, and, after allowing the ball to 
be exposed for a few hours to the light, again be replaced. Another plan 
consists in freshening the free borders of the lids for a short distance at each 
canthus, and bringing the surfaces together by fine sutures, thus diminishing 
the palpebral fissure and lessening the exposed surface of the eye. 
Blepharospasm, or spasm of the orbicularis palpebrarum muscle, is a com- 
mon affection involving one or both eyes. In the severer forms of the disease 
the eyelids are forcibly pressed together, and the patient buries the face in 
the hands, in the clothing, or in the pillows. Every attempt to expose the 
eyes to the light, either by an effort of the will or by the application of force, 
is attended with a more violent contraction of the muscle, and if the resist- 
ance be for a moment overcome, it is often followed by profuse lachrymation 
and increased suffering. 
Children are most commonly the subjects of the disease. The spasm may 
be constant during waking hours, or it may come on at irregular periods. 
Blepharospasm, in most instances, is due to peripheral irritation, though oc- 
casionally it appears to have a central origin. In exceptional cases it may, 
in the absence of all detectable irritation, peripheral or central, be regarded 
as idiopathic, or dependent on some peculiar disturbance in the nutrition of 
the sarcous elements of the muscles of the eyelids. 
The peripheral irritations generally consist in inflammatory affections of 
the conjunctiva, ulcerations of the cornea, and foreign bodies in the folds 
of the conjunctiva, reflected. These irritations acting on the peripheral 
branches of the fifth pair of nerves are reflected to those of the facial,— 
the motor nerves of the orbicularis palpebrarum muscles,—and hence the 
blepharospasm. 
In order to develop blepharospasm, however, there must be something 
more than the mere presence of such irritations, as these are constantly seen 
without such disturbances of the muscles of the eyelids. There is usually 
some constitutional condition, which imparts a peculiar morbid sensibility 
to the nerves. In strumous children these phenomena are seen in their most 
typical forms. 
Besides the excitations resulting from irritation of the sensory nerves of 
the eye, there are others more remote which are concerned in the production 
of blepharospasm, as those resulting from ulcerations of the tongue, painful 
diseases of the jaw, supraorbital neuralgia, etc. In all of these the primary 
irritation reaches the muscles of the eyelids through branches of the fifth 
pair of nerves. 
When the blepharospasm is interrupted by periodical intermissions, there 
remains for some time a marked soreness of the palpebral muscle, just as 
a like supersensibility is experienced after severe attacks of cramp in other 
muscles. 
The extension of blepharospasm to spasm in other muscles, terminating, 
finally, in mild imitations of epilepsy, has been referred by Graefe to the 
propagation of the primary irritation in the fifth to other nerves; but I 
am disposed to believe that in these exceptional cases the primary irritation 
was not peripheral, but central. 
Treatment.—In the treatment of blepharospasm, the discovery of the 
cause is of the first importance. If conjunctivitis or ulceration of the cornea 
is present, the usual treatment for such affections must be instituted. In 
doing this, the local remedies must, in many cases, be supported by con- 
stitutional ones, as cod-liver oil, iodide of iron, sea-bathing, and the local 
immersion of the face and eyes in cold and sometimes in hot water. 
Foreign bodies which have been caught in the conjunctiva are to be re- 
moved, and neuralgia of the supraorbital nerve must be controlled by hypo- 
dermic injections of morphia over the brow, or by the use of the constant 
current. PTOSIS. 
165 
When the blepharospasm persists after the removal of inflammatory 
and other visible causes, the reflex influence of the supraorbital nerve in 
perpetuating the disease must not be overlooked. If the nerve is at fault, 
the fact will be determined by firm pressure made on its trunk with the 
finger at the point where it emerges from the supraorbital foramen; this 
will be followed by relaxation of the spasm. It was for the cure of such 
cases of blepharospasm that Romberg suggested the division of the supra- 
orbital nerve, an operation which has been performed a number of times 
with success by Graefe. 
Subcutaneous myotomy has also been recommended, but the operation has 
been performed with indifferent success, and is not entitled to confidence. 
In cases of the affection which continue after the removal of all detectable 
causes, a free division of all the structures at the external canthus of the 
lids, including skin, fibrous tissue, and muscle, will sometimes put an end to 
the spasm. 
Dr. Mathewson, of Brooklyn, New York, has suggested, in the treatment 
of otherwise unmanageable cases of blepharospasm, an ingenious mechanism 
in the shape of a thin band of rubber, one-eighth of an inch wide and one 
inch long, to be secured to the middle of the eyelid and to be covered with 
isinglass plaster and collodion. When thoroughly dry and fixed in place, 
the lid is drawn up by making traction on the free end of the elastic band 
and securing it to the forehead in the same manner as in attaching it to the 
eyelid. 
Choreic or Nictitating Movements of the eyelids occur in various degrees, 
affecting one or both eyes. These spasmodic twitchings may be constant 
during waking hours, or they may recur at intervals, long or short. The 
movements in some cases are but slight exaggerations of the normal action 
of the eyelids, while in others they are quite rapid. 
The affection is a neurosis of the lids, and is chiefly met with in persons of 
a weak, delicate organization and with an irritable nervous system. Young 
girls approaching the period of first menstruation are not unfrequently the 
subjects of nictitation. 
The exciting cause is often a local irritation of the eyelids, produced by a 
slight conjunctivitis, a stray eyelash, or some error of refraction, as in hy- 
permetropia. This affection is influenced very much by emotional causes, 
being always aggravated by passion or other mental excitement. 
Treatment.—If any local cause for the disease can be discovered, it must 
be removed by proper remedies; errors in refraction are to be corrected by 
the use of proper glasses. In the absence of any local explanation for the 
spasm, general treatment will be demanded, as iron, arsenic, cod-liver oil, and 
fluid extract of cimicifuga racemosa, with nourishing food and an out-door 
life. 
Ptosis.—By ptosis is meant a dropping of the upper eyelid, by which the 
ball of the eye is concealed to a greater or less degree. The derivation of 
the term is Greek, nTwais signifying “ a falling.” Ptosis may affect one or 
both eyes, and may be complete or incomplete. In the incomplete form the 
patient, by a strong exercise of volition and with the aid of the occipito- 
frontalis and orbicularis palpebrarum, may raise the lid somewhat from the 
eye. The immediate cause of ptosis is loss of power in the levator palpebrse 
superioris muscle, owing to some cause which interferes with or overpowers 
the conducting power of the third nerve. 
Among the determining causes of ptosis, some are central and others 
peripheral. 
Central causes may affect the other muscles of the eye, as is witnessed 
in diphtheria and in constitutional syphilis. Ptosis often suddenly occurs 
in children during a brief attack of indisposition in which head-symptoms 
are prominent. Alcoholic ptosis may also be recognized under the head of 166 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
central causation. The effort which an intoxicated person makes to raise 
the eyelid, by calling into play the frontal portion of the occipito-frontalis 
muscle, and which gives a puzzled expression to the face, is due to paresis 
of the levator muscles of the eyelids. 
A wound of the levator palpebrae, a blow over the eye, an intraorbital 
growth, and neurosis of the orbital plate of the frontal bone are among the 
local causes of ptosis, although there is a temporary dropping of the eyelid, 
which depends upon serous infiltration of the subcutaneous or submucous 
tissue, from redundancy of structure, and also from degeneration in the fibres 
of the levator palpebrae muscle. 
Treatment.—Success in the management of ptosis will depend on our 
ability to discover and remove the cause. 
When accompanying a severe attack of congestion of the brain, local 
blood-letting, purgatives, and blisters, followed by mercurials and iodide of 
potassium, will be required. If an intraorbital tumor interferes with the 
function of the levator palpebrae muscle, its removal must be considered. 
Syphilitic ptosis will frequently yield to large doses of iodide of potassium. 
When the disease is a sequel of diphtheria, mineral tonics and time are the 
remedies. When redundant tissue, whether over the eye or over the root 
of the nose, as in epicanthus, is the source of the ptosis, it must be excised 
and the parts brought together by sutures. Muscular degeneration of 
the levator palpebrae is counteracted to some extent by electric stimu- 
lation. 
When the usual remedies fail to relieve, resort must be had to operative 
measures, and these, to be successful, require no small degree of judgment, 
in order that the proper amount of tissue be removed, neither more nor less, 
and the incisions made in the proper position. 
Two incisions are required, which shall include an elliptical portion of the 
integument and the subjacent muscular fibres of the eyelid. The upper in- 
cision should be carried along the lower border of the eyebrow, its extremi- 
ties resting on the eyelid, and the lower one, in well-marked cases of the 
deformity, over the eyelid at the junction of its lower and middle thirds, 
constituting the smaller segment of the ellipse. It is well to make a pre- 
liminary definition of the lines of incision with iodine or ink. A number of 
interrupted stitches are next inserted, and 
the edges of the wound secured together 
(Fig. 1813), the great object being, in every 
case, not to raise the lid so much as to create 
a stare, or so little as unduly to conceal the 
eye. 
Another operation devised by Graefe, but 
which has no advantage over the one de- 
scribed, consists in making a single incision 
through the skin the whole length of the 
eyelid, and between two and three lines 
from its ciliary border. The integument is 
next dissected upward from the muscle, and 
a sufficient amount of the latter excised, 
taking care not to damage the submuscular 
connective tissue or the tarsal cartilage, after which the edges of the wound 
are to be sutured, the threads including both the integument and the under- 
lying muscle. 
Fig. 1813. 
Operation for the correction of ptosis. 
Coloboma is the name given to congenital fissure of the eyelids. The 
defect may be confined to one lid, or it may affect both lids, the upper one 
being most generally implicated. The malformation is often associated with 
others, as cleft palate, hare-lip, division of the iris, and other deformities of 
the body. 
The treatment consists in freshening the borders of the cleft and bringing CHALAZION. 
167 
them into contact by means of sutures, in the same manner as clefts arising 
from sloughing wounds of the eyelids are managed. 
Epicanthus.— This is a 
congenital redundancy of 
the integuments at the root 
of the nose, extending from 
the latter as a crescentic fold 
to the eyebrow, and conceal- 
ing to some degree the inner 
canthus of the eye. These 
folds, very unsightly at first, 
often disappear as the child 
grows older, and may not re- 
quire any operation. When 
they remain, they are to be 
removed by excising an el- 
liptical portion of integu- 
ment from the middle of 
the root of the nose, in ex- 
tent corresponding to the 
size of the folds, and, after 
dissecting up each side of the wound a short distance in the direction of the 
eye. bringing the parts together by twisted sutures. (Fig. 1814.) 
Fig. 1814. 
Operation for epicanthus. 
Tumors of the Eyelids. 
Tumors of different kinds, both benign and malignant, occur on the eye- 
lids. These neoplasms are cystic, including the chalazion, the sebaceous, and 
the piliferous cyst. In addition to cysts, there are molluscum, warts, horns, 
fibroma, lipoma, angeioma, sarcoma, and epithelioma. 
Chalazion.—This tumor is formed of inflammatory residua, and commences 
as an inflammation in the connective tissue around a Meibomian gland,— 
probably a stye,—producing an infiltration of both, with new cell-elements, 
resulting finally in the formation of granulation-tissue and the cyst-wall, 
containing pus, a muco-purulent, a gelatinous, or a sebaceous material. 
These tumors usually present on the inner surface of the eyelid, though 
sometimes they appear nearest to the cutaneous surface, and by preference 
on the upper eyelid. By everting the latter, the growth, seldom exceeding 
a small pea in size, and of a pale yellow or bluish color, is made to stand out 
prominently. 
Treatment.—These tumors of the eyelid generally require to be removed 
by operation, and, as a rule, should be attacked on the conjunctival surface, as 
by this course no cicatrix is visible. If, however, the chalazion is nearest to 
the cutaneous surface, the mere consideration of a linear cicatrix following, 
which will be concealed by the wrinkles of the eyelid, should not prevent 
the surgeon from removing it through the skin. 
If the first plan is adopted, let the lid bp strongly everted and fixed with 
the finger, while an incision, single or crucial, is made over the tumor with 
a sharp-pointed bistoury or with a cataract-knife. Its contents should then 
be squeezed out, or, if too adherent to be thus dislodged, should be scraped 
out with the end of a director. After waiting a few minutes until the bleed- 
ing moderates, the sac is next treated, either by applying to its interior a 
probe dipped in nitric acid, or by penciling it with a fine-pointed stick of 
nitrate of silver. The operation is followed for a few days by inflammation 
of the conjunctiva and some swelling of the eyelid, but these soon subside 
on the application of pledgets wet with water. 
When the chalazion is removed from the cutaneous surface of the eyelid, 
single, not crucial, incisions should be made, in order to leave as few traces 168 
DISEASES AND INJURIES OF THE EVE AND ITS APPENDAGES. 
of the operation as possible. The operation will be facilitated by embracing 
the lid in the plain fenestrated forceps, allowing the tumor to present through 
the opening in the instrument. 
Sebaceous tumors are much more common on the brow than on the eyelids. 
They attain to a larger size than the chalazion, and grow in the direction of 
the skin. Their removal is effected by making an incision over the most 
prominent portion of the growth and beyond its boundaries, and, after ex- 
posing the cyst-wall, hooking into it a tenaculum and dissecting it away 
from its connections with the bistoury. 
Millet-grains are small, yellowish-white discolorations which appear, often 
in considerable numbers, over the surface of the lids in persons somewhat ad- 
vanced in life. (Fig. 1815.) These bodies are diseased follicles of the skin, 
disposed to become confluent, and require to be removed with the knife, if 
any operation is necessary. 
Piliferous cysts, sometimes described as fibrous cysts, are congenital 
growths, belonging rather to the temporal than to the palpebral region, and 
containing hairs along with sebaceous matters: if allowed to remain, they 
Fig. 1815. 
Fig. 1816. 
Millet-grains, or sebaceous disease. 
Piliferous cyst. 
may attain to a large size. (Fig. 1816.) They require to be removed by a 
careful dissection. 
Molluscum, or the so-called albuminoid tumor, is met with on the eyelids. 
This neoplasm is rarely solitary, others of the same character occupying 
different parts of the face and body. The growth may be slightly lobulated, 
or it may have a pedunculated form, though differences in shape indicate 
different varieties of the tumor, the lobulated neoplasm containing a peculiar 
material, which is discharged through a minute orifice on the surface of the 
tumor, and to which contagious properties are ascribed, whence the name, 
molluscum contagiosum. 
The pedunculated tumor, which grows to a larger size than the one just 
described, is really a fibroma, being made up of a basis of connective tissue 
infiltrated with serum, or containing cysts. Neither variety is painful. 
Those in which the attachments are pedunculated can be removed either 
by the ligature or by scissors, and those with a broader base, if demanding 
operation, are best treated by excision. 
Fibroma of the eyelid is rare, and when met with is found to be a hard 
nodule on either aspect of the lid, somewhat movable and often quite pain- 
ful. It will remain a long time without any perceptible increase. A tarsal 
cyst is susceptible of being converted into a fibroma through degenerative TUMORS OF THE EYELIDS. 
changes in which granulation-tissue is produced. This neoplasm may be 
congenital. The indication for the removal of fibromata is increase of 
growth. 
Warts are located on the edge of the lids, and do not differ in appearance 
from similar growths elsewhere. They disappear under repeated applica- 
tions of glacial acetic acid, or they may be clipped off with the scissors. 
Horns.—Closely akin to warts are horny growths, a few examples of 
which have been recorded as growing from the edge of the eyelids. They 
are readily removed by excision. 
Lipoma of the eyelids is an uncommon neoplasm. When present, the 
tumor possesses the same characteristics as fatty growths elsewhere, being 
soft, doughy, and lobulated. They are to be got rid of only by excision. 
Ncevi of the eyelids are very common in childi-en, and should be subjected 
to early treatment, in order to avoid, as much as possible, deformities of the 
lid. These growths are easily recognized by their scarlet, purple, or bluish 
color, by their increased turgescence under excitement, as in crying, and by 
the facility with which they can be emptied of the blood by compression : 
this latter peculiarity belongs particularly to the venous varieties. 
When the n*evus is small and located in the skin, a few applications of 
nitric acid, or of corrosive sublimate and collodion, will be sufficient to effect 
a cure, or it can be effectually destroyed by passing two delicate pins cross- 
wise beneath the growth and strangulating it with a thread. When the 
angeioma is deeper and bulky, the venous element preponderating, it is best 
disposed of by applying the lid-clamp and dissecting the skin from the growth 
and the latter from all its surrounding connections, keeping outside of the 
diseased tissue. After ligating any vessels which bleed, the skin is to be re- 
placed and retained in position by sutures. Subcutaneous ligation is some- 
times preferable to excision. Injections are attended with risk, and the same 
is true of other irritants, as setons soaked in chloride of zinc or in strong 
acids and passed through the tumor, sloughing sometimes following their 
use. Very good results have been obtained from electrolysis. Galvano- 
puncture also has its advocates. 
Adenoma.—In a few instances growths answering in their histological com- 
position to adenomata, that is, composed of follicles and connective-tissue 
elements, have been recorded. The position of these neoplasms was near 
the free border of the lid, and they had undergone ulceration. Tumors of 
this character can be identified only by microscopic examination. Their 
removal by the knife would be necessar}T, and this most likely at the expense 
of a portion of the cartilage. 
Elephantiasis Grcecorum, or Lepra, commences with falling of the eyelashes 
and eyebrows, accompanied and followed by infiltrations of the subcutaneous 
tissue, forming dark-colored masses or nodules, which ultimately ulcerate, 
but are unattended with suppuration. Excision, to be available, must be 
done before ulceration begins, otherwise no good will result from the opera- 
tion. 
Cysticerci are among the growths observed in the eyelids, the subjects 
being, for the most part, children. As there is nothing peculiar in the ap- 
pearance of these tumors, their true nature can be ascertained only after 
excision. 
Amyloid disease of the eyelids has been observed both as a primary affec- 
tion and as a result of neoplastic degeneration.* The symptoms consist 
in great thickening, induration, and expansion of the lids, unattended with 
pain. The infiltration implicates both the walls of the vessels and the sub- 
cutaneous connective tissue. The true character of this tissue-degenera- 
tion is established by employing, as tests, iodine and sulphuric acid, which 
furnish the characteristic reaction with the starch like matter of the 
tissue. 
The malignant affections of the eyelids are epithelioma, sarcoma, lupus, 
* Transactions of the American Ophthalmologieal Society, 1878; also Archiv fiir Ophthal., xxv. 1. 170 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
and rodent ulceration. The last two, in almost all cases, extend to the nose 
from the face or the eyebrow. Sarcoma is rarely seen on the eyelids. 
Epithelioma is the most common form in which carcinoma appears on the 
eyelids. It is not often seen earlier than at the age of forty-five years, and 
usually appears on the lower eyelid. The disease commences either as a 
small induration, a wart-like prominence, or a small crust, near the free bor- 
der of the lid. It may remain for a long time without making any very 
noticeable progress, but sooner or later will undergo ulceration, the ulcer 
having edges somewhat elevated. 
Epithelioma is liable to be confounded with lupus, but there are certain 
tolerably uniform distinctions, the consideration of which will enable the 
surgeon to form a correct diagnosis. The ulceration of lupus, unlike that of 
epithelioma, rarely begins on the lids; it almost always reaches them by 
extension from the adjoining parts. It is much more rapid in its progress 
than that of epithelioma, and is generally surrounded by an area of discolora- 
tion and thickening, which does not exist in epithelial disease. 
The lachrymal apparatus embraces the lachrymal gland, canaliculi lach- 
rymales, lachrymal sac, and ductus ad nasum. 
DISEASES OF THE LACHRYMAL APPARATUS. 
Lachrymal Gland.—This body, situated in the upper and outer part of 
the orbit, is liable to functional and organic disturbances. 
The functional disturbances consist either in an inordinate or a diminished 
secretion. 
Increased secretion is one of the results of inflammatory disease, both of 
the conjunctiva and of the eye, of the presence of foreign bodies under the 
lid, and of neuralgia of the supraorbital nerve. The lachrymal secretion is 
influenced by emotional causes, and by those, too, which are most diverse, as 
in paroxysms of laughter and of grief, both of which find expression in a flow 
of tears. There is a stormy grief, which is too deep for tears, the nerve- 
depression being so great that the excito-secretory function of the nerves 
is suspended. There are certain structural changes in the conjunctiva, tarsal 
cartilage, and glands of the lids, which have been induced by long studying, 
or by chronic inflammation,—in xerophthalmia, for example,—the effects of 
which extend to the lachrymal gland, arresting its secretion and adding to 
the patient’s distress from the dryness of the eye. 
Treatment.—The proper management of these anomalies of secretion 
depends on a clear understanding of the cause. As in all the inflamma- 
tory conditions of the lids or eyes the inordinate lachrymation is only a 
symptom, it will naturally disappear with the removal of the cause. 
Time only, not drugs, can correct those cases of abnormal lachrymal se- 
cretion which have an emotional causation. They are rarely the subjects of 
medical consultation. 
Dacryoadenitis, or inflammation of the lachrymal gland, is a very rare af- 
fection. It may follow a blow upon the eye, or it may arise secondarily from 
an extension of the inflammation in strumous conjunctivitis. Even before 
the disease is clearly recognized there will be an antecedent excitation of the 
gland, as seen in the eye suffused with tears. After a time the swollen gland 
can be discovered at the upper and outer portion of the orbit; and even the 
irregularity of its lobules can be distinguished by the touch. This may 
increase so as to displace the ball of the eye downward and inward, and re- 
strict its movements. The lid and conjunctiva participate in the glandular 
inflammation, the former becoming swollen and red, and the latter deeply in- 
jected and chemosed, though little pain may be experienced. The disease 
may be bilateral, both lachrymal glands being affected either simultaneously 
or with a brief period intervening. MORBID GROWTHS IN THE LACHRYMAL GLAND. 
171 
The course of dacryoadenitis is ordinarily slow or chronic, rather than 
acute, and with a strong tendency to terminate in suppuration, in which 
case there may follow a fistula through either the lid or the retrotarsal fold 
of the conjunctiva, by which tears will escape. In acute inflammation of the 
gland, followed by abscess, it has happened that the orbital plate of the 
frontal bone has become diseased. 
Treatment.—In acute cases of dacryoadenitis the treatment must be de- 
cided and vigorous if it is hoped to secure the resolution of the disease. 
Local blood-letting, moderate purgation, and hot fomentations should be em- 
ployed. When, in consequence of the swelling and tension, there is reason 
to fear suppuration, it will be proper to make a free incision between the lid 
and the orbit, so as to open a way for the escape of inflammatory products, 
purulent or otherwise. In chronic or asthenic inflammation of the gland, 
resolution may be induced by blisters, followed by the local application of 
tincture of iodine, hot poultices, and full doses, internally, of iodide of potas- 
sium with bichloride of mercury. The probability of abscess, even in chronic 
dacryoadenitis, must not be overlooked. When suspected, its presence can 
be ascertained by the use of the exploring needle, and, if detected, it should 
be immediately evacuated by an incision. Suppurative dacryoadenitis, in 
which the pus has a tendency to burrow in the orbit, and which does not 
subside on making a proper opening externally, will demand the removal of 
the gland. 
After the subsidence of all acute symptoms, the lachrymal gland may re- 
main hypertrophied for a long time, the newly-formed elements attending 
the inflammatory infiltration undergoing retrograde changes very slowly. 
Mercury administered internally and applied externally, in the form of 
blue ointment, constitutes the most efficient means of resolving such en- 
largements ; or, if there are any constitutional reasons adverse to the use 
of mercurials, iodide of potassium must be substituted. Electrolysis may 
also be employed with advantage. 
Fistula of the lachrymal gland may be caused by tumors, penetrating 
wounds of the orbit, abscess, or inability to remove a lachrymal cyst. The 
constant flow of the tears becomes a source of great annoyance to the patient, 
although the fistulous opening may be very small. 
Treatment.—The tract of the fistula should first be cauterized with nitric 
acid, nitrate of silver, or, what is still better when available, the galvano- 
cautery. A fine needle heated to a white heat and introduced into the 
fistula may be substituted for the galvano-cautery when the latter is not at 
hand. Paring the fistula and bringing the freshened surfaces together with 
delicate sutures is another method in use. Another plan, and one which 
probably commands the greatest confidence, is that of Hulke. A thread 
armed with a needle at each extremity is passed—both needles together, or 
first one and then the other—through the fistulous tract. These needles are 
made to pass through the retrotarsal fold of the conjunctiva of the superior 
eyelid, one above the other, and a short distance apart. The ligature is next 
tightened and its ends cut off, the loop being allowed to cut its way through. 
The operation is not materially different from that of Bowman, who, in 
order to cure a case of lachrymal fistula, made an opening in the conjunctiva 
by means of a seton, thus diverting the tears into the new channel, after 
which the external fistula closed. 
When all other measures fail, the lachrymal gland can be extirpated. 
Morbid Growths in the Lachrymal Gland. 
Primary neoplasms other than those of a temporary or an inflammatory 
origin are exceedingly rare in the lachrymal gland; and even when morbid 
growths have occurred, much confusion and uncertainty have existed as to 
their proper pathological classification. 172 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
Carcinoma, except as including the gland secondarily by extension, is 
almost unknown. One case is given by Knapp. An enchondroma of the 
lachrymal glands has been described by Busch. Sarcoma is regarded by some 
writers as the most common morbid growth in the lachrymal gland, while 
others, as Becker, embrace all neoplasms of the gland under the general 
head of adenoma, a classification to which there can be no particular objec- 
tion, provided it is allowed to stand as a family name, to which may be 
added a number of surnames, as adeno-sarcoma, adeno-carcinoma, etc. 
In addition to the morbid growths already noticed, cystomata of different 
kinds are met with in the lachrymal gland, as retention cysts, dermoid and 
hydatid cysts, and also vascular growths, as angeiomata. 
The symptoms of these tumors are, in the main, very significant,—namely, 
swelling and displacement of the eye. As they increase in magnitude they 
require for relief or cure the extirpation of the diseased gland. 
Dacryops, or cyst of the lachrymal gland, has been observed in a few in- 
stances by Graefe, Schmidt, Wecker, Boer, and others. These cysts were the 
result either of closure or stricture of one or more of the ducts of the glands, 
—retention cysts, in which the tears, accumulating behind the obstruction, 
gradually distended the canals into a tumor, which appears at the upper and 
outer part of the eyelid, and which, on everting the latter, is seen at the 
reti’otarsal fold as a bluish, translucent, and elastic enlargement, resembling 
very closely an ordinary ranula, and varying in size from that of a cherry 
to that of an almond. The tumor is susceptible of being suddenly enlarged 
from any cause which may increase the secretory action of the gland. 
The ectasia of the ducts is probably inflammatory. It was thought by 
Schmidt that these cysts are often congenital, and, as they occur generally 
in young children, this is probably the case. 
Treatment.—Different plans have been pursued for the cure of dacryops, 
—namely, incision, excision, and the seton. 
The simplest and perhaps the most satisfactory method is to evert the 
lid and make an incision into the swelling, emptying its contents, and then 
keep the sac open introducing into its interior daily an ordinary probe. 
In this way the cyst-wall is allowed to contract until it closes by cicatriza- 
tion ; or, should complete obliteration not take place, the interior of the sac 
may be treated by the introduction of a very fine pencil of sulphate of cop- 
per, or by touching it with the end of a silver probe previously dipped into 
nitric acid. Excision, in consequence of the fragile nature of the cyst-wall,, 
will be likely to fail. The seton has been used with success by Graefe, and 
is applied by turning up the eyelid and passing a silk thread through the 
cyst, the loop being allowed to cut its way out. The thread creates the 
necessary inflammation for the obliteration of the sac, but will not keep the 
latter drained of the secretion while the closure is progressing. 
Hydatid or Dermoid Cysts, not distinguishable from other morbid produc- 
tions of the gland, are to be treated by excision. 
Removal of the Lachrymal Gland.—The extirpation of the lachrymal 
gland may be required on account of morbid growths, chronic abscess, oblit- 
eration of the lachrymal canals, or incurable fistulae of the gland. 
The operation is performed by dividing first the external commissure of 
the eyelids, and afterwards making a curved incision from the extremity 
of the first upward along the external third of the orbit. After cutting 
through the skin, fascia, orbicularis palpebrarum muscle, and the subjacent 
fibrous tissue, the flap is turned forward, exposing a space between the ball 
of the eye and the upper and outer part of the orbit. A finger introduced 
will serve to distinguish the gland, which should be drawn out with a 
tenaculum or a volsella, and enucleated with the end of a director, or with 
the handle of the scalpel. The bleeding which follows, though free, subsides DEVIATIONS OF THE PUNCTUM LACRYMALE. 
173 
in a short time spontaneously, or, if it does not, it can be arrested by press- 
ure made with a pledget of lint for a short time. After the bleeding ceases, 
the flap is to be replaced and stitched in position by a sufficient number of 
interrupted sutures, and the wound covered with a compress moistened "with 
carbolated oil and lightly fastened in place by a roller. 
Overflow of the Tears.—The fact that the tears sometimes overflow the 
lower does not necessarily imply that there is disease of the lachrymal 
passages between the eye and the nose. The secretion may under various 
excitants be supplied in such abundance that these canals are inadequate to 
convey it away. Thus, in crying, the tears run over upon the cheek, and 
the same phenomenon is observed when a person faces a cold wind, or when 
particles of dust or other foreign matter lodge on the eye. The same result 
will bo observed in certain cases of paresis or of wasting of the orbicularis 
palpebrarum muscles, permitting the lower lid to hang down ; also from 
hypertrophy of the canaliculi lacrymales and malposition of the puncta, 
following wounds of the lids, the cicatrices of scalds, burns, operations for 
epithelioma, etc. 
Affections of the Lachrymal Passages. 
Deviations of the Punctual Lacrymale.—The natural direction of the punc- 
tual lacrymale is upward and inward. If from any cause, traumatic or 
pathological, that direction is changed, the tears, instead of entering the 
canals, will accumulate in the corner of the eye, and finally run over upon 
the cheek. 
The treatment is both simple and effective, and consists in passing a fine 
grooved director (Fig. 1817) along the canaliculus and slitting it up with a 
Fig. 1817. 
Grooved director for canaliculus. 
delicate bistoury (Fig. 1818), or with a Weber knife (Fig. 1819), as far as 
the caruncula (Fig. 1822), and keeping it from closing, either by running the 
probe daily along the groove, or by the in- 
stillation of a few drops of sweet oil. 
In order to pass a probe successfully and 
safely along the canaliculi the operator 
must have an accurate knowledge of the 
course of these canals. The canaliculi have 
each a short and a long arm. The upper canaliculus, beginning at the 
punctum at the inner extremity of the free border of the superior lid, runs 
Fig. 1818. 
Bistoury for slitting canaliculus. 
Fig. 1819. 
Weber knifo. 
front in an upward and inward direction for a short distance, and then, form- 
ing an abrupt angle, is continued downward and inward to the lachrymal 
sac. The canaliculus of the lower lid is directed downward and inward, and, 
after making the bend or elbow, like its fellow, is continued upward and 
forward to the lachrymal sac. (Fig. 1820.) These canals open separately 
into the sac. 
The relation of the lachrymal passages to the eyelids and internal pal- 
pebral ligament is shown in Fig. 1821. 
Directions for passing probes.—In introducing a probe or other instrument 
into the lachrymal canal, the surgeon, standing behind, allows the head of  DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
174 
the patient to rest against his breast. If operating on the lower canal, the 
skin immediately beneath the lower lid is put upon the stretch with the 
Fig. 1821. 
Fig. 1820. 
Diagrammatic view of the cana- 
liculi and the lachrymal sac. 
1, lachrymal canals; 2, summit of the puucta or commencement 
of the lachrymal canals; 3, palpebral cartilages; 4, edges of eyelids; 
5, lachrymal sac; 6,internal palpebral ligament, or tendo oculi; 7, 
its point of division in front of the lachrymal canals. 
thumb of one hand, slightly everting the lid, while with the other hand the 
probe, held tightly between the thumb and the index finger, is introduced 
perpendicularly into the punctum, and 
without force carried to the bottom 
of the short arm of the canal, less 
than a line in depth, when its direction 
is suddenly changed until it is nearly 
parallel with the lower border of the 
orbit, in order to pass the abrupt bend 
in the canal, after which it is carried 
upward and inward to the lachrymal 
sac. (Fig. 1822.) If it is desired to pass 
the instrument downward towards the 
lachrymal duct, it must, after entering 
the sac, be swept over the brow of the 
patient so as to incline across the root 
of the nose and slightly to the oppo- 
site side. It is often, in an unpracticed 
hand, difficult to know whether the 
probe has passed into the cavity of the 
sac and is resting against its outer 
wall, or has become arrested at the 
point where the canaliculus joins its 
external wall. If the latter is the 
case, pressure on the probe will cause 
a dragging or wrinkling of the soft 
parts at the inner commissure of the 
lids, while if the instrument has 
crossed the sac and rests against its 
outer wall, the firm resistance offered 
by the os unguis will be felt. 
Fig. 1822. 
A, probe entering the punctum and short branch of 
the lower canaliculus; B, dotted line indicating the 
curve necessary for the instrument to traverse to reach 
0, in order to pass the angle and enter the long arm 
of the canal; D, position of the probe required in 
passing into the sac. 
Obstructions of the Canaliculi.—The canaliculi may be temporarily or per- 
manently obstructed. When temporarily swollen it is generally owing to 
a catarrhal, phlegmonous, or syphilitic inflammation, extending from the 
vessels of the conjunctiva or the mucous membrane of the nose. The sub- 
mucous infiltration encroaches upon the lumen of the canals to a degree INFLAMMATION OF THE LACHRYMAL SAC, 
175 
which prevents the tears, often mixed with muco-purulent discharge, from 
making their way through, and causes them to overflow the cheek. 
Permanent or organic stricture is due to a different condition. Here in- 
flammation also precedes the coarctation of the canal; but the swelling is not 
simply due to an cedematous infiltration of the lining membrane; it is, as in 
organic stricture of the urethra, followed by a granular and finally cicatricial 
tissue, the contraction of which not only narrows the canaliculi, but destroys 
to a considerable degree the normal dilatability of these canals. The seat of 
lachrymal stricture is generally near the lachrymal sac. Besides these causes 
of obstruction in the course of the canaliculi, there are others, as the pressure 
of a morbid growth, the presence of a hair from an eyelash, a polypus, or the 
impaction of a calculus in the canaliculus. 
Treatment.—When the obstruction is produced by simple inflammatory 
or catarrhal swelling, it usually subsides, leaving the canals pervious, after a 
few days’ rest and the use of two or three leeches applied near the corner 
of the eye, a gentle purgative, and hot fomentations over the parts. When 
the inflammatory swelling is referable to a syphilitic diathesis, the continued 
use for some time of the iodide of potassium will frequently bring about 
absorption of the deposit and remove the obstruction to the passage of the 
tears. 
The existence of organic stricture can be satisfactorily overcome only 
by dilatation with graduated probes (Fig. 1823) or by slitting up the cana- 
liculus on a grooved director. 
A less radical plan has been proposed when the stricture is near the en- 
trance of the sac. It is to introduce a canula-knife, which can be conducted 
to the seat of coarctation concealed in its sheath, and then uncovered and 
made to divide the obstruction, the subsequent dilatation being maintained 
by graduated probes. 
Foreign bodies, as hairs, when they have passed the punctum, or calculi 
(dacryoliths), which may be diagnosed by sounding, can be extracted only 
after laying open the canaliculus or other portions of the lachrymal passages. 
Obstruction of the canaliculi from the pressure of tumors will be corrected 
by the removal of the offending growths. 
Obliteration of the Punctum is liable to follow any protracted inflammation 
of the tarsal border of the lids in which there is abrasion followed by granu- 
lation and the formation of a cicatrix. 
When after a careful scrutiny, aided by a pocket-lens, it is positively ascer- 
tained that such closure exists, the safest plan by which to restore the patu- 
lency of the punctum is to slit, after the manner of Streatfield, the sound 
canaliculus, and then to introduce the director through it into the affected 
canal, in the reverse direction, by which the punctum can be safely reached 
without injury to the canal; or, if the operator is foiled in this, the cana- 
liculus can be laid open upon the director. 
Inflammation of the Lachrymal Sac, or dacrocystitis, especially the syph- 
ilitic form, frequently begins in the nasal mucous membrane, extending up- 
ward, and when acute is attended by both local and constitutional symptoms 
of marked severity. There are severe pain, redness, and swelling over the 
region of the lachrymal sac, accompanied by rigors and an accelerated cir- 
culation. The eyelids and the face participate in the swelling. Immediately 
beneath the tendo oculi the distended sac is seen forming an oblong tumor, 
the integuments covering which are red, shining, and extremely sensitive, 
even to the slightest touch. The conjunctiva is also inflamed and swollen. 
Pressure over the tumor, when it can be tolerated, is soon followed by a dis- 
charge of matter from the puncta, unless the latter have been obstructed at 
their entrance into the sac. Yery soon, if the disease is not actively com- 
bated, ulceration of the sac and overlying integuments takes place, an open- 
ing forms, and the pent-up pus is discharged, affording immediate relief from 176 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
the severe suffering. After six or eight days the opening may heal up and 
remain permanently closed, or it may continue to discharge, the orifice occa- 
sionally scabbing over and again opening, leaving a fistula lacrymalis, through 
which pass the tears. 
In subacute cases of the affection it has happened that the sac has ulcer- 
ated and discharged its contents into the subcutaneous connective tissue 
before any opening in the skin occurred, giving rise to a dissecting or diffuse 
abscess. 
Treatment.—At the very inception of the disease it is possible, by apply- 
ing leeches at the inner corner of the eye, over the angular vessels, and by 
hot fomentations, to abort the inflammation and to prevent suppuration, 
although so fortunate a termination is by no means common. When the 
patient is seen, it is usually at a time when the prime object of the surgeon 
is not to prevent suppuration, but to open a favorable avenue for the escape 
of the pus, and thus save the sac from ulceration. This can be done either 
by slitting the canaliculus on a director into the sac, or by puncturing the 
latter directly through the inner palpebral commissure. When called too 
late for these operations, the abscess having already pointed over the front 
of the sac, it will be better to lay the latter open with a delicate bistoury 
and give free vent to its contents, applying afterwards warm slippery-elm 
or flaxseed-meal poultices. As soon as the swelling, redness, and sensi- 
bility of the soft parts have subsided, the canaliculus should be slit up into 
the sac and the lachrymal duct rendered pervious by the use of probes. 
The old route for the tears having been once more established, the external 
opening or sinus will soon close up, or, if not, the process may be hastened 
by touching its sides with a crayon of niti'ate of silver. 
Mucocele, or catarrh of the lachrymal sac, differs from acute dacrocystitis 
in the subjective character of the attending phenomena. Slow in its prog- 
ress, the patient may not, for a long time, even suspect any unusual trouble 
about the eye. A slight occasional stillicidium of tears, or a watery eye, fol- 
lowed after a time by a little swelling beneath the tendo oculi, which subsides 
spontaneously, or is readily emptied by the pressure of the finger forcing out 
a little turbid, ropy fluid through the puncta, constitute the usual symptoms. 
Sometimes the swelling of the sac is seen above the tendo oculi, and may con- 
tinue for months together without causing any serious inconvenience, until 
at length, from exposure to cold or from some other excitant, acute symp- 
toms set in, and the catarrhal becomes a phlegmonous inflammation of the 
sac, running rapidly into suppuration and ulceration. 
The causes which originate a mucocele of the lachrymal sac are inflamma- 
tory diseases of the Schneiderian membrane of the nose, periosteal disease of 
the nasal bones, particularly syphilitic periostitis, and granular and other 
forms of conjunctivitis. These finally produce coarctation, or stricture, in 
some portion of the lachrymal passages, which culminate in abscess or other 
mischief to the ducts. 
Stricture, while it may arise in any portion of the tear-ducts, will generally 
be found to occur either where the canaliculi enter the lachrymal sac or 
where the latter becomes continuous with the nasal duct. There are suf- 
ficient anatomical reasons for this localization of stricture. With regard to 
the first, it is the rectangular entrance of the canaliculi into the sac and the 
amount of subcutaneous connective tissue which exists in the bridge between 
their orifices which favor the occurrence of the contraction; while in the 
second locality it is the unyielding nature of the surrounding walls of bone. 
Women appear to bo more frequently the subjects of lachrymal stricture than 
men, and the left duct is more commonly affected than the right. 
Treatment.—The great indication in the treatment of mucocele is to 
establish an unobstructed passage for the tears into the nose. At one time 
it was the fashion to dilate the canaliculi into the sac by the use of graduated STRICTURE OF THE LACHRYMAL DUCT. 
177 
probes; this was followed by astringent injections. It cannot be doubted 
that much harm was done by these instruments in the hands of persons 
who lacked the skill in their use which could be attained only by constant 
practice. 
Instead of attempting to dilate the canaliculi in these catarrhal affec- 
tions of the sac, it will be better, in the absence of special skill, that these 
canals be laid open in the usual manner, and a probe passed down through 
the lachrymal sac and nasal duct into the inferior meatus of the nose, as 
already described. The probes in general use are those of Bowman. They 
are made of silver, run in graduated sizes from one to six (Fig. 1823), and 
should have nicely rounded, bulbous or spherical extremities. The flexible 
Fig. 1823. 
Bowman’s lachrymal probes. 
olive-pointed probes, recommended by Williams, of Boston (Fig. 1824), will 
be found not only easier to manipulate than those which are stiff and un- 
yielding, but also less likely to wound the walls of these delicate passages. 
Fio.1824. 
In skilled hands, an attempt should always be made to overcome the stric- 
ture and to restore the calibre of the lachrymal passages by dilatation, using 
for the purpose graduated probes, after the manner already described, and 
introducing one every two or three days, according as their use is tolerated, 
but never persisting in their employment should inflammation be developed. 
After each dilatation, during which the probe may be allowed to remain live 
minutes, the eyelids ought to be well bathed with hot water. When, how- 
ever, the surgeon is baffled in establishing an unobstructed route for the tears 
by this method, or when ulceration has already taken place and a fistula has 
been established, from stricture of the lachrymal sac or ducts, it will be 
necessary to adopt other measures, of which there are several. 
There is, first, the old plan of making a free opening into the front of the 
sac below the tendo oculi, and introducing into the nasal duct a silver or 
leaden style. This operation has almost entirely passed into desuetude, 
although occasionally it cannot well be dispensed with ; for example, where 
a patient living in some remote portion of the country, far removed from 
proper professional aid, applies for relief, having, as is usually the case, a 
fistulous opening into the lachrymal sac, and being only able to remain for 
twenty-four or thirty-six hours under the care of a surgeon,—under these 
Williams’s flexible probes. 178 
DISEASES AND INJURIES OF T1IE EYE AND ITS APPENDAGES. 
circumstances I always introduce the style, as it insures a pervious route 
for the tears at once, and need not be removed for a considerable time. 
The style should be from one inch and a quarter to one inch and a half in 
length, its head standing at an obtuse angle with the rest of the instrument. 
(Fig. 1825.) 
Introducing the style—The patient being seated on a chair, with the head rest- 
ing against its back or supported by an assistant, or, 
if preferred, in the recumbent posture, the surgeon, 
standing in front, makes the tendo oculi, which lies 
across the front of the lachrymal sac, distinct by 
putting the lids upon the stretch, with a finger or 
the thumb applied over the external palpebral com- 
missure. A narrow-bladed, sharp-pointed bistoury (Fig. 1826), held horizon- 
tally, is now carried into the sac immediately below the tendo oculi, after 
which,in order that the instrument shall 
enter the nasal duct, its handle must be 
raised into a vertical position and in- 
clined slightly to the opposite side (Fig. 
1827), when by using a little pressure 
the blade will pass down towards the 
nasal fossa. The stricture having been 
divided, the knife is to be removed and 
the style introduced into the nasal duct, its head resting upon the sides of 
the wound. If any difficulty is experienced in conducting the instrument 
into the duct after the withdrawal of the knife, the way for its admission 
may be cleared by using a large probe. Should the head of the style show 
a disposition to slip into the opening 
made in the soft parts, it can be pre- 
vented by securing a thread to the neck 
of the instrument and fastening it with 
a strip of plaster to the inner angle of 
the brow, or the style may be passed 
through a little circular piece of isinglass 
plaster of larger circumference than the 
head of the instrument, which will effect 
the same object. To conceal the head 
of the style from observation, it can be 
covered with a piece of court-plaster. 
The same end is attained by having the 
head of the instrument japanned; though 
the color wears off after a time. Usually 
very little blood is lost in the operation ; 
though I have known a free hemorrhage 
to occur, which could be controlled only by removing the style for a time 
and applying cold wet compresses over the wound. 
After the operation has been completed, the patient should be directed to 
30ver the parts, for the first twelve hours, with pledgets of lint wet with cold 
water. The removal and cleansing of the style need not be repeated oftener 
than once a week, though many persons wear the instrument continuously 
for months, or even for years, without having it disturbed. 
Styles made of bone, the lime-salts having been previously removed by an 
acid, were at one time in fashion. The external wound was allowed to close 
jver these instruments, under the impression that by the time the latter 
aecame absorbed all tendency to the reformation of stricture would have 
iisappeared. The results were not such as to recommend a repetition of 
he procedure. 
The operation which receives the most general acceptance, and which I 
dunk will be found to yield the best results in cases of coarctation located in 
die lachrymal sac or duct, is that in which, after slitting up the canaliculus- 
Fig. 1825. 
[Style. 
Fig. 1826. 
Knives for opening the lachrymal sac and duct. 
Fig. 1827. 
Different positions of the knife in operating for 
lachrymal fistula, and the style about to be in- 
serted. STRICTURE OF THE LACHRYMAL DUCT. 
179 
into the sac, the stricture is dilated by graduated probes or is incised by pass- 
ing a narrow-bladed, sharp-pointed bistoury (see Fig. 1822) between the eye- 
lids into the sac, and onward down through the nasal duct, afterwards keep- 
ing the passage free by the tri-weekly use of graduated probes conducted 
along the groove of the slit canaliculus into the lachrymal sac and duct, and 
repeated until the incisions have healed and the tendency to contraction has 
in a good measure ceased. Patients themselves, by a little pi’actice, and after 
undue sensibility of the parts has passed away, are often able to introduce 
the probes; and tho surgeon should always endeavor to educate them in this 
manipulation, as it is one which, as in stricture of the urethra, requires to be 
continued at shorter or longer pei’iods for many months. 
In order to pi-event the contraction of the stricture, Bowman employed, 
for a few days after the opei’ation, a hollow style with an arm. Tliis was 
passed into the lachi’ymal sac and duct, and its arm allowed to lie in the 
gi’oove of the slit canaliculus. The leaden style recommended by Gi’eene, 
being very flexible and uniri’itating, is much better adapted for fulfilling the 
indications of this plan of treatment. Neither form of style, however, is 
likely to come into general use. 
Intractable cases of lachiymal obstruction are sometimes encountered, where, 
in consequence Of the long-continued inflammatory changes in the sac and 
disease of the periosteum, the tear-passage is hopelessly blocked. Under 
these circumstances, all other means of treatment having been thoroughly 
tested without success, the surgeon will be called to consider the propriety 
of adopting one of three plans for the relief of the patient,—namely, the 
destruction of the sac, the formation of a new avenue for the tears to the 
nose, or the removal of the lachrymal gland. 
The first method, that of destroying the sac, would not, of eoui*se, ameli- 
orate the condition of the patient if the lachrymal secretion were up to the 
normal amount, as it would necessai’ily in that event overflow the lid; but 
if the secretion is small, no more, for example, than could be disposed of by 
evaporation, there is no reason why the obliteration of the sac should not 
be carried into effect. The destruction of the lachrymal sac, by whatever 
method effected, must be preceded by the oblitex-ation of the puncta and 
canaliculi. This can be quickly done by the galvano-cautery,—a fine plati- 
num probe being passed along the canaliculi and brought to a dull-red heat 
by being connected with the batteiy. The inflammation thus excited results in 
the destruction of these canals, after which the lachi’ymal sac should be laid 
open in front by a vei’tical incision, cutting directly thi’ough the internal pal- 
pebral ligament or tendo oculi; after cleaning out its inner surface, the solid 
niti’ate of silver or the galvano-cautery should be freely applied. Bull de- 
scribes another plan of x-eaching the same result, and with the advantage of 
leaving no exposed cicatrix; that is, by fii’st cutting across both canaliculi, 
and then laying open the sac by a vertical cut behind the caruncle, and, after 
dragging the outer lip of the wound away from the inner one, introducing 
into the sac some nitric acid by means of a little dossil of absoi’bent cotton 
secured to the end of a probe; or the galvano-cautery may be substituted for 
the caustic. Pagenstecher employs for the obliteration of the sac the chloride 
of zinc, which he inti’oduces, mixed with thi’ee or four parts of stai’ch and 
encased in some absorbent cotton, through a triangular incision made in front 
of the caruncle, dividing both canaliculi. 
The second plan of overcoming the impermeability of the sac and duct 
consists in dialling an opening directly through the os unguis,—the operation 
of the late Professor Horner; but as long as the sac x’emains unclosed the 
tears will reach it in preference to following the new route provided. 
Lastly, the extirpation of the lachrymal gland has its advocates, espe- 
cially Mr. Lawrence, whose l’ecommendation of the operation for the relief 
of lachrymal obstruction is based on a considerable number of successful 
cases. The absence of all lachrymal secretion, which must follow extii’pation 
of the tear-gland, I cannot help believing must leave the eye exposed to va- 180 
DISEASES AND INJURIES OF THE EVE AND ITS A UPEND A OES. 
rious irritants of an injurious character. The destruction of the sac in favor- 
able cases, or under the conditions already designated, appears to me to be 
the least objectionable of the different operative measures devised for over- 
coming the evil effects of otherwise unmanageable lachrymal obstruction. 
Leptothrix, or the production of an unusual fungus, has been observed in 
the lower canaliculus and in the lachrymal sac by Graefe and others. This 
fungus is made up of round and filiform bodies. The symptoms of the affec- 
tion are those of lachrymal obstruction, accompanied by some eversion of the 
lid, inflammatory redness of the caruncle, swelling in the course of the cana- 
liculus, and the discharge of a slightly yellow or cream-like material from 
the punctum, either spontaneously or on pressure being made along the 
course of the canaliculus. 
The treatment of this affection requires the laying open of the canaliculus 
and cleaning it of the peculiar formation. 
SUKGICAL AFFECTIONS OF THE MUSCLES OF THE EYE. 
Strabismus.—By the term strabismus, or “ squint,” is meant an inability to 
direct simultaneously both rnaculse on the same object: the visual axes conse- 
quently not intersecting at a fixed point, the image of the object is formed on 
different parts of the retinae of the two eyes. 
The muscles of the two eyes, when acting normally, so nicely harmonize 
that both organs are kept directed not only upon the same object, but also on 
the same points of the object, by which the rays of light or the images of visual 
objects are focused upon corresponding portions of the retina. This consti- 
tutes binocular vision. If from any cause whatever there occurs a loss of 
balance in the action or power of the muscles of the two eyes, so that they 
cannot be kept in the same visual line, then we have the deformity of squint, 
or, what is the equivalent, when the images from the same object are de- 
picted on different portions of the two retinae, there follows double vision, 
or diplopia. 
Squint is either convergent or divergent. In the former the eyes are turned 
towards the inner canthus, and in the latter towards the external canthus. 
When only one eye is maldirected, the squint is said to be single; when both 
are out of place, it is double. Strabismus generally begins in early childhood. 
Convergent Strabismus.—This is by far the most common form of squint. 
In monocular strabismus the eye which is always directed forward in look- 
ing at objects directly in front is the useful or unaffected organ, while the 
one which turns inward or towards the internal canthus is the faulty one. 
In double convergent strabismus both eyes are directed inward. In order to 
discover the squinting eye, the finger may be held before the patient at the 
distance of two or three feet, and exactly opposite the median line of the 
eye; then, placing the hand first over one eye of the patient and then over 
the other, one will be seen to remain fixed on looking at the object, and the 
other to turn inward. The former is the working and the latter the idle or 
squinting eye. 
The degree of actual deviation in the squinting eye may be more accu- 
rately estimated by using the strabismometer, either that of Lawrence (Fig. 
1828) or that of Galezowski. (Fig. 1829.) The first is an ivory plate, curved 
on its upper border to conform to the shape of the lower eyelid, and marked 
off with an equal number of lines on each side of the middle. When this 
instrument is placed against the lower eyelid, so that the referential or mid- 
dle line shall be exactly opposite the middle of the eyelid, the deviation of 
the centre of the cornea from this line will convey an accurate idea of the 
degree of the squint. In the instrument of Galezowski, which is binocular, 
two needles slide in a groove in a horizontal bar having a scale on its face. 
These needles, after the instrument is adjusted across the nose, are placed CONVERGENT STRABISMUS. 
181 
exactly opposite the centre of the cornea of each eye ; the difference in the 
figures on the index answering to the needles of the two sides, expresses 
the degree of squint. 
Even without any mechanism of the kind described, the degree of squint 
Fig. 1829. 
Fig. 1828. 
Lawrence’s strabismometer. 
Galezowski’s strabismometer. 
can be determined by simply making a dark point on the lower lid with ink, 
answering to a supposed vertical line drawn through the centre of the cornea 
of the squinting eye, the other eye being at the same time steadily fixed on 
some object a few feet distant. The unaffected eye is then closed, and the 
eye affected with strabismus directed upon the object, when, by observing the 
deviation of the central vertical meridian of the cornea from the dark spot 
on the tarsus, the degree of the squint will be ascertained. 
These tests should be made for both near and remote objects, as the 
squint is generally increased in proportion to the nearness of the object 
viewed. Frequently the acuteness of vision in the squinting eye is very 
imperfect, a fact which considerably affects the success of the operation. 
The existence of binocular vision can be determined by the use of prisms. 
Causes.—Among the causes producing convergent squint are paralysis of 
the external rectus muscle, opacity of the cornea, demanding a change in 
the position of the eye in order to expose a clear portion for the entrance 
of light, and especially hypermetropia, which, according to the estimate of 
Bonders, is the cause in seventy-five per cent, of all cases. Occasionally con- 
vergent squint is seen to follow a low degree of myopia. In hypermetropia 
the antero-posterior axis of the eye is too short, or, to use a more common 
phrase, the ball of the eye is too flat. In consequence of the low refracting 
power in an organ having this faulty construction there must be an increased 
effort at accommodation, and this in proportion to the nearness of the object 
viewed. But why, it may be asked, should a taxed accommodation be ac- 
companied by convergence of the eye? The answer is obvious. The ciliary 
muscle, which, by modifying the form of the crystalline lens, changes the de- 
gree of refraction and is therefore the muscle of accommodation, receives its 
nerve-filaments from the same source, namely, the third pair, as do the 
internal straight muscles, or those of convergence, so that unusual activity 
in the former is accompanied by corresponding energy in the latter muscles. 
Mimicry is also enumerated among the causes of strabismus, and probably 
when repeated efforts at convergence are made, the internal recti muscles 
may acquire a preponderating power which cannot be neutralized by the 
antagonizing muscles or the external straight muscles. There are cases 
of strabismus, also, which are temporary, depending on general muscular 
fatigue, the muscles of the eye participating in common with those of other 
portions of the body. A few hours’ rest in such cases is sufficient to remove 
all obliquity of the eyes. 
Disorders of the intestinal tract and the irritation attending dentition will 
also, in children of a highly-impressible organization, give rise to temporary 182 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
squint, particularly when such irritations culminate in a convulsion. A 
tumor within the orbit, by pressing on the external straight muscle or on 
the abducent nerve, is another cause for convergent squint, and a like result 
frequently follows the presence of growths and other morbid conditions 
within the brain. 
In permanent convergent strabismus one might expect that the internal 
straight muscle would become permanently shortened, and its antagonist, 
the external straight, correspondingly lengthened and atrophied. In true 
paralytic squint this undoubtedly takes place, but in ordinary cases it is pre- 
vented by the suspension of accommodation for a considerable part of every 
twenty-four hours during sleep. 
Treatment.—Slight cases of convergent strabismus frequently correct them- 
selves as the child grows older, and hence in such cases it is well not to be 
hasty in resorting to an operation. When the acuity of sight is fair in the 
squinting eye and the vision is binocular, and the two images, when in close 
proximity, are blended into one by muscular effort, a marked correction of 
the strabismus will often be secured by exercising the weakened muscles by 
the use of prisms, bringing the two images sufficiently close to become fused 
into one, diminishing the strength of the prisms with the increasing power 
of the muscles, and in this way gradually increasing the distance between the 
images. The vision of the squinting eye, so often imperfect, may also be ma- 
terially improved by closing or covering the working eye and compelling 
the patient to use the affected organ for one or two hours every day. Such 
a discipline, even should it not succeed in correcting the defect, will adminis- 
ter in no small degree to the perfection of the operation. In a large propor- 
tion of cases, however, persons who are the subjects of strabismus will not 
be content with orthopaedic exercises, preferring the more expeditious method 
of getting rid of the deformity by tenotomy. 
The great object to be accomplished in squint by an operation is to detach 
the internal straight muscle from its normal connections with the sclerotic, 
allowing it to contract an attachment farther back, thus enabling the ex- 
ternal straight muscle to draw the affected eye outward, or into parallelism 
with the sound or working eye. The question whether one or both eyes ai’e 
to be operated on must be determined by the extent of the squint. The 
fact that the strabismus is confined to one eye does not argue against the 
necessity for tenotomy on the unaffected eye. It is generally conceded 
that when the deviation amounts to 21"' both internal straight muscles will 
require division; when over 2'", a more decided advantage can be given to the 
external rectus muscle and the necessary correction secured by making a 
somewhat more free division of the fascia which surrounds or encases the 
tendon of the internal straight muscle. In all cases when tenotomy is per- 
formed on both eyes it should be done so that the major correction will be 
given to the squinting eye. 
Operation.—As the operation is attended with considerable pain, it is 
always proper to administer an anaesthetic, after which the lids are to be 
separated by a spring speculum, the patient being in the recumbent position. 
A deep fold of the conjunctiva and subconjunctival tissue is next picked 
up, with a pair of delicate rat-toothed for- 
ceps (Fig. 1830), near the cornea and di- 
rectly over the middle of the tendon of 
the internal straight muscle. This fold 
is now cut through, either vertically or 
longitudinally, with a pair of scissors the 
blades of which—one being blunt-pointed 
—are somewhat cur ved (Fig. 1831), the opening made being just large 
enough, ordinarily, to admit conveniently of the introduction of a hook with 
a rounded extremity. (Fig. 1832.) This hook is to be passed into the wound 
to the lower border of the tendon, and slid under the latter, its point being 
kept close against the sclerotic, in order neither to perforate nor to pass 
Fig. 1830. 
Rat-tootlied forceps. CONVERGENT STRABISMUS. 
183 
above the tendon, but to raise it in its entire breadth, after which the blades 
of the scissors are to be inserted and the tendon of the muscle severed as 
Fig. 1831. 
Fig. 1832.- 
Tenotomy scissors. 
Two forma of strabismus hooks. 
near as possible to its insertion. (Fig. 1833.) This accomplished, the sur- 
geon again inserts the hook, and carries its point upward and downward to 
ascertain if all the fibres belonging to the lateral expansions of the tendon 
have been divided. If this is neg- 
lected and some of these bands 
escape the scissors, the operation 
and its results will be incomplete, 
as these fibres will oppose the 
necessary abduction of the eye. If 
the wound in the conjunctiva and 
subconjunctival tissue has been 
pretty free, it may be desirable to 
insert a single fine silk suture, but 
unless this is the case it is as well 
to dispense with this stitch. 
The after-treatment consists in 
frequently bathing the eyes with 
cold water or applying over them 
wet compresses. The subcutaneous 
extravasation of blood following 
the operation will in the course of 
eight or ten days be absorbed and 
the parts will assume a natural ap- 
pearance. When one eye only is 
operated upon, correction is facilitated by covering the sound organ with a 
bandage for a few days. Should a little crop of granulations sprout from the 
distal end of the divided tendon and protrude through the opening in the 
conjunctiva,—an occurrence frequently witnessed when the tenotomy has been 
made too far back from the insertion of the muscle,—the growth can be easily 
destroyed by snipping it off and touching the stump with a point of nitrate 
of silver. 
A careful examination of the eyes should always be made after the operation, 
or at least as soon as the immediate effects of the anesthetic have passed over, 
with a view to determine exactly what has been accomplished. The finger 
or some other object should be held in front of the patient at a distance cor- 
responding to the previously-ascertained refraction, say about five inches for 
the normal, and less when the patient is near-sighted. If the visual lines of 
the two eyes during accommodation are found to be parallel, the result may 
be considered favorable. When, however, the affected eye with a normal 
refraction shows a tendency to divergence when objects are held nearer than 
eight inches, it is highly probable that its abduction will increase in the 
future, to prevent which it will be proper to lessen the distance between the 
divided ends of the tendon by stitching together the external wound in the 
conjunctiva and its underlying connective tissue. Or possibly the squinting 
eye, when tested by objects at a distance demanding accommodative vision, 
will be seen to turn inward as before the operation. Such a deviation, de- 
Fig. 1833. 
Lids separated by the stop speculum; conjunctiva and 
subconjunctival tissue seized by the forceps and divided by 
the scissors; tendon of the internal rectus muscle raised on 
the blunt hook, and one blade of the scissors slid under, 
ready to divide the tendon. 184 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES 
pending as it does on hypermetropia, will demand for its correction the use 
of proper glasses. 
After all operations for convergent strabismus there will remain more or 
less sinking of the caruncula lacrymalis. It will always be least when the 
incisions are all made as near as possible to the insertion of the tendon of the 
internal rectus, and when there has been the least possible disturbance or 
laceration of the subconjunctival tissue. 
Besides the operation for squint which has been described, and which is 
known as that of Graefe, there is a modification practiced by Critchett, who, 
with a pair of straight scissors having blunt points, opens the conjunctiva 
and subconjunctival tissues along the inferior border of the tendon of the in- 
ternal rectus muscle, and, after raising the latter on the curved hook, as near 
its insertion as possible, divides it by successive snips of the scissors, pressed 
through the external wound, one blade passing in front of and the other behind 
the tendon. 
Liebreich has introduced an operation for squint founded on certain views 
which he entertains in regard to the relation of Tenon’s capsule to the 
orbital muscles. By his method the conjunctiva is divided, as in Critchett’s 
operation, over the lower border of the internal straight muscle, near its 
insertion. By the blades of the scissors the conjunctiva is next separated 
from Tenon’s capsule as far back as the caruncula lacrymalis and the plica 
semilunaris, and the latter from the parts more posterior, after which the 
tendon is divided, as in other operations, including its lateral expansions up- 
ward and downward. The external opening in the conjunctiva is then closed 
by a suture. It is claimed for this method by its author that it is not fol- 
lowed by the usual sinking of the caruncle, and that it gives a larger field for 
dividing the correction between the two eyes. 
Dr. Noyes, of Detroit, Michigan, instead of dividing the internal straight 
muscle in convergent strabismus, shortens the opposing or external straight 
muscle by overlapping the ends of its tendon after division, and securing them 
together by two sutures passed through the conjunctiva and the tendons. 
While all the methods named have certain advantages in special cases, 
the simplicity of the operation and the results obtained by the plan of 
Graefe render it, on the whole, the most desirable procedure. 
In divergent strabismus the affected eye turns outward, so that it is im- 
possible for the visual lines of the two eyes to harmonize or to converge 
properly on a given object. This variety of squint is much less common than 
the convergent form. 
Causes.—The causes which produce divergent squint are myopia, a too 
free division of the structures in operating for convergent strabismus, paral- 
ysis or insufficiency of the internal straight muscles, and loss of vision in 
the distorted eye. Myopia, however, is the most common cause. The severe 
tension kept up on the internal recti muscles, which is necessary for binocular 
vision in short-sighted persons, tends to exhaust the power of the muscles 
and to favor the divergence of one eye, accommodative visual labor being 
more easily performed by the other alone. 
Treatment.—Operative measures for the treatment of divergent strabismus 
are not often resorted to, and when these are deemed necessary a consider- 
able degree of skill is demanded for effecting a correction of the deformity. 
It may be sufficient to make a longitudinal incision through the conjunctiva, 
over the internal rectus muscle, and, after exposing and cutting away a por- 
tion of the tendon, to bring the remainder forward and secure its attach- 
ment nearer the cornea by means of two sutures, one above and one below, 
carried through the conjunctiva and tendon. It may be necessary to divide, 
also, the external straight muscle. The subsequent treatment will be the same 
as after the operation for convergent squint. 
Divergent Strabismus. CONGESTION OF THE CONJUNCTIVA. 
185 
AFFECTIONS OF THE CONJUNCTIVA. 
The conjunctiva is divided into three portions, the palpebral, the sclerotic, 
and the corneal, each differing from the others in anatomical structure. The 
palpebral portion is made up of connective tissue closely attached to the carti- 
lages, is highly vascular, and contains numerous glands, which, having the base- 
ment membrane covered by cylindrical epithelium, form small eminences or 
papillae, giving to the surface of the membrane a velvety appearance when 
examined with a magnifying-glass. The sclerotic conjunctiva is thinner, 
less vascular, contains no papillae, and is loosely connected to the sclerotic 
coat. The corneal portion is wanting in all the elements of the other two, 
except the epithelial, and, as such, covers the cornea. The transition from 
the sclerotic to the corneal conjunctiva is abrupt, and at the line of junction 
—namely, the circumference of the cornea—the connection of the membrane 
to the latter is firm. These anatomical facts possess important pathological 
bearings on the diseases of the conjunctiva. 
Congestion of the Conjunctiva.—This condition of the mucous membrane of 
the eye is generally confined to its palpebral portion, although it may extend 
to the sclerotic. It is characterized by a sense of burning, smarting, or itch- 
ing of the eye, with a desire to rub the lids, and is often attended with slight 
lachrymation. The symptoms become more pronounced as the day ad- 
vances, until evening, when the discomfort is greatest. During the hours of 
the night given to rest and sleep a temporary amelioration is experienced, 
and the patient resumes the labors of the day with comparatively little in- 
convenience. The respite, however, is short; the same symptoms again arise, 
and the eyes at length become fatigued, are unduly sensitive to strong lights, 
and vision is indistinct or blurred. On everting the lids the mucous mem- 
brane is seen to be unduly red and somewhat swollen. 
The eversion of the upper eyelid is easily effected by observing the 
following directions. 
Let the surgeon seize the eyelashes, at the middle of the tarsus, between 
the thumb and index finger of one hand, and draw the lid downward and 
away from the ball of the eye, at the same time directing the patient to look 
downward. While this is being done, let the tip of the free index finger be 
placed on the middle of the lid and make counter-pressure, when, upon suddenly 
l’aising its tarsal border, the eversion will follow. Those not familiar with 
such manipulations will succeed 
better by using a pencil or probe 
in the same manner instead of the 
tip of the finger. (Fig. 1834.) The 
eyelid, once everted, is readily 
maintained in the new position 
by pressing its tarsal border, with 
the thumb, back against the lower 
border of the brow. 
The condition of congestion is 
induced by the long-continued use 
of the eyes at night under gaslight, 
by the constant study of micro- 
scopic objects, and by exposing the 
eyes to dust and to the glare of sun- 
light reflected from white sand. It is frequently attributable to some error 
of refraction, as astigmatism or hypermetropia, while in some instances it 
is symptomatic of disease of the interior of the eye. 
Treatment.—This, to be successful, requires that the cause be discovered 
and removed. If arising from the prosecution of any employment requiring a 
close and constant exertion of accommodative power, that employment must 
Fig. 1834. 
Turning the eyelidB. 186 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
be suspended or exchanged for another less exacting on the vision; if from 
refractive defects, the use of proper glasses will be required. 
The local applications which afford most relief, by lessening the circulation 
of the lids, are lotions of cold water and acetate of lead or sulphate of zinc 
(gr. i of the salt, water, These ai*e to be freely applied over the 
closed lids, the brows and temples, several times during the day. Smoked 
glasses can be worn with advantage when the patient is exposed to strong 
sunlight, wind, or dust. When it becomes necessary to use a collyrium, a few 
drops of a solution of boracic acid (grs. vij, rose-water, fgi) or sulphate of 
zinc (gr. i, distilled water, fgi) dropped on the eye once or twice daily will 
hasten the removal of the congestion. 
The application of collyria can be made in several ways: by dropping the 
liquid directly from the bottle upon the eye while the head of the patient is 
thrown back and tbe palpebrae are separated by placing the index finger on 
the upper and the thumb on the lower lid and pressing them apart; or by 
loading a camel’s-hair brush with the collyrium, and, after depressing the 
lower lid, applying the liquid to its inner surface. A few winking move- 
ments of the lids will distribute the fluid over the entire surface of the eye. 
Lastly, the application is very conveniently made 
by the use of the stopper dropper (Fig. 1835), 
which is a hollow glass tube having a little gum 
bulb affixed to its upper extremity. Placing the 
tube in the liquid, and compressing the bulb and 
then allowing it to expand, the dropper will be 
charged; then insinuating the point of the instrument between the lids at 
the external canthus and compressing the gum, the fluid will be discharged 
upon the eye. 
Fig. 1835. 
Stopper dropper. 
Catarrhal Conjunctivitis is met with in varying degrees of intensity, from 
a strip of vascular redness, limited to the anterior margin of the eyelids, to 
a general injection and swelling of the entire 
palpebral and sclerotic conjunctiva. (Fig. 
1836.) 
Symptoms.—The disease commences with a 
sense of heat, of fullness and stiffness of the 
eyelids. The latter are usually red, slightly 
swollen, and feel as though irritated by dust. 
The disease may stop at this stage and the 
inflammation disappear. When it advances 
to the more typical form, the inflammation 
extends over the entire membrane, both 
palpebral and ocular, not exempting the 
plica semilunaris and the lachrymal caruncle. 
The vessels of the conjunctiva are deeply 
injected, imparting an intensely red or a brick- 
dust color to the membrane, with here and 
there spots of ecchymosis or extravasated 
blood. The patient suffers more from a sense 
of itching than from pain, though ciliary neu- 
ralgia may be present. At first the reticular arrangement of the over- 
distended vessels is apparent, but after a time this is in a measure lost, in 
consequence of the oedema or serous transudation which takes possession 
of the lids and the submucous connective tissue. When the inflammation 
invades the ocular conjunctiva, the redness is not so marked, but it is often 
characterized by an appearance which is not seen in the palpebral portion 
of the membrane, one in which both a reticulated and a straight system 
of vessels can be distinguished. The discharge, which at first consists of 
increased laehrymation, at length is transformed into a viscid and finally a 
muco-purulent secretion, more or less abundant, especially during the evening, 
Fig. 1836. 
Catarrhal conjunctivitis. CATARRHAL CONJUNCTIVITIS. 
187 
which, accumulating about the borders of the lids during the night, glues 
the eyelashes together, requiring both time and care for their separation in 
the morning. There is usually in catarrhal ophthalmia no great intolerance 
of light, nor any serious impairment of vision. Objects may be seen in- 
distinctly, but this will be due to muco-purulent accumulations over the 
cornea, and not to any defect in the eye itself. Shadows, from the presence of 
fragmentary particles of epithelium and mucus upon the eye, cause the beads 
and rings so frequently complained of by patients with this affection as 
floating before the eyes. 
Causes.—Among the ordinary excitants of catarrhal conjunctivitis are 
sudden atmospheric changes from hot to cold, exposure to strong currents 
of air, to particles of dust, to smoke, or other foreign materials, and, not 
unfrequently, to the glare of reflected sunlight. The disease is frequently 
among the accompaniments of certain exanthemata, as measles, smallpox, 
and scarlet fever, also erysipelas. It may be secondary to a nasal catarrh, 
the inflammation reaching the conjunctiva by continuity of tissue through 
the lining membrane of the lachrymal passages. Finally, it may originate 
from contagion, communicated from one person suffering from the inflam- 
mation to another, by using the same towel or wash-basin or occupying 
the same bed. It is for these reasons that the disease often prevails so 
extensively in some of our public charitable institutions. 
Prognosis.—When promptly attended to, catarrhal conjunctivitis can 
usually be mastered in five or six days, but when allowed to progress for 
even a short time unchecked, it will often require as many weeks. In 
neglected cases the inflammation may be followed by incurable structural 
alterations of the conjunctiva, as hypertrophy followed by cicatricial con- 
densation, or by deformity of the lids, as ectropion, or by changes in the 
direction of the lachrymal puncta. Such sequels are most common in old 
persons. 
Treatment.—The indications are to remove all sources of irritation, to 
control inflammatory action and secure the removal of inflammatory prod- 
ucts, to favor the proper tonicity of the vessels and contraction of the tissues 
of the conjunctiva. 
In fulfilling the first object, the lids should be everted and the subpalpebral 
portions of the conjunctiva carefully scrutinized back to the retrotarsal 
folds in search of an}7 foreign matters which may have found a lodging- 
place on the membrane or on the eye, the removal of which would prob- 
ably terminate the disease. If dust, smoke, or cold, damp currents of air 
are responsible for the inflammation, the patient must be removed from 
their influence. At first pledgets wet with cold water should be laid over 
the eyelids, the degree of temperature depending on the constitutional vigor 
of the patient. In the strong and plethoric the water may be quite cold; 
in the weak, pale, or lymphatic, it should be a little warm, or even hot. 
A gentle aperient will prove useful if there is reason to suspect any 
derangement of the intestinal secretions. Ciliary pain, when present, is 
best relieved by hot hop fomentations or by the instillation of a two-grain 
solution of atropine. When the discharge begins to assume a purulent 
character, an indication that the acute symptoms have commenced to abate, 
the time has arrived for the use of astringents, in order to secure tho con- 
traction of the distended vessels and to restore the other components of the 
mucous membrane to their normal density. For this purpose collyria of 
the sulphate of zinc (grs. ij, rose-water, fgi), boracic acid (grs. vij, water, 
fji), alum (grs. vij, water, fgi), or chloride of zinc (gr. ss, water, f£i), will be 
found beneficial. These should be dropped on the eye at least two or three 
times a day. Should the muco-purulent discharge continue or become 
notably thicker, associated with a flabby, swollen state of the conjunctiva, 
it will be necessary to apply a more potent stimulus to its surface, and for 
this purpose a solution of nitrate of silver (grs. i to iii, distilled water, f3i) 
will be the best, addressed to the inner surface of the lower lid by means 188 
of a camel’s-hair brush, twice daily, the patient being directed to close and 
open the lids several times in rapid succession after each application,'in 
order to diffuse the collyrium over the whole extent of the conjunctiva. 
Not only should the purulent accumulations be washed from between the 
lids by injecting a stream of tepid water before using the collyrium, but 
the same procedure can with great advantage be repeated several times 
during the day. Bichloride of mercury, of the strength of half a grain to 
six ounces of thin warm mucilage of slippery elm, constitutes an admirable 
substitute for the tepid water for preliminary washing. 
In order to prevent the gluing together of the eyelashes by hardened se- 
cretions, the edges of the lids should be smeared at bedtime with benzoated 
lard rendered firm by the addition of a little spermaceti. The disease is 
often aggravated by forcibly tearing the eyelids apart. No attempt ought 
to be made to separate the lids until the adherent crusts have been softened 
by the use of warm water. Excoriation of the tarsal borders, caused either 
by the acridity of the discharge or by rudely pulling apart the lids, is best 
remedied by the use of the red oxide of mercury (one grain to one drachm 
of simple cerate). 
In public institutions, where numbers of young boys or girls are congre- 
gated, and also in private practice, the importance of separate towels and 
basins must not be overlooked : except attention is given to this matter and 
to the most rigid cleanliness, the eradication of the disease is impossible. 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
Purulent Ophthalmia. 
Various names have been employed to designate this affection, as Egyptian 
ophthalmia, ophthalmia neonatorum, ophthalmia contagiosa, etc. 
Purulent ophthalmia differs from catarrhal ophthalmia chiefly in the ten- 
dency of the inflammation in the former disease to extend to the sub- 
conjunctival connective tissue, and also to implicate the cornea, iris, and 
deeper structures of the eye. 
Symptoms.—The disease in its commencement does not differ materially 
from catarrhal conjunctivitis. There is the same feeling of heat and itching 
in the lids, with a sensation of something similar to sand being lodged beneat h 
the palpebrte. The lachrymation is succeeded by a viscid and muco-purulent 
discharge, which collects in concrete masses along the edges of the lids 
and cements the cilia together. The conjunctiva is uniformly red and 
swollen, with its papillae very prominent and fleshy, and the eyelids are 
red and puffy. But the disease does not rest here. The discharge becomes 
yellow, thick, opaque, and profuse, often slightly red from admixture with 
blood; the inflammatory infiltration ex- 
tends into the submucous connective tissue; 
the conjunctiva becomes much swollen 
and chemotic, forming a red collar around 
the cornea; the discharge collects in the 
eyelashes, matting them together in sepa- 
rate groups, and runs down upon the cheek. 
(Fig. 1837.) Photophobia is marked, and 
pain, both in the eyes and in the temples, is 
often very severe. The latter symptom is 
usually among the earlier phenomena, sub- 
siding with the appearance of the puru- 
lent discharge. The tendency of the dis- 
ease is to implicate the cornea. This will 
be announced by a hazy or cloudy ap- 
pearance of this membrane, obscuring 
the vision, and unless arrested will be fol- 
lowed by ulceration, beginning near the corneo-sclerotic junction. This, 
extending in all directions, is likely to perforate the membrane and allow 
Fig. 1837. 
Purulent ophthalmia. PURULENT OPHTHALMIA. 
189 
the escape of the aqueous humor, with prolapse of the iris, escape of the 
lens, and possibly entire disorganization of the ball. 
In that variety of purulent ophthalmia commonly styled ophthalmia neona- 
torum (Fig. 1838) both eyes genei*ally suffer: the papillae of the conjunctiva 
are preternaturally large, and the lids greatly 
swollen. Though referred almost invariably 
to contagion, by contact with gonorrhoeal or 
leucorrhceal matter at the time of birth, yet 
there are exceptions to this, as where the 
disease develops twenty or thirty days after 
the child is born. The usual period of in- 
cubation, when the affection arises from con- 
tagion, is about three days. 
Causes.—The same causes which give rise 
to catarrhal ophthalmia will in an enfeebled 
patient, or in one under bad hygienic sur- 
roundings, produce a purulent conjunctivitis. 
It often spreads epidemically, as is witnessed 
in Eastern countries among soldiers and pil- 
grims. The reflection of the sun over long 
stretches of sand, together with the heat and 
dust, is the cause of its prevalence in such 
localities. The contagious origin of the disease is unquestionable. New- 
born children contract it from the discharges of the vagina. It can be 
readily communicated from one person to another by contact. It is only 
when the discharge assumes the muco-purulent character that it certainly 
acquires the property of communicability. 
Treatment.—The first thing requiring attention in the treatment of 
purulent ophthalmia occurring in schools, camps, or institutions where many 
persons ai*e congregated is isolation of those affected. The towels, basins, 
and water must not be in common, but each person, sound and affected, must 
be supplied separately. The apartments in which the inmates are lodged re- 
quire to be thoroughly ventilated, and to be purified by the spray of carbolic 
acid. The eyes of the unaffected should be examined carefully every day, 
in order to detect the disease in its earliest manifestations, when it can 
be arrested with less difficulty. When the inflammation is located in one 
eye it will very soon attack the other, unless preventive measures are taken. 
With this object in view, close the lids of the sound eye, cover them with 
a pad of carbolized absorbent cotton, and secure the dressing by a few turns 
of a monocular or oblique bandage. This should be removed and renewed at 
least once every day. The physician, in making the requisite applications, 
must be careful not to allow the discharge to come in contact with the 
mucous membrane of his own eyes. 
At the earliest manifestation of the inflammation, the latter may be cut 
short by the timely use of a collyrium of nitrate of silver (grs. iss to iij, dis- 
tilled water, fgi) dropped on the eye or applied to the lids, and followed by 
the ice-bag or by compresses wet with cold water and frequently renewed. 
At the same time the discharge which collects beneath the lids must be re- 
moved several times every day, and occasionally during the night, as by 
remaining in contact with the mucous membrane it acts as a violent irritant. 
Its removal can be best effected by insinuating gently between the palpebrse, 
at their commissures, the nozzle of a syringe charged with a little tepid milk- 
and-water or a very weak solution of alum and forcing the contents between 
the lids and the ball of the eye. To prevent excoriation of the cutaneous 
surfaces of the palpebrse by the discharge, vaseline or benzoated lard applied 
to the mai’gin of the lids will be found useful. 
When the discharges have become purulent, the use of cold, locally, loses 
much of its value,—may, indeed, act injuriously. The time for astringents 
has now arrived, and these may be employed both as cleansing liquids and 
Fig. 1838. 
Ophthalmia neonatorum. 190 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAOES. 
for the purpose of contracting the overstrained and overloaded vessels. A 
tepid solution of the sulphate of zinc (grs. i-ij, rose-water, fgi), or of alum 
(grs. iv, water, fgi), or of corrosive sublimate (gr. water, should be 
injected between the lids once every two hours, and if no amendment is 
effected in the course of twenty-four hours, a solution of the nitrate of silver 
(grs. ij, distilled water, f.v) should be dropped on the eye, or, what is better, 
applied to the lids directly with a camePs-hair brush. 
If the eyelids become much swollen, accompanied by muscular spasm, and 
causing injurious pressure on the eye, a marked amelioration of the symp- 
toms will be experienced if the surgeon, with a delicate bistoury, divides the 
external commissure of the lids, observing not to incise the mucous mem- 
brane. The operation will be most conveniently executed by introducing 
the point of the knife between the conjunctiva and the other tissues of the 
lids and incising the parts for a short distance. When the inflammation runs 
high, the local abstraction of blood from the temples will do much good. 
In the purulent stage of the disease, other measures failing to control the 
morbid process, the very best results will be obtained by everting the lids 
and carefully penciling their conjunctival lining wTith a crayon of nitrate of 
silver (strength thirty per cent.). The use of atropine will be advisable 
throughout the course of the treatment, or, at all events, until the disease is 
well on the decline. A solution of two or three grains to an ounce of water, 
dropped on the eye twice daily, will prevent infiltration of the cornea and 
secure the integrity of the pupil, should inflammation of these structures 
occur. 
When the patient experiences much pain, either ciliary or supraorbital, or 
is unable to sleep, anodynes will prove useful. 
In some instances there is considerable constitutional disturbance, in- 
dicated by an elevated temperature, an accelerated pulse, and headache. A 
few grains of blue mass, followed by a saline cathartic, will remove these 
symptoms and react favorably on the local trouble. 
Gonorrhoeal Ophthalmia. 
That variety of ophthalmia termed gonorrhoeal conjunctivitis is an ex- 
ceedingly aggravated and dangerous form of purulent ophthalmia. Except 
when traced directly to gonorrhoeal origin, it is very difficult to distinguish 
between the two affections. Men suffer from the disease much more fre- 
quently than women. The inflammation may be limited to one eye, although 
both eyes are frequently affected, sometimes simultaneously. Usually one 
eye becomes affected, after which the other suffers, being inoculated from 
the first. 
The inflammation is caused by some of the gonorrhoeal discharge being 
conveyed from the urethra or vagina to the eye by the fingers or clothing of 
the patient. 
It has been suggested that inoculation of the conjunctiva may occur by 
the transportation of pus-corpuscles through the air of a venereal ward, the 
niateries morbi being adherent to floating dust or some fragmentary particles 
of the dressings employed. The suggestion is a reasonable one, although I 
know of no facts to verify it. That epithelial and pus debris have been found 
in the air of hospital wards has been established by Frank Marston and by 
specimens of ward-dust in my own possession; but the power of such mate- 
rial in its dried state to inoculate seems very questionable. 
Secondary or metastatic gonorrhoeal conjunctivitis, contended for at one 
time, has few advocates at present: indeed, there are no facts in favor of 
such an origin which will bear criticism. The filthy habit of a gonorrhoeal 
patient bathing the eyes with his urine has also been regarded as another 
cause of this form of ophthalmia. In the very few instances of gonorrhoeal 
ophthalmia which have come under my observation occasioned, as was alleged, 
by contact with the urine, there had existed a previous inflammation of GONORRHCEAL OPHTHALMIA. 
191 
the conjunctiva, which was doubtless produced by contagion conveyed to 
the lids by pus from the urethra. The urine was afterwards applied as a 
wash to the eye, under a popular notion that this secretion was an excellent 
remedy for ophthalmia. The aggravation of the disease following the use 
of so potent an irritant might be anticipated, and the urine was charged 
accordingly with being the origin when in reality it only augmented the pre- 
existing disorder. 
Symptoms.—Between the application of the contagious material and the 
development of the disease there is a short period of incubation, which varies 
from six or eight hours to two or three days. The inflammatory symptoms 
are ushered in by itching or smarting of the eyelids, and a feeling as though 
sand or some rough substance rested beneath the palpebrae. The conjunctiva 
presents a uniform redness. The secretion, at first watery, consisting chiefly 
of tears, soon becomes of a muco-purulent character, and finally purulent or 
cream-like. It glues the edges of the lids together, adheres to the eyelashes, 
and runs over upon the face, excoriating the parts with which it comes 
in contact, and after exposure to the air 
forms adherent crusts. During sleep the 
discharge, though not so abundant as in 
the daytime, continues to flow freely. 
(Fig. 1839.) The eyelids become greatly 
swollen, hot, red, with a tint of blue, and 
oedematous, so as to close over the eye. The 
vessels of the conjunctiva become engorged 
with blood, and the subconjunctival tissue 
is filled with serum, giving rise to chemosis. 
The swollen membrane spreads over and 
conceals from view the entire cornea. Se- 
vere pain is experienced, not only in the eye, 
but over the brow, frequently extending 
into the temporal region, accompanied by 
great intolerance of light. It is during the 
height of the symptoms that the purulent 
discharge is most highly charged with the property of infection. 
The progress of the disease is always rapid, the acute symptoms running 
their course in five or six days. The declination is sometimes protracted, 
extending over three or four weeks. 
There is almost always present some degree of constitutional disturbance, 
especially well marked in subjects whose previous habits have been dissolute 
and their health impaired. These general symptoms are headache, loss of 
appetite, frequent and feeble pulse, and diminished strength. 
Prognosis.—Gonorrhoeal ophthalmia under any circumstances is an exceed- 
ingly dangerous inflammation, not unfrequently resulting in serious impair- 
ment of vision, or even in the loss of the eye. The cornea is particularly ex- 
posed to danger, either from inflammatory infiltration of its lamina? and 
suppuration, or from marginal ulceration and perforation, followed by escape 
of the aqueous humor and prolapse of the iris. When this occurs, it is seldom 
that the deeper structures of the ball escape the destructive process which 
results in its entire disorganization, leaving only a wasted and contracted 
stump. 
The inflammation of the conjunctiva may take on a diphtheritic character, 
the redness being replaced by pallor, and the soft infiltrate in the submucous 
tissue by a firm, stiff, fibrogenous exudate, the purulent discharge at the 
same time changing to a watery one. This transformation does not lessen 
the danger of the disease, but rather enhances it. Even when recovery takes 
place without the evils spoken of, the conjunctiva is often injured by inflam- 
matory products leaving it permanently thickened and granular. Alteration 
in the form of the lids is also among the sequels of the disease, caused by 
softening of the tarsal cartilages. 
Fig. 1839. 
Gonorrhoeal ophthalmia. 192 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
Ptosis is another effect of this variety of ophthalmia, caused by thickening 
of the retrotarsal fold of the conjunctiva, together with the presence of in- 
flammatory tissue in the structures of the palpebrse. It disappears in the 
course of time, as the parts return to their normal state, though in a few 
instances it has remained as a permanent defect. 
Treatment.—In the treatment of gonorrhoeal conjunctivitis there is no 
time for temporizing. Even a few hours’ delay may prove fatal to the eye, 
and under the best management the disease will sometimes ruin the organ 
before it can be subjugated. 
As a prophjdactic precaution, a patient with gonorrhoea should be warned 
as to the danger resulting from contact of the urethral discharge with the 
eye, and the necessity, therefore, of giving scrupulous attention to personal 
cleanliness, always washing the hands clean after using injections or making 
any dressing of the parts affected. 
When the inflammation is confined to one eye, the other must be carefully 
fortified against the contagion by closing the lids, covering them with car- 
bolized cotton or charpie, and fastening the dressing with a bandage. This 
dressing should be renewed twice in twenty-four hours. The muco-purulent 
secretion must next be washed from beneath the lids by injecting some tepid 
slippery-elm or flaxseed tea, after which a strong solution of nitrate of sil- 
ver (gr. xv-xx, distilled water, fSi) must be carefully applied to the in- 
flamed and swollen conjunctiva with a camel’s-hair brush, and repeated twice 
daily until the disease is arrested, which will be indicated by the lessening 
chemosis, the diminished vascularity of the conjunctiva, and commencing 
subsidence of the palpebral swelling. When these signs become apparent, 
the strength of the collyrium can be safely diminished one-half or two- 
thirds, and its application continued twice daily. Immediately after and 
between the periods at which the nitrate of silver is used, at intervals of two 
hours, the secretions should be washed from the eye by injections of warm 
milk-and-water, slippery-elm tea, or a solution either of alum or boracic acid. 
The liability of the disease to attack the cornea near its sclei-otic connection 
will keep the attention of the surgeon fixed upon the danger-line, and on the 
first appearance of ulceration he should, with precision and a light hand, 
touch the ulcerated surface with a finely-pointed crayon of nitrate of silver. 
The use of pledgets soaked in cold or iced water, or the ice-bag laid over the 
eye, will not in many cases be well tolerated ; indeed, they often prove de- 
cidedly harmful, by lowering the vitality of the parts, already much en- 
feebled and having a strong tendency to ulceration. Hot water will, as a rule, 
prove more grateful to the patient and favor the resolution of the inflamma- 
tion with greater certainty than a very cold liquid. I believe the latter to 
be frequently instrumental in causing sloughing of the cornea. 
In addition to these local measures, the constitutional treatment must not 
be overlooked or underestimated. Pain and wakefulness demand opium in 
some form. Very many patients who suffer from gonorrhoeal ophthalmia 
will be found to possess little general vigor. The tendency of the in- 
flammation will be in an asthenic direction, and, consequently, an ample 
supply of nutritious pabulum, a reasonable quantity of stimulus, and the use 
of quinia in liberal doses will be demanded. The abstraction of blood, either 
local or general, is not to be thought of. In looking back to the period when 
this affection was attacked by repeated and copious general bleedings and 
by incisions into the chemosed conjunctiva, it cannot be a matter for sur- 
prise that so many eyes were hopelessly destroyed. 
Phlyctenular Ophthalmia. 
Phlyctenular conjunctivitis — herpes of the conjunctiva — is met with 
chiefly among children who possess those constitutional peculiarities which 
are usually regarded as strumous, or whose hygienic surroundings are un- 
favorable. PHLYCTENULAR OPHTHALMIA. 
193 
The disease manifests itself by the appearance of a number of minute semi- 
transparent vesicles of a pale-yellow color, situated on the ocular conjunctiva 
or the cornea (Fig. 1840), and always preceded by a sense of heat and itching 
in the palpebne, with increased lachryma- 
tion and neuralgic pain in the eye and 
often over the brow and temple. The ac- 
companying conjunctivitis may be circum- 
scribed or general. When the former, the 
injected vessels undergo a remarkable fan- 
like expansion, the apex presenting to- 
wards the cornea and the base towards 
the retrotarsal reflection of the mem- 
brane. A certain amount of serous infil- 
tration of the subconjunctival tissue is 
present, causing some swelling of the con- 
junctiva. The detachment of the epithe- 
lial covering or the rupture of the vesicles 
leaves a minute ulcer, which either be- 
comes larger both in depth and in circum- 
ference or contracts and heals up sponta- 
neously. The vesicles either occur in groups or are scattered irregularly 
over the conjunctiva. They are often noticed to observe the laws of sym- 
metry, occupying corresponding portions on the two e}7es. The efflorescence 
or eruption makes its appearance about the third day following the primary 
irritation, and runs its course, in favorable cases, in eight or nine days. The 
appearance of the vesicles marks the zenith of the inflammatory irritation, 
and with the cicatrization of the ulcers the vascularity and swelling of the 
conjunctiva decline. It is during the progress of this declination that the 
discharge becomes muco-purulent, which, by one not familiar with the dis- 
ease, might be construed as an unfavorable symptom, but which is, as in 
ordinary catarrhal conjunctivitis, only the final stage of the inflammation. 
Among the eccentric phenomena of phlyctenular ophthalmia are occasion- 
ally seen the circular arrangement of the vesicles at the sclerotico-corneal 
junction, a succession of fresh crops of vesicles, and the aggregation of nu- 
merous vesicles imbedded in a portion of hypertrophied conjunctival tissue 
(pannus herpeticus), which is apt to remain a long time as a chronic condition. 
Causes.—Phlyctenular ophthalmia is the result of local irritation of various 
kinds, inducing hyperamiia of the vessels of the conjunctiva. 
Treatment.—When the disease is met with among children who are sub- 
ject to conditions unfavorable to health, it is very important that as far as 
possible these should be corrected. Cleanliness, pure air, good ventilation, 
and nourishing food are of prime importance as preliminary measures to any 
treatment. Local irritation will be diminished by injections of warm water 
between the lids, either alone or medicated by the addition of borax or alum 
(grs. ij, rose-water, f3i). The photophobia and ciliary neuralgia will be re- 
lieved by applying an ointment of belladonna over the brows, and by closing 
the eyelids with a compress and bandage, thus controlling their movements 
and removing a certain degree of irritation- The astringent collyria most 
useful are those made from the acetate of lead, sulphate of zinc, boracic acid, 
and nitrate of silver. When the violence of the inflammation has culminated 
and the irritation subsided, there is no remedy which acts with the same 
efficacy as calomel, applied to the eruption by means of a camel’s-hair brush. 
Other preparations of mercury have their advocates, the best being that of 
the yellow oxide, the strength of which should be from three to seven grains 
of the oxide to one ounce of simple cerate. The red oxide of mercury in 
ointment, one grain to one drachm of simple cerate, is also a very valuable 
agent. These ointments are to be applied to the conjunctival surface of the 
palpebra? by means of a camel’s-hair brush. 
The reflex blepharospasm, due to the exposure of some of the nerve-fibres 
Fig. 1840. 
l’hlyctenular ophthalmia. 194 
DISEASES AND INJURIES OF THE EVE AND ITS APPENDAGES. 
of the conjunctiva or cornea at the seat of ulceration, is best corrected by 
going out into the open air, the eyes being protected against the stimulus of 
sunlight by wearing a shade or by smoked glasses. Shutting a child up in 
a dark room or bandaging the eyes does no good : indeed, such a course 
rather intensifies the photophobia. In strumous children this symptom, as 
well as the ulceration, will be greatly benefited by the use of constitutional 
remedies, as cod-liver oil and the syrup of the iodide of iron. 
Exanthematous Ophthalmia. 
In certain of the exanthemata, as in measles, scarlatina, variola, and ery- 
sipelas, the eyes become affected. 
The inflammation varies much in severity. In rubeola it may amount 
only to slight redness and increased lachrymation, or it may assume a ca- 
tarrhal character, followed by a mucous or muco-purulent discharge. It may 
give rise to ulceration of the cornea, as is frequently witnessed in variola, 
a condition often improperly referred to pre-existing pustules. When the 
patient has been much enfeebled by an exanthematous disease, or when the 
latter occurs in one of a strumous habit of body, the inflammation is liable to 
linger about the edges of the tarsi, and to extend into the tarsal or Meibomian 
glands, and even along the lachrymal passages. Many young persons with 
red eyelids, whose palpebrse are found glued together in the morning by an 
inspissated muco-purulent discharge, can trace the origin of the ophthalmia 
to an attack of scarlet fever, measles, or smallpox contracted when children. 
Treatment.—In most instances the inflammation disappears during the 
progress of convalescence, requiring little, if any, medication. Should this 
not follow, or should the secretions and discharges assume a catarrhal ap- 
pearance, it will be necessary to resort to local treatment, as bathing the 
eyelids with hot water two or three times daily, removing from the edges of 
the palpebrse any crusts or other secretions which may cling to the tarsal 
border of the cilia, and dropping on the eye a weak collyrium of sulphate 
of zinc. To protect the delicate skin over the eyelids and face against the 
irritation from the discharges, these parts should be smeared with simple 
cerate or zinc ointment. 
Granular Conjunctivitis—Trachoma. 
In granular ophthalmia the palpebral conjunctiva is red, swollen, and 
studded with numerous eminences or papillary elevations, which give to the 
membrane a roughened appearance, and, in consequence of friction, tend to 
produce a dull, hazy condition of the cornea, with straggling vessels run- 
ning across its surface. Often the redness of the conjunctiva is not greater 
than normal; it may even be less. The characteristic elevations may be 
very fine, resembling somewhat the pile of velvet, or .may be large, papillary, 
or granular. 
The disease is met with at all ages; males and females are alike subject to 
the inflammation. 
The pathology of granular ophthalmia consists partly in an inflammatory 
enlargement or hypertrophy of the normal papillae and follicles of the con- 
junctival membrane, and partly in a new formation, which, although of similar 
origin to the first, is more deeply seated in the subconjunctival tissue, and 
answers to true granulation-tissue. 
Symptoms.—The disease frequently begins in so quiet a manner as scarcely 
to attract the attention of the patient. A little unusual warmth of the lids, 
some increased lachrymation, and a feeling of something like particles of 
sand scratching the eye, will often be the sensations first noticed. After 
a time the irritation becomes more pronounced. There is increased redness 
of the conjunctiva, with some intolerance of light, drooping of the eyelids, and 
a slight muco-purulent discharge, which serves to glue the eyelids together TRACHOMA. 
195 
during the night. If the lids are everted, the nature of the disease will be 
discovered at once by the villous, papillary, or granular elevations which are 
upon the conjunctiva. (Figs. 1841 and 1842.) 
Fig. 1841. 
Fig. 1842. 
Granular conjunctivitis. 
Granular conjunctivitis with enlarged papillse. 
Causes.—Granular conjunctivitis may result from a precedent catarrhal 
or purulent ophthalmia, from exposure to fine dust, from habits of intemper- 
ance, or from exposure to cold and damp currents of air. Badly-ventilated 
apartments, unwholesome food, and uncleanly habits play no small part in the 
production of the disease. Strumous children are often the subjects of this 
form of ophthalmia. When attended with a purulent discharge the disease 
is inoculable. 
Course.—Unless attacked by proper remedies, granular conjunctivitis will 
continue for years, and even when subjected to treatment the progress of 
the disease towards recovery will often be interrupted by fluctuations, during 
which the inflammation will be rekindled and a new deposit of lymph occur 
in the parenchyma of the conjunctival papillae. The neoplastic formations 
or granulations often so preponderate that the characteristic appearance and 
structure of the conjunctiva disappear, leaving a yellowish-white membrane 
composed largely of fibrous or cicatricial tissue, all traces of the normal 
villous or papillary structure having vanished. The follicles and blood- 
vessels participate in the degeneration, and in consequence the membrane 
is deprived of moisture and becomes preternaturally pale. An alteration 
so profound in the nutrition of the conjunctiva cannot fail to affect that 
of the palpebrse, and hence atrophy and distoi’tion of the lids follow, causing 
entropion and all the evils consequent upon the contact of the eyelashes with 
the surface of the eye. Another evil brought about by the friction of the 
lids over the eye is inflammation of the cornea, causing its opacity, and at 
the same time developing a membranous expansion of blood-vessels—pannus 
—over its surface. 
Prognosis.—When application for relief is made early, before advanced 
morbid changes have taken possession of the conjunctiva, a satisfactory ter- 
mination of the disease may be anticipated. Under the most favorable cir- 
cumstances the improvement will be slow, and great patience is required, 
on the part both of the patient and of the surgeon. 
Treatment.—No disease of the body, perhaps, has been so barbarously 
treated as granular ophthalmia. The object being to get rid of the hyper- 
trophied papillie scattered over the conjunctiva, they have sometimes been 
shaven off w7ith the knife and often cut down by potent caustics. To 
such unsurgical procedures, enlarging the extent of cicatricial tissue, the 
morbid alterations of structure in the conjunctivae and eyelids are often 
attributable. 196 
DISEASES AND INJURIES OF THE EVE AND ITS APPENDAGES. 
The indication is to secure the removal of the granulations by absorption., 
not by excision or by destructive cauterization, and to effect this the physician 
is compelled to call to his assistance a certain degree of inflammation. 
In treating cases of granular ophthalmia, attention must first be given to 
the hygienic surroundings of the patient, including well-ventilated rooms, 
wholesome food, cleanliness, and exercise in the open air. If the general 
health is impaired, as is so often the case, great benefit will follow the use of 
cod-liver oil and iodide of iron, or strychnia, quinia, and iron. In patients of 
intemperate habits a mercurial purge will often constitute the best prelim- 
inary measure to other treatment. 
The local applications require to be changed from time to time. The most 
useful agent is the nitrate of silver, applied either in solution or in crayon. 
The strength of the solution will vary from two to twelve grains of the salt 
to one fluidounce of distilled water. The crayon should consist of about one- 
third of the nitrate of silver and two-thirds of the nitrate of potash. The 
applications must be made every second day, the lid being everted and the 
agent restricted to the granulated surface, observing to neutralize the redun- 
dant salt by washing the parts with a lotion of nitrate of potash and thus 
preventing its diffusion over the eye. After using the nitrate of silver for 
a time, it may be desirable to exchange it for some other astringent, the best 
being alum, tannin, acetate of lead, and sulphate of copper. These agents 
can be employed either in the form of an ointment (grs. i to xij, benzoated 
lard, 50 or as a collyrium (grs. i to x, distilled water, fSi). A portion of 
the ointment is to be placed on the inside of the lower lid, trusting to the 
winking movements of the palpebrse for its diffusion. The collyria are best 
applied with a camel’s-hair brush. 
In order to lessen the vascular supply of the granulations and favor their 
atrophy, Buys has strongly advised the use of very finely powdered acetate 
of lead, which is to be packed in between the granulations, filling up the 
interspaces and leveling the surface of the conjunctiva. The redundant 
powder is to be washed off by directing a fine stream of water from a small 
syringe upon the inner portion of the lids, or by douching the parts. This 
application should be repeated once every three or four days. In addition 
to diminishing the supply of blood to the fleshy prominences, it lessens the 
evils resulting from the rubbing or friction of the mucous membrane and its 
papilla against the ball of the eye. The method is a good one, though 
attended for a short time with severe smarting. The absorption of the 
fleshy eminences of the conjunctiva may be hastened by combining local 
alteratives with pressure. Thus, after brushing or penciling the granular 
surface, paint for some time the cutaneous surface of the eyelids with the com- 
pound solution of iodine, rendered unirritating by the addition of equal parts 
of powdered loaf-sugar and gum acacia (aa grs. xxxv, comp, solution of iodine, 
fSi), after which a compress and bandage must be placed over the eye and 
made as tight as consistent with the comfort of the patient. This may be 
worn for five or six hours at a time, and be repeated every second day. 
Dixon commends the liquor potassse as particularly effective in destroying- 
granulations. It is to be freely applied with a camel’s-hair brush. There 
can be no doubt that under the use of such a caustic the conjunctiva can be 
cleared of hypertrophied papillae; but the cicatricial tissue which replaces 
the latter is almost as bad as the disease. 
Should an ulcer make its appearance on the cornea, the acetate of lead 
must not be applied to the eye, as the resulting insoluble chloride of lead may 
form a permanent opaque stain in the cornea. The use of atropia to the eye 
will also be indicated when there exists a corneal lesion, in order to preserve 
the pupil in case an iritis should follow. 
The cornea, under the long and repeated friction of the roughened lids or 
of maldirected cilia, often becomes inflamed and loses its lustre. Blood-vessels 
creep over its surface, forming at length a vascular membrane, with opacity 
or pannus, which seriously impairs the vision. The treatment under these PTERYGIUM. 
197 
circumstances consists in securing the absorption of the granulations as early 
as possible, or of correcting the entropion, when such exists. This done, the 
cornea may recover itself. Permanent opacities, however, too deeply situ- 
ated among the laminae of the cornea to be influenced by sorbefacients, will 
often remain after the granular ophthalmia has disappeared. Sometimes the 
evils of opacity can be overcome by performing an iridectomy. 
In cases of pannus the vascularity of which resists the ordinary caustics 
and astringents, as nitrate of silver, tannin, alum, chlorine-water, etc., and 
when the cornea is covered to an extent which renders vision impracticable, 
Pringer advises inoculation. This has been practiced to a considerable ex- 
tent, both on the Continent and in England, and in many instances with 
favorable results. 
Inoculation is effected by taking pus from a case of purulent ophthalmia, 
preferably from a child suffering with suppurating ophthalmia, and intro- 
ducing it into the eye affected with pannus. The violence of the inflamma- 
tion and suppuration which follow destixtys the vascular veil covering the 
•cornea, and restores in some degree its original transparency. The experi- 
ment. however, is attended with danger, as the inflammation may prove 
intractable, destroying the cornea by suppuration, or occluding the pupil 
with lymph. In consequence of such possible terminations, the best au- 
thorities agree that it is only when the pannus is thick and fleshy, and 
when other measures have failed to remove the obstruction, that it is ad- 
visable to resort to inoculation. Lawson, in order to lessen the danger to 
the cornea, has advised that the inoculation be preceded sometimes by a syn- 
dectomy,—that is, by cutting out a narrow collar of the conjunctiva and sub- 
conjunctival tissue half a line behind and around the entire sclerotico-corneal 
junction,—a practice which has met the approval of other ophthalmologists. 
When inoculation is determined on, it must not be attempted in both eyes at 
the same time: on the contrary, one eye is to be closed and protected against 
the discharge from the eye inoculated. It is undesirable that antiphlogistic 
measures be employed with a view to limit or lessen the induced inflamma- 
tion. Save removing the discharges from the integument beyond the eyelids, 
the disease is allowed to run its course without opposition. 
Pterygium. 
Pterygium consists in a triangular or fan-like expansion of connective tis- 
sue and blood-vessels, its base directed towards the internal cantkus, or semi- 
lunar fold of the conjunctiva, and its apex towards the cornea (Fig. 1843), 
over which it frequently extends, even to a 
point opposite the pupil. In exceptional 
cases this membrane may approach the 
cornea from other quarters of the ocular 
circle. Its deep connection is usually ef- 
fected by fine fleecy threads of connective 
tissue, which allow the pterygium to be 
raised up some distance from the subjacent 
parts. In other instances the membrane 
is planted firmly upon, or even incor- 
porated with, the cornea, as will appear 
by the rough state of the latter when the 
pterygium is removed. The vascularity 
of these growths varies. The fibrous ele- 
ment predominates in some cases, partic- 
ularly in the portion over the cornea, while 
in other instances the blood-vessels appear 
to constitute the major part of the membrane. The preference exhibited by 
this growth for the inner canthus is probably in consequence of this being not 
only the most exposed portion of the conjunctiva, but also the part where, from 
Fig. 1843. 
Pterygium. DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
the duplications or irregularities of the latter membrane, it is most likely to 
retain dust. 
Although seen at all ages, the disease is generally met with in persons 
in late adult life. It may affect one or both eyes. 
The pterygium tenue and pterygium crassum of authors are terms used to 
express the greater or less transparency of the membrane. The triangular 
form characteristic of pterygium is difficult to explain, unless, as has been 
suggested by Arlt, the disease is preceded by a point of ulceration on the 
cornea, the existence of which is followed by a prolongation of blood-vessels 
designed to carry on the work of repair. 
Causes.—Whatever is calculated to develop a very chronic inflammatory 
state of the vessels of the conjunctiva will favor the formation of pterygium : 
hence all irritants, as dust, smoke, the volatile emanations from chemical 
substances, strong sunlight, and different forms of ophthalmia, are included. 
The disease is much more common among those who live in hot climates and 
where there are extensive stretches of sand. 
Treatment.—As long as the membrane encroaches only slightly upon the 
cornea and exhibits no tendency to grow, it may be allowed to remain with- 
out interference; but when it continues to steal upon the cornea, threatening 
to extend so as to constitute an obstruction to the light entering the pupil, 
it should be removed. The operations practiced for the cure of pterygium 
are excision, transplantation, and strangulation. 
Excision.—After etherizing the patient and separating the lids with a 
speculum, the membrane is seized and drawn away from the subjacent parts 
by a delicate pair of rat-toothed forceps; then, beginning at the apex, it is 
dissected carefully away from the cornea either by a cataract-knife or by 
scissors. The cornea being cleared, the membrane should be detached from 
the sclerotic to the extent of one-eighth or three-sixteenths of an inch, ob- 
serving to keep along the upper and lower borders of the membrane, after 
which the lines of incision should converge, meeting at the base of the 
growth, and thus effecting its removal. 
(Fig. 1844.) Two or three fine silk 
sutures are next passed through the 
borders of the conjunctival wound and 
the chasm closed, the ends of the su- 
tures being brought out at the internal 
canthus and attached to the root of 
Fig. 1845. 
Fig. 1844. 
Lines of incision for removing pte- 
rygium ; also form of wound and posi- 
tion of sutures. 
Strangulating pterygium. 
the nose. A binocular bandage is next applied, and this may be allowed 
to remain until the third or fourth day, when it is to be removed, together 
with the sutures. 
Strangulation—the operation of Szokalski—is performed by passing two 
double ligatures beneath the pterygium (Fig. 1845), and, after cutting away 
the needles, tying the threads firmly together in order to cut off the vascular XEROPHTHA LMIA. 
199 
supply and cause the death of the membrane,—the work usually of five or 
six days. 
Transplantation.—In this operation the pterygium is dissected up from the 
cornea and sclerotic inward to its base, and, after closing the sides of the 
wound with two or three fine stitches, a horizontal incision is made in the 
conjunctiva below, into which the pterygium is thrust and there secured by 
one or two sutures. As this operation is adapted more especially to a large 
pterygium, the cord-like ridge which results from its one-sided transplanta- 
tion will mar somewhat the appearance of the eye. This may be avoided 
by the modification recommended by Knapp, which consists in dissecting up 
the growth from the cornea and sclerotic, cutting off its corneal part, and, 
after splitting the sclerotic portion, turning each half into an opening made 
into the conjunctiva above and below the pterygium, and closing the wounds 
thus made by sutures; or the pterygium, after being dissected back, may be 
turned inward on itself, secured by a fine stitch, and the sides of the incision 
closed by two or three sutures. 
Operations for the removal of a pterygium are too often unsatisfactory. 
Sometimes there is a return of the neoplastic membrane; frequently the sur- 
face of the cornea from which the membrane has been shaven is left, after 
repair has been completed, more or less opaque; and sometimes the granula- 
tion-tissue, which arises on the surface from which the pterygium has been 
excised, is changed into a dense cieati’icial membrane, the contraction of 
which, in the coux-se of time, restricts very much the movements of the ball 
of the eye. 
Xerophthalmia and xerosis are terms used to express a cicatricial degen- 
eration of the conjunctiva, characterized by a white, thickened, tendinous, 
shrunken, rough, and dry appearance of that membrane. The absence of 
moisture is caused by the loss of the muciparous glands, which have, in 
common with the other components of the conjunctiva, participated in the 
destructive process. The contracted and unyielding nature of the scleral 
part of the conjunctiva causes it, during the movements of the ball of the 
eye, to fall into concentric ridges around the cornea. 
The disease affects both the tarsal and the ocular conjunctiva, and is accom- 
panied generally with some atrophy of the tarsal cartilages; and, as the 
atrophic contraction in time obliterates both the retrotarsal and the semi- 
lunar folds of the conjunctiva, the latter is reflected from the sclera to the 
eyelids so directly that the palpebrse are very much restricted in their move- 
ments. This difficulty is sometimes further increased by a fine, thread-like 
false band passing between the ball of the eye and its lids. This limitation of 
palpebral mobility favors the retention of the conjunctival epithelium, which 
becomes dry and accumulates in the posterior part of the false conjunctiva 
at the angle of reflection from the sclera to the cartilage. The cornea also 
becomes hazy, and at length opaque, partly from the alteration of its epithe- 
lial layer and partly from infiltration of its superficial lamin®. The sensi- 
bility of the conjunctiva and cornea is lowered to a degree which renders 
them almost indifferent to external impressions or irritants. The patient is 
much annoyed with a feeling of heat and dryness of the eyes. Persons in 
whom the disease has existed for some time cannot shed tears. 
Causes.—Xerophthalmia is the result usually of long-continued ophthalmia, 
especially of the granular form. In not a few cases there is reason to be- 
lieve that the cicatricial degeneration was fairly attributable to the severe 
cauterizations employed in the treatment of trachoma. Diphtheritic oph- 
thalmia, scalds, trichiasis, or indeed any long-continued irritation, may give 
rise to xei-osis. 
Treatment.—When the disease is limited to the sclerotic and palpebral 
conjunctiva, and is so slight as to implicate only the epithelial portions of the 
membrane, the case can possibly be benefited b}r supplying moisture to the 
Xerophthalmia. 200 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
eye. The best substances for the purpose, on account of their bland nature, 
are tepid milk and glycerin. Either of these agents, or both alternately, 
can be instilled between the lids twice or thrice daily. When the xei-osis 
extends over the cornea, or involves the deeper elements of the conjunctiva 
and subconjunctival tissue,—parenchymatous xerophthalmia, as it has been 
tei-med,—all remedies are valueless; the case is hopeless. 
Attempts have been made by a number of German ophthalmologists to 
overcome the difficulty by cariying into effect the suggestion of Wolfe, that 
of transplanting to the diseased eye healthy conjunctival tissue from the 
ejre of a rabbit. Although the results of these experiments have been deemed 
encoux-aging by their advocates, they certainly have not been so l’egarded by 
ophthalmologists at large. 
The lachrymal caruncle, a group of sebaceous glands situated at the in- 
ternal canthus of the eye, is sometimes the subject of a disease designated 
encanthis (lv, “ in,” “ angle”). Except in the position of the enlarge- 
ment, there is nothing significant in the name. The caruncle may become 
hypertrophied, either in consequence of an inflammatory deposit in the in- 
terlobular connective tissue, or from proliferation of the glandular elements. 
(Fig. 1846.) The disease is very common in horses, and has usually an 
inflammatory origin. The caruncle belongs properly 
to the lachrymal passages, serving by its secretion to 
keep the puncta lacrymalia in a soft, pliable condi- 
tion, and to direct the tears towards their canals: 
hence whatever tends to produce disorder in the tear 
apparatus will favor disease of this body. The morbid 
conditions most commonly encountered are hypertro- 
phy and carcinoma. The former, arising in most in- 
stances from inflammation, either primarily in the 
follicles, or secondarily by extension from some part 
of the lachrymal passages, may be relieved by local 
antiphlogistics, as leeching, astringent washes, nitrate of silver, or sulphate 
of copper. When the glands become the seat of carcinoma, indicated by the 
presence of a hard, irregular, livid, and rapidly-growing mass, extirpation 
should be done early and thoroughly, notwithstanding a return of the disease 
may be anticipated. 
Encanthis. 
Pig. 1846. 
Encanthis. 
Tumors of the Conjunctiva. 
Pinguicula.—This neoplasm, named from its fatty appearance, although it 
contains no adipose matter whatever, is a small, flat, yellowish-white bod}’, 
composed of connective tissue and covered with enlarged vessels. The 
growth is situated in the sclerotic conjunctiva, near the outer or the inner 
border of the cornea. It is not accompanied by pain or other uneasiness. 
It occurs in the aged much moi’e frequently than in the young. Once 
foi’med, the neoplasm exhibits no tendency to increase, but will pi-obably re- 
main stationaiy as long as the individual lives. Local irritation from various 
foi'eign matters is regarded as the determining cause of the growths, and, as 
they rarely gi'ow to any size, or cause any trouble to the eye, no operation 
for their removal is required. 
Lipomata of the conjunctiva are rarely seen, and when present generally 
have a congenital origin. When these growths appear, they manifest a de- 
cided preference either for the upper and outer pai’tof the ocular conjunctiva, 
or for the sulcus between the lower lid and the ball of the eye. In appear- 
ance they possess the same ehai*acteristies as adipose neoplasms elsewhere, 
being lobulated, elastic, and painless, and having a yellowish coloi\ 
Treatment.—In the event of their growing, lipomata should be removed TUMORS OF THE CONJUNCTIVA. 
201 
early. This is easily done by separating the eyelids widely, and, after making 
an incision into the conjunctiva over the growth, seizing the tumor with a 
pair of forceps and shelling it out with the back of the knife or the curette 
end of a director. 
Membranous Lipomata.—A dense membranous fold of the conjunctiva, in- 
cluding a considerable amount of fat, is sometimes seen in new-born children, 
at the inner canthus of the eye, resembling the nictitating membrane of 
birds. 
The treatment consists in excising the redundant fold, sutures having been 
previously introduced in order to bring together the edges of the wound. 
Polypi arc small, flesh-like, pedunculated growths in the conjunctiva, not 
often reaching the size of a pea, and generally arising at or near the inner 
canthus of the eye. These growths consist chiefly of connective tissue. 
Possessing a pedicle, which allows them to move about, they are necessarily 
prone to develop local irritation and inflammation of the conjunctiva. 
The proper remedy is to seize the tumor with a pair of forceps, place the 
pedicle on the stretch, and then clip it off at the place of its attachment to 
the conjunctiva, at the same time cauterizing with nitrate of silver the 
surface from which it sprang. 
Cystomata are met with both in and beneath the conjunctiva. The}’ are 
not confined to the ocular portion of the membrane, but occasionally are seen 
on the palpebral surface. These cysts vary in size from that of a pea to that 
of a cherry-stone, although in some instances they have attained a much 
larger size, growing into the orbit and causing displacement of the eyeball. 
In form these tumors are round, and, under a favorable light, sometimes 
translucent. The wall of these cysts is formed either by condensation of 
the connective tissue of the conjunctiva or from one or more follicles of the 
part, the contents being fluid and having a thick, ropy consistence. 
These growths should be removed, taking care to extirpate the entire cyst, 
otherwise there will be danger of recurrence. 
Warts occasionally appear on the conjunctiva as small, round, or irregular 
spongy growths, having a slightly reddish color, and may be seated on any 
portion of the scleral or palpebral surfaces. They excite inflammation of the 
conjunctiva, and should be removed by excision, touching the raw surface 
with a crayon of nitrate of silver. 
Dermoid Tumors are congenital. They are seated generally over the 
sclerotico-corneal region, possess a white, slightly red, or very faint yellow 
color, seldom exceed an apple-seed in size, and usually have a uniform or 
smooth surface, rising often only a little above the level of the cornea, al- 
though in some instances the growth is quite prominent and conical in shape. 
These tumors consist of the ordinary components of skin,—namely, connective 
tissue, fat, sebaceous glands, and hair. The latter is often seen growing from 
the tumor. , 
Excision is the only remedy, and can readily be effected by grasping the 
tumor with a pair of rat-toothed forceps, pulling it forward, and shaving it 
off, with a keen-edged bistoury or cataract-knife, on a level with the cornea. 
The base of the growth, as a rule, is implanted in the laminae of the cornea, 
and it would be unsafe to carry the incision deeper into its structure. The 
granulation- or reparation-tissue which arises from the surface of the cornea 
after the operation, when once cicatrized, necessarily leaves a degree of opacity 
which will never disappear. 
Cysticercus is generally met with in the humors of the eye, though occa- 
sionally it is seen beneath the conjunctiva, both palpebral and ocular. Al- 202 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
though in some respects resembling ordinary barren cysts in this region, yet 
in cysticercus the white mass which constitutes the head and neck of the 
hydatid can usually be discerned through the inclosing cyst-wall, whereas 
in the ordinary cyst the wall is so thin, the contents so transparent, and 
the overlying conjunctiva so attenuated and so free from blood-vessels, that 
no opacity at any point will be discovered. 
This entozoon is derived from diseased or measly pork, and will be found 
most common among people who indulge largely in the flesh of swine, as in 
the north of Germany. The risk from the use of such food can only be 
avoided by thoroughly cooking the meat before using it. 
Tbe remedy for cysticercus is excision. 
Epithelioma.—The conjunctiva is seldom the primary seat of epithelial 
cancer. In most cases the disease extends to the mucous membrane by con- 
tinuity of tissue from the palpebrae, on the edges of which this variety of 
carcinoma is quite common. The disease appears in the conjunctiva as a 
little nodule or excrescence, at first not differing in color ft-om the membrane 
in which it is seated, but later becomes red, more irregular on its surface, 
and finally terminates in the formation of fungous granulations, from which 
a discharge more or less purulent occurs. As the epithelioma enlarges, the 
area of mischief extends by cell-infiltration beyond the limits of the con- 
junctiva, and in time invades the cornea, producing opacity and ulceration, 
and destroying, by installments, the entire organ. Sometimes the disease 
destroys all the fat, connective tissue, and muscles, leaving the ball of the 
eye untouched and standing solitary in the orbit. 
Epithelioma commences in the epithelial cells of the conjunctiva, the pro- 
liferation of which is followed by a similar activity in the cell-forms of the 
connective tissue of the membrane. 
Treatment.—An early removal of the morbid growth by the knife is ex- 
ceedingly important, observing to close up the resulting wound by fine silk 
sutures. When the disease has implicated the cornea, penetrating the dif- 
ferent laminae of that structure, nothing short of the complete extirpation of 
the ball of the eye will be productive of any benefit. 
Encephaloid Cancer as a primary affection of the conjunctiva is uncommon, 
it being generally, as in epithelioma, secondary to the disease in the lids or 
ball of the eye. 
Sarcoma.—This neoplasm is occasionally seen in the palpebral and ocular 
conjunctiva. When originating in the latter, 
the disease appears to have a preference for the 
sclerotico-corneal region. Both the round and 
spindle-cell varieties are met with in this part, 
and are occasionally mixed with a melanotic 
element. These tumors may remain apparently 
stationary for a considerable time, and then 
without appreciable cause commence to grow 
rapidly, not only destroying the structures of 
the eye, but extending to the bones of the orbit, 
into the adjacent sinuses, and even into the 
brain. 
Fibromata of the conjunctiva are exceed- 
ingly rare. In the very few instances noticed, 
the growths commenced near the commissure 
of the eyelids. The tumors were oval in form, 
firm and inelastic in consistence, and had a 
grayish-white color. (Fig. 1847.) 
Treatment.—Early excision and subsequent closure of the wound in the 
Fig. 1847. 
Fibroma of lower lid. CONJUNCTIVAL ECCHYMOSIS. 
203 
conjunctiva by delicate interrupted silk sutures constitute the proper treat- 
ment. 
Angeiomatous or Vascular Growths are frequently seen in the conjunctiva, 
commencing originally in the membrane, or extending to it from the tegu- 
mentary covering of the lids. When seated in the conjunctiva, the disease 
exhibits a partiality for the inner canthus, and is frequently congenital. 
Nsevi in which the arterial element predominates may be easily recog- 
nized by the circumscribed mass of tortuous interlacing vessels, which be- 
come distended and swollen under any unusual excitement, as crying, cough- 
ing, and the like, and also by the red color of the enlargement and the 
presence, in some cases, of pulsation. 
Conjunctival tumors or swellings having a blue color are made up chiefly 
of tortuous, dilated veins,—phlebectasia, varices. They are frequently in- 
fluenced much by position, subsiding in the recumbent and reappearing in 
the erect or the bending-forward posture. These enlargements of the venous 
trunks are usually symptomatic of obstruction, either in the cavernous 
sinuses or in the ophthalmic vein. (See Angeiomata, vol. i. page 600.) 
Treatment.—Ntevi of the conjunctiva should be removed as early as pos- 
sible, either by excision, when small, bringing the wound together by fine 
sutures; or, when large, by seizing the growth with forceps, drawing it for- 
ward, and transfixing the underlying healthy membrane with a delicate 
needle bearing a double thread, by tying which the two halves are strangu- 
lated. The ends of the ligatures may be either cut oft* or brought out between 
the eyelids. During the time required for the separation of the namis the 
eyelids should be covered with compresses of cold water, in order to counter- 
act inflammation. 
Glandular Concretions.—In the Meibomian and also in the other glands of 
the conjunctiva will sometimes be observed small white bodies, round and 
elongated, quite firm to the touch, which, rising above the level of the mem- 
brane, cause considerable irritation and conjunctivitis. These bodies are 
masses of inspissated secretions which collect in the glands and contain a con- 
siderable amount of lime. This condition has been termed lithiasis. The 
disease is most common in advanced life, and is closely akin to that of reten- 
tion cysts. The accumulation is not the result of obstruction, but is due to 
changes in the character of the glandular secretion, in which there is a pre- 
ponderance of the lime-salts present. 
Treatment.—This is quite simple, and consists in dividing the conjunctiva 
over the enlargement and scooping out the hardened secretion. 
Ecchymosis of the conjunctiva is of frequent occurrence. It may be cir- 
cumscribed or diffused. When the former, it is often the result of violent 
coughing or vomiting, a vessel of the ocular conjunctiva having given way 
in consequence. Operations upon the eye, especially those for squint, are 
often followed by subconjunctival extravasations of blood. 
Diffused ecchymosis arises usually from traumatic causes, as blows, fracture 
of the orbital plate of the frontal bone, or, indeed, any fracture which pene- 
trates the orbit. This variety of ecchymosis is regarded as diagnostic of a 
lesion at the anterior part of the base of the brain ; but there are many ex- 
ceptions to this rule. The blood in traumatic cases, at least in those in which 
the bony walls of the orbit have been involved, reaches the eye behind the 
retrotarsal folds, and gradually travels forward beneath the mucous mem- 
brane until it reaches the cornea, around the circumference of which it 
spreads. 
Treatment.—Time alone is sufficient for the absorption of these extrava- 
sations, although the process may be somewhat facilitated by stimulating 
lotions of alcohol and water applied by compresses over the eye, assisted by 
the pressure of a bandage. 204 
DISEASES AND INJURIES OF THE EVE AND ITS APPENDAGES. 
(Edema, or Chemosis, of the conjunctiva is among the common phenomena 
of inflammatory affections of the eye, particularly in purulent and gonor- 
rhoeal ophthalmia. Any condition which offers an obstruction to the escape 
of the venous blood from the eye, such, for example, as the formation of a 
clot in the cavernous sinus of the brain, following pyaemia, tumors of the 
orbit, or an injury of the head, may give i*ise to this condition. There is, 
however, a slight oedema which is seen in persons advanced in life, and 
which may with propriety be regarded as idiopathic. In Bright’s disease 
the conjunctiva is often the seat of serous accumulations in common with 
other parts of the body. 
Treatment.—Should the oedema not disappear spontaneously, and if it is 
sufficiently great to render interference necessary, some relief can be obtained 
by dropping on the eye a stimulating collyrium of sulphate of zinc or ace- 
tate of lead. It is only in extreme cases that the necessity for puncturing 
or incising the swollen conjunctiva will arise. 
Emphysema of the conjunctiva may follow a fracture of the os unguis, or 
an opening in the lachrymal sac, the air passing from the nose into the sub- 
conjunctival connective tissue. The crackling sound elicited on pressure 
will reveal the nature of the swelling. 
Treatment.—The air will be absorbed after the closure of the lesion in the 
sac, or the bone, rendering any local treatment unnecessary. Should the 
swelling not be removed in time, which is extremely improbable, the mem- 
brane may be punctured and the air allowed to escape. 
Amyloid Disease of the conjunctiva has recently been recognized by Leber 
and others. The palpebral conjunctiva suffers more frequently than the 
ocular. In addition to the swollen state of the eyelid, the conjunctiva is 
thickened by the lardaceous infiltration, although the vascularity of the 
membrane is very slight. The verity of the disease may be established by 
applying the test of iodine and sulphuric acid to a portion of the mucous 
membrane, excised for the purpose, when the violet, succeeded by the brown 
color, will appear in case the disease is truly amyloid. This curious affection 
is one of the results of granular conjunctivitis. 
Excision of the degenerated portion of the conjunctiva is the only remedy. 
Recurrence of the disease is improbable. 
Stains of the Conjunctiva.—Long-continued use of nitrate of silver as a 
collyrium in affections of the eye is often followed by a brown discoloration 
of its tissues. 
Considerable improvement can be effected by using a strong solution of 
the sulphite of soda (grs. xl, water, fgi). The best method of applying the 
remedy is by means of an eye-glass, which, after being two-thirds filled with 
the liquid, is to be turned upon the open eye every day. 
Keratitis.—It is only by being acquainted with the normal appearance of 
the cornea that the surgeon can properly appreciate slight deviations from 
a healthy condition of tins tunic. The cornea, when free from all disease, is 
perfectly transparent, smooth, and has a brilliant lustre. 
Symptoms.—Among the earliest effects of inflammation of the cornea is 
the loss of normal smoothness and lustre. It becomes hazy. From the cii-- 
cumference of the cornea, or sclerotic line, there extends a complex net- 
work of extremely fine vessels forward into the cornea. With the vascular 
extension the opacity spreads from the periphery towards the centre of 
the cornea, sometimes covering the entire membrane with a thick vascular 
veil, in which may be distinguished, by using a glass, two sets of vessels, the 
DISEASES OF THE TUNICS OF THE EYE. KERATITIS. 
205 
one venous and the other arterial,—the former being a prolongation of the 
veins of the conjunctiva, arranged in the form of a net-work, and the latter 
consisting of straight arteries, derived from the circle of vascular inosculation 
located at the periphery of the cornea. 
This fibro-vascular expansion constitutes the affection known as pannus. 
Two forms are recognized by systematic writers.—viz., pannus crassus (Fig- 
1848) and pannus tenuis. The differ- 
ence consists only in the relative vas- 
cularity and thickness of the opacity. 
Along with the other symptoms, 
one or many vesicles or phlyctenulae 
appear, scattered over the surface of 
the cornea, and located either be- 
neath the epithelium or deeper in the 
superficial layers of the cornea, and 
are likely to terminate in the forma- 
tion of superficial ulcerations of a 
yellow or grayish-yellow color. Ac- 
companying the disease, particularly 
when pursuing an acute course, there 
is a certain degree of intolerance of 
light, and an unusual flow of tears. 
Keratitis is for the most part a dis- 
ease of childhood, not often seen after 
the period of adolescence. It does not 
appear in subjects of strong, vigor- 
ous constitutions, but in those who 
are feeble, pale, sickly, and suffering 
often from enlargement of the lymph-glands of the neck. The disease is 
not always confined to one eye, but often attacks the other, either early 
during its progress in the first, or, what is more common, after the first has 
commenced to improve. 
Pathology.—The opacity observed at the commencement of the kera- 
titis is due to the presence of a new formation of cells grouped together be- 
neath both the epithelium and the elastic membrane of the cornea. These 
cells, assuming spindle forms, eventually develop into connective tissue. The 
blood-vessels derived from those of the conjunctiva, and also those of the sub- 
conjunctival tissues, occupy the same localities as do the cell-forms. In well- 
pronounced cases of pannus it is not uncommon to notice yellow spots in the 
opacity. These indicate the commencement of retrograde or fatty changes 
in the neoplastic formation, which foreshadow a serious structural altera- 
tion or softening of the layers of the cornea. The phlyctenulce are minute, 
conical, circumscribed infiltrations, which, by detachment of the epithelium 
or by softening of the superincumbent lamina3 of the cornea, become points 
of ulceration. 
Causes.—Among the most notable causes of keratitis are the different 
forms of ophthalmia, particularly the granular. The irregularities of the 
tarsal conjunctiva in the latter disease create, by rubbing over the cornea, a 
constant irritation. While local influences no doubt play a prominent part, 
constitutional peculiarities cannot be ignored as factors in the causation of 
the disease, strumous subjects being most commonly the ones who suffer 
from this affection. 
Prognosis.—The issue or termination of keratitis will depend on the age 
of the patient and the severity of the attack. In young subjects, where the 
inflammation is subacute and treatment has been adopted early in the 
disease, a favorable termination may be anticipated. When, however, the 
keratitis has been of an acute nature, the patient over fourteen or fifteen 
years of age, and the disease allowed to progress without treatment for some 
time, the outlook is far from favorable. The phlyctenular ulcerations may 
Fro. 1848. 
Pannus. 206 
DISEASES AND INJURIES OF THE EVE AND ITS APPENDAGES. 
heal, but in their place are left points of cicatricial tissue, which, together 
with a similar material, the product of inflammatory infiltration below its 
lamime, cause numerous opacities over the cornea, which must necessarily ob- 
struct the entrance of light. Jn addition to the defect of vision arising from 
these material obstructions there is one which results from change in the 
curvature of the cornea, in consequence of which there follows an error of 
refraction which cannot be overcome by artificial measures. 
Treatment.—Keratitis, under the most favorable circumstances, will prove 
a tedious affection. The remedies employed must be both constitutional and 
local. The intestinal secretions, if disordered, must be corrected by a mild 
aperient, after which the tincture of the sesquichloride of iron or the iodide 
of iron should be administered, in many instances with cod-liver oil, at the 
same time directing a generous but unirritating diet and keeping the child 
out in the open air whenever the weather will permit. 
The local remedies which possess peculiar value are atropia instilled in the 
eye, with frequent applications of warm water over the lids, brows, and 
temples, or, if the lids are hot and the eye very irritable, cold water fre- 
quently renewed. Should the atropia cause any irritation, it may be replaced 
by softening the extract of belladonna with a little water and smearing it 
freely over the brows. The experiments made by Dr. Williams, an eminent 
oculist of Boston, tend to show that intolerance of light and the phlyctenular 
eruptions are often greatly benefited by the use of the sulphate of eserine, in 
the proportion of one or two grains to the fluidounce of water. The same 
authority, in order to relieve these conditions, has employed with success 
the hydrochlorate of pilocarpine, two or three grains to the fluidounce of 
water. 
After the acute symptoms have been subdued and the disease is on the 
decline, the transparency of the cornea and the prevention of new crops of 
herpes will be promoted by the use of calomel dusted upon the eye. 
There is a variety of inflammation of the cornea called fascicular keratitis, 
which occurs in very much the same class of patients as those subject to the 
affection just described. 
The distinguishing characteristics of the disease are increased vascularity 
of the ocular conjunctiva, with a prolongation of vessels, venous and arterial, 
which run forward on the cornea parallel with one another. At the anterior 
termination of this fasciculus of vessels the cornea appears to be a little raised, 
and beneath there will be seen an infiltration of a gray color, over which 
after a time the epithelium is detached and a shallow ulcer forms. At the 
commencement of the disease, and to some extent during the entire active 
stage, the eye is inordinately sensitive to light and the lachiymation profuse. 
There may also be present a few phlyctenulae, situated near the sclero- 
corneal juncture. 
The treatment does not materially differ from that employed in ordinary 
keratitis,—namely, atropia applied to the eye once or twice daily, and, as soon 
as the inflammatory symptoms begin to abate, the insufflation of calomel. 
An ointment consisting of the yellow oxide of mercury (grs. ij-iij, cold cream, 
3ss) sometimes proves more efficacious than the calomel, although more liable 
to cause irritation, should the acute symptoms not have subsided. Cod-liver 
oil, tincture of iron, sunlight, fresh air, and a liberal diet, are all to have a 
large place in the treatment. 
Suppuration or Abscess of the cornea, sometimes termed suppurative kera- 
titis, is one of the results of inflammation of the cornea, although certain 
writers believe that pus may form in this tunic independently of inflam- 
mation, an opinion in which I do not concur. 
Symptoms.—Suppurative keratitis, when of an acute character, commences 
with the ordinary signs of conjunctivitis, possibly accompanied by some 
cedema or chemosis, and with great intolerance of the eye to light, lachry- 
mation, and ciliary neuralgia. The vessels, which in other forms of keratitis INTERSTITIAL KERATITIS. 
207 
creep over the cornea, are seldom seen extending any distance over this 
tunic. A grayish-white infiltration is seen in some portion of the cornea, at 
first circumscribed, but if the disease be not checked it becomes more diffused. 
The inflammatory exudation in a short time changes, assuming a light- 
yellow color, and may be superficial or between the deeper laminte of the 
cornea. Both the primary transudation and the purulent degeneration which 
follows tend to spread towards the lower half of the cornea, the result, prob- 
ably, of gravity. Not infrequently the infiltration occupies separate points, 
and subsequently coalesces. 
The course of the keratitis varies in different cases. In the most favorable 
the infiltration undergoes a retrograde change, and is gradually absorbed, 
leaving the translucency of the cornea almost normal. This change is usually 
foreshadowed by the infiltration losing its yellow appearance and becoming 
gray, thus resembling the first infiltrate. In some instances the termination 
is not so fortunate, the infiltration finding its way between the laminfeof the 
cornea to the lower part of the tunic, and leaving a dense Avhite spot,— 
lunula,—which becomes serious according to the extent of the cornea involved, 
or approaching so near its anterior surface as to produce loss of the epithe- 
lium and form a superficial ulcer; or the abscess may destroy the posterior 
laminae of the cornea and open into the eye, the purulent matter gravitating 
to the lower part of the anterior chamber,—hypopyon. The opacities left in 
the midst of the laminae of the cornea from suppurative keratitis may be 
expected to remain, and when situated in front of the pupil will cause blind- 
ness. Perforation of the cornea and pi'olapse of the iris are also among the 
accidents attending the disease. 
Causes.—Suppuration of the cornea may follow any of the forms of oph- 
thalmia, when severe; or it may arise from various traumatic injuries, acci- 
dental or operative. Paralysis of the ophthalmic branch of the fifth nerve, 
by lessening the sensibility of the eye and thus leaving the organ defenseless 
against foreign irritants, is another cause of the disease. 
Treatment.—In robust, vigorous patients, the abstraction of a little blood, 
by means of leeches applied near the internal angle of the eye, or by cups 
over the temples, may be very cautiously ventured upon ; but generally such 
measures are and in subacute cases they are positively danger- 
ous. The local remedies are atropia dropped on the eye twice daily, hot 
fomentations of chamomile-flowers or hops, and a small blister applied to 
the temporal region. When the pain is great, the use of anodynes will be 
indicated. Little benefit can be expected from puncturing the cornea in 
order to evacuate the purulent matter: its diffusion and the manner in which 
it is encased between the laminae of the tunic do not admit of its discharge 
by such a measure. When, however, the infiltration is large and threatens 
external ulceration, or when an opening has taken place posteriorly and the 
pus has found its way into the anterior chamber, paracentesis, the opening 
being made below, by relieving the intraocular tension, will be productive 
of excellent results. 
Tonics, and even stimulants, may become necessary with a view to coun- 
teract the tendency to sloughing of the cornea. 
The opacity which so frequently remaips after attacks of suppurative 
keratitis, and which seriously obstructs vision, can often be overcome by an 
iridectomy, making an opening in the iris at a point opposite to a clear or 
undamaged portion of the cornea. 
If perforation of the cornea occurs, there will follow prolapse of the iris, 
the protruding portion of which should be clipped off, the eyelids closed, 
and a bandage applied in order to support the ball and favor the adhesion 
of the iris to the sides of the opening in which it is engaged. 
Interstitial Keratitis.—This form of keratitis is chiefly remarkable for the 
depth and diffusion of the opacity. The vascularity of the cornea is some- 
times very marked in this disease, while at other times few, if any, vessels 208 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
can be discovered. The vessels, when present, come from the vascular zone at 
the corneo-sclerotic line. They penetrate the deeper laminae of the cornea, 
advancing towards the centre, are extremely closely set, and are accompanied 
by a cloudy infiltration or opacity, the density of which lessens from the 
circumference forward, and is seldom uniform, being thicker at some points 
than at others; or it may pursue the reverse order, beginning anteriorly and 
spreading backward. In not a few instances of the disease the opacity 
spreads through the cornea, little or no antecedent vascularity being dis- 
coverable. So dense may be the interlamellar infiltration that objects can 
be seen only as shadows. Intolerance of light, and increased lachrymation. 
are often but not invariably present. The surface of the cornea may recover 
its polished appearance after a considerable time, though often the nutrition 
of the membrane becomes so disturbed by the diffusion of the infiltrate that 
the displacement and irregular detachment of the epithelial layer impart 
to the surface of the tunic a roughened appearance. Both the vascularity 
and the opacity exhibit a marked predilection in many cases for the upper 
part of the cornea. Not unfrequently with the keratitis there exists an 
iritis. 
The class of subjects who most commonly suffer from interstitial keratitis 
are children under five or six years of age and young persons under eighteen 
or twenty. 
Interstitial keratitis is seldom seen independent-of inherited constitutional 
vice, either strumous or syphilitic. When arising from the latter, its parent- 
age is often revealed by its affecting both eyes simultaneously, and, as 
has been particulai’ly pointed out by Mr. Hutchinson, by coexisting de- 
formity of the permanent teeth, which are stumpy, atrophic, and notched. 
The central incisors of the upper maxilla exhibit most fully these peculiari- 
ties. In addition to these dental irregularities, and even they are 
absent, there is a striking physiognomy, the face being marked by scars 
and cicatricial depressions, the mouth puckered with fissures about the com- 
missures of the lips, the features shrunken, and the countenance having an 
appearance of premature age. 
Course of the disease.—Interstitial keratitis is very slow in its progress, 
often extending over two or three months. Yet, unpromising as the opacity 
appears to be, there is little danger of ulceration or suppuration, and it is 
astonishing to what extent the cloudiness at length disappears, leaving the 
patient with a fair degree of vision. 
Treatment.—No treatment will cut short the disease. It will pass through 
certain stages in defiance of all remedies. Yet much can be done in the way 
of carrying the patient safely through these stages with a minimum amount 
of damage to the tissues of the cornea or iris. The subjects of the disease, 
having a faulty nutrition, will not bear antiphlogistic or depressing treat- 
ment, but require a tonic and alterative plan of management. The iris is to 
be protected by the local use of atropia upon the eye, or by the free use of 
extract of belladonna smeared over the brow. All strong lights are to be 
withdrawn, and the organ shielded against dust and wind. Iodide of potas- 
sium, alternating with iodide of iron and cod-liver oil in conjunction, are the 
most valuable internal remedies. The disappearance of the opacity is has- 
tened somewhat by the insufflation of calomel. These remedies, with a good 
diet and fresh air, promise the most satisfactory results in ordinary cases of the 
disease. Should the iris become implicated, the instillation of atropia must 
be made two or three times a day, and fomentations of hot water frequently 
applied over the eye. If the inflammation is not soon brought under con- 
trol, it will be proper to lessen the intraocular tension by performing para- 
centesis. It is under the same conditions, and when, from the diminution 
of sight, it is apparent that the structure of the iris is endangered, that 
iridectomy can be done with positive benefit. 
Ulcers of the Cornea arise from various causes, and demand great judgment ULCERS OF THE CORNEA. 
209 
and care in their management. They are not peculiar to any age, though 
most common in the young. The local irritation which they produce varies 
greatly, sometimes being accompanied with intense photophobia, profuse 
lachrymation, and ciliary neuralgia, and at other times being singularly free 
from such phenomena. 
Ulcers of the cornea usually appear first as slight opacities, followed by 
superficial or deep excavations, round, oval, and sometimes irregular in form, 
with smooth and sharply-defined or ragged edges. A few straggling vessels 
will often be seen stretching from the cir- 
cumference of the cornea across to the 
border of the sore. (Fig. 1849.) The 
reparation of the ulcer is accompanied 
with some opacity. 
Saemisch and other writers notice a form 
of corneal ulceration—crescentic or serpigi- 
nous— which commences near the cir- 
cumference of the cornea, and gradually 
travels around the membrane. This ulcer, 
usually met with in males, is exceedingly 
dangerous and intractable, being often 
little affected by treatment, and likely to 
destroy the cornea by sloughing, and to 
end in the loss of the entire’ eye. 
The danger attending ulcers of the cornea 
is in proportion to their depth and to the 
impairment of the constitution. Although the internal elastic layer of 
the cornea appears to possess a remarkable power of resisting ulcerative 
action, it is sometimes perforated in common with the superincumbent 
laminre and the anterior chamber of the eye opened, followed by prolapse 
of the iris; or should the elastic lamina remain intact after the overlying 
layers of the cornea have been destroyed, it is likely to pass through the 
aperture and form a small transparent sac or hernia filled with the aqueous 
fluid. 
Superficial ulcers of the cornea may readily be overlooked unless the eye 
is exposed to a favorable light and the observer views its surface at an angle 
or from the side, or while standing behind the patient and looking over his 
shoulder, the eyelids at the same time being separated and the ball directed 
downward. The use of oblique illumination, reflecting the rays of light by 
means of the ophthalmoscopic mirror, will also reveal any loss of substance 
which may have taken place in the cornea. 
Causes.—Ulcers of the cornea are frequently observed among the protean 
manifestations of struma, tuberculosis, and the different varieties of oph- 
thalmia. There is also a causal connection between injuries of the fifth pair 
of nerves and corneal ulceration. Traumatic violence frequently produces 
similar lesions. 
Treatment.—The treatment of corneal ulceration must be determined by 
the severity of the inflammation and the constitutional vigor of the patient. 
In a case where the local inflammation is pronounced and the general system 
unimpaired, antiphlogistic remedies and regimen will be demanded. An 
active purge, followed by a few leeches over the temple, and the exclusion of 
light and dust, together with a restricted diet, will result in an immediate 
amelioration of the local symptoms and a favorable change in the appear- 
ance of the ulcer. After arresting the destructive process it may be necessary 
occasionally, or once in three or four days, to touch very lightly the surface 
of the sore with the mitigated nitrate of silver. 
All preparations of lead are to be eschewed in the treatment of corneal 
ulcers, as the chlorine derived from the tears combining with the lead forms 
an insoluble chloride, which is likely to remain as a dense white opacity, 
impenetrable by light. The instillation of atropia into the eye must not 
Fig. 1849. 
Ulcers of the cornea.  DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
be overlooked whenever intolerance of light, lachrymation, or pain is 
pi’esent. 
Ulcers following traumatic injury, in healthy persons, heal with no other 
treatment than covering the eyelids with a pledget wet with lukewarm 
water and securing it with a monocular bandage. In cases, however, where 
the patient is debilitated and the recuperative forces are feeble, or where 
scrofulosis is intrenched in the sj’stem, difficulty will be experienced in 
curing these ulcerations. In such it is of paramount importance that the 
sore be aroused from its chronicity. If a few vessels concentrate on its 
border, all the better; they must he cherished, not destroyed, as they 
furnish the material for the work of repair. In cases where the ulcers 
remain indolent, exhibiting no tendency to repair, a stimulating treat- 
ment is indicated. The yellow oxide of mercury applied to the parts, fol- 
lowed by frequent ablutions of hot water, conduces to this end. A bandage 
firmly applied over the eye constitutes another help, by favoring the re- 
moval of marginal induration in the sore, and removing from it one source 
of irritation,—namely, the friction of the lids. The internal administration of 
tonics, especially iodide of iron and cod-liver oil, with wffiolesome, nutritious 
food, constitutes an important part of the treatment. 
Ulcers of the cornea will often prove very intractable to treatment, and re- 
quire much patience and tact to prevent serious lesions of the eye from taking 
place. When the ulceration deepens and enlarges its boundaries by the de- 
struction of the anterior corneal laminae, there will be great danger of hernia 
either of the membrane of Descemet or of the iris. When such a result is 
apprehended, it becomes important to lessen intraocular pressure by paracen- 
tesis, the most available point for the puncture being through the bottom 
of the ulcer, provided the latter is small, for which purpose a fine needle 
should be employed. By thus anticipating the perforation, the opening into 
the anterior chamber of the eye will not be so large, and the escape of a por- 
tion of the aqueous humor will be less profuse. This operation may require 
to be repeated. After the tapping the iris will float forward against the inner 
face of the puncture, and will probably become adherent to it through the re- 
parative material which is deposited against the posterior orifice of the ulcer. 
This adhesion will often be so slight that the subsequent accumulation in the 
aqueous humor detaches it; or, should this force not be sufficient, it may be 
aided by the use of atropia dropped into the eye. Should the ulcer be large, 
there will be much risk in executing the operation of paracentesis through 
its floor. In such an event the opening must be made at the circumference 
of the cornea. A corneal ulcer may refuse to heal in consequence of excessive 
vascularity; or, should it close, it will be, for the same reason, prone to reopen. 
Division of the vessels at the sclerotico-corneal line will frequently remove 
the retarding cause and favor cicatrization. It is in this variety of ulcera- 
tion, as in that accompanied by inter- or postlamellar suppuration,—hypopyon 
ulcer of writers,—that Mr. Critchett uses with great advantage a seton of 
silk thread introduced under the hair of the temporal region. The success of 
this plan had attracted so much attention that, as he jocularly told me, his 
reputation might be said to hang on a thread. 
In the management of extending chronic ulcers accompanied by surround- 
ing suppuration,—hypopyon keratitis or ulceration,—other measures besides 
the seton have been adopted to arrest the progress of the destructive pro- 
cess and induce healing. By some ophthalmologists iridectomy—Saemisch’s 
method—is believed to be the most promising measure, while others rely 
with equal confidence upon the stimulating plan of hot fomentations, the ap- 
plication of the yellow oxide of mercury ointment, and firm pressure applied 
with the roller bandage. 
Some judgment must be exercised in the use of atropia in corneal ulcera- 
tions. The nearer the ulcer to the centre of the cornea, the greater is the 
necessity for employing this alkaloid, as it is desirable, in the event of perfora- 
tion taking place, that the margins of the pupil shall not fall into the opening 
210 OPACITIES OF THE CORNEA. 
211 
or become incorporated with the cicatrix and thus shut out the light; 
whereas in cases where the ulcer is near the circumference of the cornea the 
use of atropia is to be deprecated, as it is desirable that the pupil be kept 
as remote as possible from the perforation, should it ensue. 
Prolapse of the iris and adhesions of the iris to the cornea, complications 
which often follow perforating ulcers, will be treated of under affections of 
the iris. 
Fistula of the Cornea may follow a perforating ulcer, the operation of 
iridectomy, or any wound of the membrane. The opening may be so 
small as scarcely to admit a hair, and can be detected by the drop of aque- 
ous humor which, on a careful inspection, will be seen to issue from the 
orifice. 
Treatment.—Fistulae of the cornea, after the lapse of several months, 
frequently heal spontaneously. Should spontaneous cure not follow, the 
edges of the opening should be scratched or freshened by a fine cataract- 
needle, or they can be touched with a weak solution of nitrate of silver, 
when the opening is not central, after which pressure should bo made over 
the eye with the roller bandage. The continued use of the extract of Cal- 
abar bean, as directed by Zehender, has been successful in closing these fistu- 
lous openings. When the above measures fail, iridectomy should be performed 
as a final resort. 
Opacities of the Cornea.—Opacities of the cornea arise from a variety of 
causes, but chiefly as a result of keratitis, ulceration, different forms of oph- 
thalmia, wounds, collyria containing lead, and occasionally of calcareous 
degeneration of the elastic laminae. They vary in extent and in depth, in 
some instances being spread over the entire cornea, and in others limited 
to a small spot; sometimes not being deeper than the epithelial layer, and at 
other times being situated in the laminae beneath. The opacity may amount 
only to a slight degree of haziness, or it may be more dense, assuming a gray, 
cloud-like appearance,—nebula,—or still more dense, having a pearl-like ap- 
pearance,—albugo, leucoma. There is also a multiple opacity of the cornea, 
several distinct cloudy spots being seen scattered over its surface. These are 
the sequels of old phlyctenular ophthalmia, and resemble somewhat grains 
of calcareous matter. They consist of inflammatory tissue, often possessing 
the characteristics of true cicatricial tissue. 
Treatment.—Superficial opacities, such as are frequently seen after in- 
flammatory attacks of the cornea, gradually disappear, particularly in young 
subjects, without any application. The more deeply the opacity is situated 
in the laminse of the cornea, the less probable will be its removal. When 
the inflammatory transudation has assumed the condition of connective or 
cicatricial tissue, or if the opaque spot is due to a lead deposit, no treatment 
can be expected to benefit the patient. The absence of blood-vessels in the 
cornea necessarily operates against the absorption of inflammatory deposits:: 
hence the permanence of the latter when once formed. While it is true that 
in many cases the opacity cannot be entirely removed, it may be partly,, 
and the remedies which conduce to this end are weak collyria of sulphate of 
copper (gr. ss, water, fSi) or of nitrate of silver (gr. ss, distilled water, f£i) 
applied to the eye daily. The insufflation of very finely powdered calomel, 
upon the eye, when well borne, exerts a decided sorbefacient effect; so also 
do certain ointments containing mercury, as red precipitate (red oxide of 
mercury, gr. i, ointment of rose-water, 5i), or citrine ointment reduced to 
two-thirds of the officinal strength, or iodoform (gr. i, lard, 30- 
particle of one of these ointments should be placed upon the eye every night.. 
If there is any subacute or chronic keratitis present, nitrate of silver should 
be preferred to all other agents, but when the cornea is free from this con- 
dition, mercurial or iodoform ointments and calomel do the most good. 
Whatever lessens intraocular pressure will favor the action of sorbefacients; 212 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
and hence the use of atropia to the eye during the employment of the above 
remedies is desirable. 
Those singular opacities which arise from calcareous deposits are overcome 
sometimes by scraping away the incrustation from over the centre of the 
cornea with a delicate curette, the membrane underneath being found, prob- 
ably, free from damage. In a case of this nature which was under my care 
at the Wills Ophthalmic Hospital, and in which both eyes were affected, the 
underlying cornea was damaged to an extent which rendered any operation 
futile. 
When the opacity is a fixed one, and so situated in front of the pupil as to 
exclude the light, the difficulty may be measurably overcome by performing 
an iridectomy, making the opening in the iris opposite to a clear point in the 
cornea. Mr. Critchett introduced as a substitute for iridectomy in cases of 
incurable corneal opacities an operation which he termed iridodesis, and 
which consisted in making an opening through the corneo-sclerotic line into 
the anterior chamber with a broad, flat needle, and then, with a delicate hook 
passed around the border of the pupil, drawing the latter out through the 
opening, and including the prolapsed portion in a ligature, the loop of which 
had been previously laid over the puncture in the cornea. After the ligature 
was tightened, one end was cut close to the knot, but the other left of some 
length, so as to have command of the iris in the event of the contraction of 
the latter threatening to draw the thread into the anterior chamber. (See 
Fig. 1807.) This operation is attended with greater risk to the eye from 
inflammation than an iridectomy, and the latter is, therefore, to be preferred 
when operative measures are demanded. 
Transplantation of new tissue has also been practiced by Power, of London, 
AVolfe, of Glasgow, and Sellerbeck, of Germany. By this method the opaque 
portion of the cornea is removed, and in its place is inserted a piece of cor- 
responding size, taken from the cornea of a rabbit. Sellerbeck substitutes 
for the cornea of the rabbit that of the human eye enucleated on account 
of disease. The experiments of transplantation made in this country have 
not been attended with the success claimed for similar experiments made 
abroad. 
Finally, for the sake of appearance alone, when the opacity is very dense 
and white, tattooing has been performed by Wecker. The materials used 
for the purpose are India ink, sepia, etc. These are introduced at dif- 
ferent sittings by means of a fine grooved needle, or by a number of delicate 
needles collected into a single bundle. Coloring-liquid is laid on the opaque 
spot, and is conducted into the latter by repeated punctures with the 
needles. 
In some cases structural changes induced by corneal opacities are followed 
by irregularities of refraction, even when the deposit is not sufficiently dense 
to warrant an iridectomy. This difficulty can sometimes be overcome in a 
measure, particularly for near vision, by allowing only the central rays of 
light to enter the pupil, which is effected by placing in a spectacle form a 
plate of metal having a perforation in its centre. 
Arcus Senilis.—Among the various degenerations of structure which occur 
after the meridian of life is that of fatty alteration in the margin of the 
cornea. It is generally observed alter the fiftieth year of life, and may be 
an inheritance; at least it is often seen in several members of the same 
family. The presence of the senile arc is presumptive evidence of degen- 
erative changes going on in other oi’gans, particularly the heart and great 
blood-vessels. This degeneration begins at the upper circumference of the 
cornea, appearing at first as a cloudy crescent, which after a time deepens 
into a grayish-white color. A similar change occurs in the inferior semi- 
circumference of the corneal tissue. The fatty metamorphosis extends up- 
ward and downward until at length the extremities of the two crescents 
join, thus including the entire circumference of the cornea, or forming a STAPHYLOMA. 
213 
complete ring. The fatt}T change is not limited to the cells of the cornea, 
but affects also the walls of the blood-vessels of the part. Notwithstanding 
that the nutrition of the cornea must be modified by a degeneration of this 
nature, it is quite clear that the reparative power of the structure is not 
seriously disturbed, as the incision made for the extraction of cataract in 
persons who are the subjects of arcus senilis heals with almost the same 
rapidity as when the operation is performed through the cornea of those 
who have no such structural alteration. 
Staphyloma consists in a change of the form of the cornea from a segment 
of a sphere to a conical or rounded projection, more or less prominent. The 
conical alteration in form may be either congenital or acquired. The bulging 
may affect a part or the whole of the cornea (Fig. 1850), and when one eye 
becomes involved the other, after a time, undergoes 
a similar change. 
Slight forms of conical cornea may be readily 
overlooked during a superficial inspection of the e}e. 
When, however, the organ is viewed in profile, tho 
convexity will generally be detected. The patient, 
in consequence of the increase in the antero-pos- 
terior diameter of the eye, behaves usually as a 
person laboring under myopia, or near-sightedness, 
objects being brought near the eyes and the pal- 
pebral fissure diminished in order to neutralize the 
defect in refraction. Looked at from the front, the chief difference likely1" to 
be noticed between a conical cornea and one of normal curvature will bo 
unusual brilliancy of the former. Irregularities of curvature in the cornea 
produce astigmatism, not, unfortunately, in any particular meridian, but in 
all directions, and so unequally as often to render correction by glasses im- 
possible. In such cases the remedy is to use only a small portion of tho 
cornea for the transmission of light, by means of a metal plate having a 
small opening, thus intercepting the outer rays of light. This form of staphy- 
loma may either be progressive or stationary, and is rarely seen to develop 
after twenty-five years of age. The summit of the cone, as the disease ad- 
vances, is likely to become opaque. 
Treatment.—In progressive cases of corneal staphyloma internal treat- 
ment exerts no arresting power, and when the vision is so impaired as to 
call for interference, relief can be obtained only through operative measures, 
a number of which have, from time to time, been devised. Two of these, 
namely, iridectomy and iridodesis, are to be preferred, the former in bad cases, 
and the latter in slight ones, the new pupil being formed in a poi'tion of the 
iris opposite the best part of the cornea. 
Efforts to lessen the convexity of the cornea have been made by producing 
ulceration, artificially, at the summit of the projection, by excising or scraping 
away with the point of a knife a few of the superficial lamina? of the cornea, 
afterwards treating the denuded surface with the mitigated crayon of nitrate 
of silver, and trusting to the subsequent contraction of the cicatricial tissue 
for causing some flattening of the structure? This, an operation of Graefe, 
has been successful in improving the vision in a number of instances in which 
the deformity was on the increase. A similar result can be obtained by ex- 
cising, with an ophthalmic drill or trephine, a small piece from the centre of 
the cornea, thus opening the anterior chamber, the escape of a part of the 
aqueous humor allowing tho cornea to sink—the operation of Bowman and 
Bull. 
Another variety of staphyloma is that in which a part or the whole of tho 
cornea (keratoglobus) and often a portion of the sclerotic and the iris are 
implicated. The bulging frequently increases to such a degree from intra- 
ocular pressure that the diseased portion protrudes beyond the level of the 
eyelids, forming an opaque, grayish-white tumor, with more or less vascu- 
Fig. 1850. 
Conical cornea. 214 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
larity. (Fig. 1851.) These cases have an inflammatory origin. They give 
rise to deformity, and are attended with considerable local disturbance, in 
consequence of the prominent part being beyond 
the protective influence of the palpebne, and neces- 
sarily exposed to contact with dust and other 
foreign matters. 
The causes which tend to develop staphyloma 
are repeated attacks of keratitis, ulcers, and wounds, 
followed by attenuation of the corneal tissue. The 
iris becomes involved, in many of these cases, by 
ulcerative perforation of the cornea, in w’liich, the 
anterior chamber being opened, tho escape of 
aqueous humor carries the iris forward, and causes 
it either to become adherent to the posterior face 
of the cornea, or to protrude through the opening made by the ulcer (hernia 
of the iris'), in either case practically obliterating, permanently or tem- 
porarily, the anterior chamber (anterior synechia). The protruding part 
is not always corneal tissue at the beginning of a staphyloma. The recon- 
structive material deposited for the repair of the ulceration, unable to resist 
the vis a tergo arising from intraocular tension, and yielding little by little, 
at length affects the surrounding cornea and assumes the chai’acteristics 
of staphyloma,—viz., bulging, opacity, and vascularity. 
Treatment.—Assuming the staphyloma to be one of moderate degree, fol- 
lowing ulcerative perforation of the cornea, and with prolapse of the iris, it 
will be proper to resort, at the earliest possible moment, to iridectomy7, the 
new pupil being planned so as to be opposite a portion of the cornea which 
still retains its transparency. The diminished intraocular pressure obtained 
by this operation allows time for the solid repair of the corneal ulcer, thus 
arresting the disease. 
In cases in w7hieh tho staphyloma is progressive, the cornea converted 
into a dense leucoma, the sight destroyed, and the protruding portion sub- 
jected to constant irritation, a resort to operative measures becomes neces- 
sary. Just what the operation shall be must be determined byr existing con- 
ditions. There are four operations practiced: amputation, or abscission, the 
operation of Critchett; strangulation (Borelli); the seton (Graefe); and enu- 
cleation. Amputation is in all cases to be preferred, save where the syunp- 
toms of glaucoma are present, as blindness, hardness of the ball, or much 
intraocular tension. In such cases the extent of ocular disorganization and 
the consequent danger to the sound eye forbid any conservative plan of 
treatment: the entire ball should be removed. 
Amputation, or abscission, is practiced in different way’s, the method of 
Critchett being perhaps, on the whole, most satisfactory. After separating 
the eyelids widely by the spring speculum, four or five curved needles, each 
armed with a thread, are to be passed across the base of the protruding mass 
and allowed to remain without being drawn entirely through. Tho staphy- 
loma is then shaved off with a cataract-knife in front of the needles, after 
which tho latter are to be drawn through and the wound closed by tying the 
threads together and cutting off their ends near the knots. (Fig. 1852.) 
The lids are next closed, a wet compress applied, and over all a bandage. 
The sutures should be allowed to remain eight or ten day’s, when they can 
be removed. 
Quite as satisfactory7 an operation consists in passing a number of threads 
equidistant through the base of the tumor, seizing the summit of the latter 
with a tenaculum, and, after making a puncture with a Beer’s knife in front 
of the sutures, introducing the blunt-pointed blade of a pair of scissors through 
the aperture, and by successive cuts detaching the staphyloma, after which 
the wound should be closed by tying the threads together, as in the other 
method. 
Knapp passes the threads through the conjunctiva only, bringing this 
Fig. 1851. 
Spherical 6tapliyloma. WOUNDS OF THE CORNEA. 
215 
membrane over the opening like a hood. In all these operations the patient 
should be placed under an anaesthetic. 
Fig. 1852. 
Approximation of wound after amputation of staphyloma. 
Strangulation, or the plan of Borelli, consists in passing two needles 
through the base of the tumor, the one horizontally, the other vertically, 
and then throwing a thread around the mass, beneath the pins, and drawing 
it sufficiently tight to strangulate the protruding portion. A wet compress 
and a bandage are next applied. In seven or eight days the staphyloma 
drops off as a slough. 
Seton.—Graefe introduced a double thread behind the circumference of 
the cornea through the ciliary region. This was tied in a bow loop and 
allowed to remain for twenty-four or thirty-six hours, or long enough to 
develop suppurative choroiditis, when it was withdrawn. The inflammatory 
changes continued until the ball became wasted and solidified by organized 
lymph. 
Staphyloma following ulceration, with perforation of the cornea, will often 
continue to increase, in consequence of the pressure of a displaced lens; and 
when this is the case no unyielding cicatrization may be expected until this 
body is removed, either in its entirety by incision, after the manner of cata- 
ract-extraction, or by breaking it up with a needle and removing the debris 
with a curette through the opening in the staphyloma. 
Wounds of the Cornea.—Wounds of the cornea admit of the same classifi- 
cation as similar accidents in other parts of the body,—namely, incised, con- 
tused, lacerated, punctured, and shot wounds. These may be divided again 
into non-penetrating and penetrating. 
Incised wounds are commonly made by pocket-knives ; contused wounds, 
by blows inflicted with any blunt body; lacerated wounds, by fragments 
of metal, glass, stone, or other irregular substances; punctured wounds, by 
needles or splinters ; and shot wounds, by percussion-caps or bird-shot. 
The danger of these injuries depends on the degree of penetration and the 
nature and form of the vuliterating body. A clean cut, or an incised wound, 
even one which opens the antei’ior chamber, though it be of considerable ex- 
tent, will often heal kindly and quickly, leaving no permanent trace of the 
injury. Sometimes a cloudy or opaque patch of lymph will remain about the 
cicatrix and interfere with vision, or some surface irregularity may follow, 
which will cause an error of refraction. The accuracy with which the edges 
of incised wounds become spontaneously adjusted may cause the injury to 
escape detection, unless the damaged organ is viewed in different lights and 
in different positions. Oblique illumination readily discloses such lesions. 
When the cornea is penetrated, the escape of the aqueous humor through the 
aperture will be likely to cause a prolapse of the iris. 216 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
Lacerated wounds are liable to be followed by inflammatory opacities, 
sloughing, staphyloma, and cataract. 
The gravity of corneal wounds is increased when the foreign body is im- 
bedded, and still more so when it enters the interior of the organ. 
Superficial wounds of the cornea, those, for example, which are merely 
abrasions or epithelial lesions, are often much more painful than deep ones. 
Treatment.—The indications in the treatment of wounds of the cornea 
are the removal of any foreign body which may be discovered, and the pre- 
vention or control of inflammation. 
The first indication is fulfilled by seizing the offending body with a pair 
of delicate forceps and extracting it, or by dislodging it with a cataract- 
needle. (Fig. 1853.) The operation will be greatly facilitated by dropping 
on the eye a four per cent, solution of cocaine a few minutes before operating, 
or by fixing the eye with a pair of forceps after 
separating the lids with a speculum. When loosely 
or superficially attached, the foreign substance can 
often be easily removed by the edge of the eye- 
scoop. When the foreign body has partially en- 
tered the anterior chamber, and cannot be with- 
drawn by a delicate forceps, a flat needle should be introduced into the cham- 
ber, to press the offending substance outward and thus favor its extraction. 
The inflammatory symptoms which follow injuries of the cornea are to 
be combated by the assiduous use of pledgets wet with cold water. Local 
blood-letting, either by leeches or by cups, may be required, while the eye 
should be screened from the light by covering the lids with a firm bandage. 
Should cold applications be followed by increased local discomfort, they must 
be substituted by hot ones. 
It will sometimes happen in penetrating wounds or perforating ulcers of 
the cornea that the iris becomes prolapsed. A restoration may be accom- 
plished by means of a delicate probe, and probably by the use of atropia; 
though both will often fail. It is exceedingly desirable that this body should 
be reduced, for when fairly engaged in the wound, and if allowed to remain 
in this abnormal position, adhesions between the two will follow, forming 
an anterior synechia. There is also danger of iritis, corneal opacity, •staphy- 
loma, and other accidents to the eye. And yet, if it is found to be adherent 
to the aperture,—a result which may occur in eight or ten hours after the pro- 
lapse,—it must be allowed to remain. The protruding portion may be clipped 
off, the surface touched with a point of nitrate of silver, and afterwards press- 
ure applied by a roller over the closed lids. The iris is sometimes swept into 
the wound, and is distended by the aqueous humor into a little pouch or bag. 
If allowed to remain, the tumor will increase; and hence the propriety of 
making a puncture and permitting the contents to escape, after which the 
part should be touched with a crayon of nitrate of silver, and the lids closed 
and bound, as in the case of prolapse above mentioned. In all wounds of 
the cornea the use of atropia is of great importance, by preserving the pupil 
and iris from inflammatory changes. 
Fig. 1853. 
Needle suitable for removing for- 
eign bodies from the cornea. 
Contusions of the eye are, in many instances, very grave injuries, occa- 
sioning cataract or displacement of the lens, and laying the foundation for 
different structural alterations in the interior of the organ. These inju- 
ries are often attended with oedema and discoloration of the eyelids and 
eyebrows. 
Cold, followed in the course of twenty-four or thirty hours with hot ano- 
dyne fomentations, atropia to the eye, and the exclusion of light from the 
organ by the roller bandage or the ocular sling, constitute the ordinary 
treatment. When the pain is persistent, and the vessels of the sclerotic 
and conjunctiva are deeply injected, local bleeding will be necessary. 
Tumors of the Cornea are rarely seen. They commence primarily in the DISEASES OF THE SCLEROTIC. 
217 
conjunctiva or at the corneo-sclerotic junction, and at length invade the cor- 
neal tissue. Those most commonly met with are carcinoma, both the epithe- 
lial and melanotic varieties, and melanotic sarcoma. 
Treatment.—When superficial and small, they are to be shaved off from 
the surface of the membrane; but when deep, implicating tho substance of 
the cornea, nothing short of enucleation of the ball is of any avail. 
DISEASES AND INJURIES OF THE SCLEROTIC COAT OF THE EYE. 
Wounds of the sclerotic, like those of the cornea, are classified as incised, 
lacerated, punctured, contused, and shot, and are always, in consequence of 
their nearness to the choroid, retina, ciliary body, vitreous humor, and lens, 
attended with great danger to the eje. The gravity of such wounds depends 
on the degree of penetration and the lodgment of the vulnerating body 
within the eye. 
Treatment.—Any foreign particles of matter imbedded in the sclerotic 
should be extracted by instruments similar to those used for a like purpose 
in wounds of the cornea. Incised and lacerated wounds require careful ex- 
amination, to see that there is no prolapse of the retina or protrusion of the 
vitreous humor. In the event of a portion of the retina being displaced, it 
should be replaced with tho probe, and should the lesion extend sufficiently 
near the sclerotico-corneal junction to allow of a prolapse of the iris, the 
latter must, if not readily replaced, bo treated in like manner. Slight pro- 
trusions of the vitreous, though they may delay union of the wound, do not 
prevent it. To favor rapid healing, and to prevent any portion of the interior 
structures of the eye from falling into the wound, the edges of the latter 
should be brought together by fine sutures. In inserting them, the needle 
should be passed from within out, first on one side and then on the other. 
By observing this pi'ecaution the danger of injury to the contents of the 
ball is materially lessened. 
A luxated lens following injury should be extracted at once by an incision, 
as practiced for cataract. 
Large wounds of the sclerotic with escape of a considerable portion 
of the contents of tho eye, destroying vision, require enucleation of the 
ball, as the patient by this course avoids not only the immediate evils of 
a protracted suppuration, but also the more remote one of sympathetic 
ophthalmia. 
Patients are frequently brought into hospitals with particles of uncon- 
sumed powder-grains imbedded in the sclerotic, from blasting. When the 
grains are only partly buried in the membrane, they may be picked out; 
but when more deeply situated, it is better that they be allowed to remain, 
as they generally do not continue to irritate the membrane for any consider- 
able time. * 
Wounds of the sclerotic require the application over the eye of pledgets 
wet with cold water medicated by a little laudanum, and supported by a 
firmly-compressing bandage. 
Staphyloma of the sclerotic occurs in both the acute and the chronic form, 
and is an inflammatory result, as in irido-choroiditis or in ulcerative keratitis. 
When from the latter cause, the staphyloma is preceded by a similar con- 
dition of the cornea. The bulging is sometimes multiple (Fig. 1854), and 
is either sharply defined or fades gradually into the rest of the sclerotic. 
Portions of the membrane not pressed upon by the recti muscles are most 
prone to become the yielding points. These protrusions vary in size, and 
as the sclerotic assumes a bluish color and becomes thinned out, either from 
intraocular pressure or from inflammatory atrophy, the dark pigment of the 
choroid becomes distinctly visible thi’ough the attenuated walls of the pro- 
trusion. 
When the staphyloma originates in an irido-choroiditis, there will be seen 218 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
a very suggestive vascularity in the region of the sclerotico-corneal line, 
including the conjunctival, subconjunctival, and ciliary vessels, and attended 
with more or less chemosis. When the staphyloma 
proves to be progressive, extensive changes occur within 
the globe of the eye, the vitreous humor loses its trans- 
parency, the retina becomes detached, the lens grows 
cataractous, intraocular hemorrhages occur, and the dis- 
tention increases until the sclerotic, no longer able to 
withstand the pressure within, ruptures and allows the 
contents of the eye to escape. In some instances the 
staphyloma increases up to a certain size and then begins 
to diminish. This change foreshadows suppuration within 
the hall, which will end in its destruction, leaving only 
a wasted and collapsed stump. In staphyloma the prog- 
ress of the disease is usually very slow, or it may even 
remain stationary for years. 
Treatment.—Although the surgeon in most cases is 
powerless to arrest the progress of the disease, yet such is not always the 
case. When commencing as an irido-choroiditis and recognized early, by 
reducing intraocular tension the bulging can often be arrested, or at least 
rendered very much less rapid in its increase. The means of reducing this 
tension are the use of atropia and tapping the ball. When these fail, the 
object may be attained by an iridectomy. The last resort in uncontrollable 
cases is to remove the protuberance, either by a cataract-knife or by stran- 
gulation ; or, if the chief part of the ball is implicated and vision destroyed, 
it will be better to extirpate the diseased organ. 
Fig. 1854. 
Multiple staphyloma. 
Sclerotitis.—Except as a result of a precedent inflammation of the cornea, 
conjunctiva, or deeper structures of the eye, sclerotitis is not a very common 
affection. That it may exist, however, as a primary disease thei-e can be 
little doubt: in such cases the cause is either rheumatic or syphilitic. 
The first symptom of sclerotitis, particularly when of rheumatic origin, 
is the appearance of a spot of a dusky red color near the cornea, with or 
without any unusual vascularity of the conjunctiva, and gradually extending 
over a larger surface of the sclera. The distended vessels of the sclerotica, 
very small, are seen radiating in parallel straight lines from the cornea, and 
impart a pink or violet color to the membrane. 
(Fig. 1855.) At the beginning of the attack the 
patient experiences neuralgia, which spreads 
to the temple, the brow, and sometimes the upper 
part of the face. The eye, sensitive to light, is 
sore to pressure, the discomfort being increased 
on moving the ball. 
When the disease arises from syphilis, the pain, 
both in the head and in the eye, is increased in the 
evening, often destroying the patient’s rest. 
In rheumatic sclerotitis, the general system often sympathizes with the 
local condition; sometimes, indeed, the manifestation of the eye-trouble is 
preceded by symptoms of systemic disturbance, such as chill, elevation of 
temperature, headache, coated tongue, loss of appetite, and an excess of 
urates in the urine. 
Treatment.—When the sclerotitis is rheumatic, the treatment should 
begin with a mercurial purge, followed by the free use of acetate or nitrate 
of potash and by colchicum. 
Iodide of potassium, when a syphilitic element is suspected, will be found 
of great value, and may be administered in association with syrup of guaiac 
and belladonna. As a local application, atropia applied to the eye once or 
twice daily relieves undue sensibility by lessening intraocular tension, and 
defends the iris against inflammatory changes. To assuage brow or temple 
Fig. 1855. 
Sclerotitis. CONGENITAL IMPERFECTIONS OF THE IRIS. 
219 
pain, painting the skin over these regions with a mixture composed of equal 
parts of the tincture of aconite and chloroform will be found useful. The 
eye must be protected against strong lights by the use of a shade. After the 
violence of the disease has been broken, quinia will be advantageous, both for 
its tonic and antineuralgic properties. 
Should the iris become involved by an extension of the inflammation from 
the sclerotic, no remedies prove so valuable as small doses of calomel with 
a little opium to restrain the bowels, frequently repeated, and the instillation 
of atropia into the eye. 
Tumors of the Sclerotic. 
Tumors of the sclerotic are as rare as similar neoplasms in the cornea; 
indeed, except as secondary growths, extending from the interior of the eye, 
they are seldom seen. 
Those which have been observed have been carcinoma, melano-sarcoma, 
dermoid cysts, and cystoma. Gummy tumors are occasionally seen in the 
sclerotic in subjects suffering from tertiary syphilis. 
These morbid growths, like those of the cornea, are, when very circum- 
scribed, to be cut off; but if extensive, implicating the deeper structures of 
the eye and destroying vision, a more radical measure will be necessary,— 
that of extirpating the ball. 
DISEASES AND INJURIES OF THE IRIS. 
Congenital Imperfections. 
The imperfections of development affecting the iris are the absence of this 
structure (irideremia), cleft iris (coloboma), the presence of the membrana 
pupillaris, and the absence of the pigmentary layer (albinism). 
Irideremia.—The entire absence of the iris is very rarely observed, there 
being in most instances of this deformity a rudimentary portion discoverable, 
which forms a small part of the circle. The partial or complete absence of 
the iris imparts a peculiar appearance to the eyes, as the whole fundus is 
lighted up with a red- or orange-colored tint, and bordered with a circle of 
yellow light. In exceptional cases the background is dark, even black. The 
light, which floods the eyes, causes an unsteady state of these organs. In 
a number of recorded cases of this congenital imperfection, where the per- 
sons had reached adult life, it appears that no difficulty was experienced in 
regard to accommodation, the individuals being able to read ordinary type 
without difficulty. A few cases have been noted in which the imperfection 
was hereditary. 
Coloboma.—In this deformity the symmetrical halves of the iris fail to 
unite, leaving an elongated gap or cleft, which, indeed, is not confined to the 
iris alone, but, inasmuch as the latter and (he choroid coat are developed 
from a common membrane, extends as a like fissure into the dark tunic of the 
eye. In some instances the failure of the two sides to coalesce is limited to 
the lower half of the iris, resulting in the formation of a pyriform pupil. 
The defect involves both eyes, though not always to the same degree. Per- 
sons who are subjects of this congenital arrest of development are, neverthe- 
less, able to use the eyes quite well. * 
Membrana Pupillaris Remaining.—The membrana pupillaris, which up to 
a certain period of intra-uterine life closes the pupil, in a few instances has 
remained after birth. Such a case would be a proper one for operation. 
Albinism consists in the absence of pigment from the iris and the choroid. 
The fundus of the eye in such cases presents a reddish appearance. The 
vision is imperfect, and light is more or less dazzling and intolerable. 220 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
Mydriasis, or dilatation of the pupil, is generally confined to one eye. 
The condition may be produced by certain medicinal substances, as atropia 
or other mydriatics. 
Rheumatism, syphilis, and cerebral compression, arising from various 
cranial lesions, as caries of the orbit or intraorbital tumors, are among the 
causes giving rise to this affection. There may be, accompanying mydriasis, 
paralysis of other muscles within the orbit. Whatever its origin, the 
immediate cause is either paralysis of tho third cranial nerve, the nerve 
which energizes the circular or pupillary muscular fibres of the iris, or some 
reflex spinal irritation acting through the sympathetic on the radiating fibres, 
thus overpowering the circular muscle. There is also a transient mydriasis, 
frequently repeated in the course of the day, which has attracted considerable 
attention since Graefe announced its presence to be one of the prodromata 
of monomania. The same dilatation of the pupil is often witnessed from 
external causes, as hysteria. One-sided mydriasis is always, in the absence 
of any extrinsic cause, suggestive of intracranial disease. 
Treatment.—In order to treat mydriasis intelligently, everything depends 
on ascertaining with accuracy the cause of the affection. When arising from 
rheumatism, iodide of potassium, with colchicum or the syrup of guaiac, con- 
stitutes the most efficient remedy. If produced by S3rphilis, iodide of potas- 
sium, with bichloride of mercury, yields the best result. 
A blister over the temple is a powerful adjuvant to constitutional remedies 
in both rheumatic and syphilitic forms of the affection. Myotics may also 
be employed with caution, as Calabar bean or eserine. Electricity—the con- 
tinuous current—can also be used in cases where, in addition to the mydriasis, 
there is a loss of accommodation. When the mydriasis is the effect of intra- 
cranial inflammation, blisters to the temples and purgation, followed by bro- 
mide of potassium, promise relief. Mydriasis following injuries of the head 
suggests a careful examination of the cranium for fracture with depression, 
or tor evidence of the presence of blood-clot on the brain. 
Myosis.—In this affection the pupil is contracted to a mere point. The 
contraction may be spasmodic or paralytic. It may be purely a physiological 
phenomenon, caused by the action of a myotic, as eserine or Calabar bean. 
It may also be produced by the poisonous action of certain drugs, as opium 
or alcohol. Intracranial inflammations induce a myosis especially of the 
spasmodic form. This affection is one of the precedent phenomena of ataxy. 
The contraction of the pupil in myosis may be due to an exalted or spas- 
modic action of the sphincter or circular muscle of the iris, from irritation 
of the third nerve, the source of that irritation often being intracranial; or 
it may result from paralysis of the radiating fibres of the iris (dilator muscle), 
the cause being located either in the spinal marrow, as in spinal meningitis, 
or in fractures of the vertebrae of the neck, or in the cervical region from 
tumors pressing upon the sympathetic cord. Spasmodic myosis may gener- 
ally be distinguished from the paralytic by the accommodation in the latter 
remaining unimpaired. 
Treatment.—The successful treatment of myosis will depend upon the 
nature and location of its cause. Antidotal and antiphlogistic measures are 
demanded when it depends on the action of poisonous substances taken into 
the system, or on inflammatory conditions of the cerebro-spinal centres or 
their meninges; and operative treatment when it is caused by tumors which 
admit of removal. 
Iridodonesis, or Tremulous Iris.—This condition is produced when the iris 
loses the support of the lens, as when the latter is either displaced or re- 
moved, or when a portion of the vitreous has been lost, as often happens in 
cataract-extractions. The same tremulous condition may also follow dropsy 
of the eye. 
The defect is irremediable. IRITIS. 
221 
Properly to understand morbid conditions of the iris, the student should 
be familiar with the normal appearance of its structure. The diversity of 
color of the iris in different races depends upon the pigment-la}"er occupying 
the posterior surface, or on a parallel disposition of its colorless fibres. The 
healthy iris exhibits a central aperture (the pupil), bounded by a bundle of 
circular muscular fibres (sphincter iridis), from which are seen on its anterior 
face, radiating in all directions, fine strife, the fibres of the dilator muscle, 
blood-vessels, and nerves. The arteries and nerves are derived from the ciliary, 
and enter the iris from the ciliary body, which is situated immediately pos- 
terior to the line of juncture between the cornea and the sclerotic. The mus- 
cular fibres are held together by a very fine connective tissue. The alternate 
exclusion and admission of light by closing and opening the eyelids, or by 
simply interposing the hand between the eye and a luminous object and then 
withdrawing it, is followed in the healthy iris by dilatation and contraction 
of the pupil. 
The causes of iritis are traumatic injuries, rheumatism, gout, syphilis, and 
sometimes violent ophthalmia. 
Whatever may be the cause, there are certain symptoms very generally 
observed in all varieties of iritis. Among these may be mentioned increased 
vascularity of the subconjunctival tissue. The vessels of this structure, being 
straight and parallel with one another, and inosculating with those of tho 
iris and choroid, form, when overfilled with blood, a rose-colored zone around 
the circumference of the cornea, which afterwards deepens into a dull or 
brown red. The vessels of the conjunctiva are also more or less engorged. 
The iris loses its usual lustro, assuming a dull appearance, the change 
being readily recognized by comparing the affected with the sound eye. 
The regularity of the pupil is lost, its mobility or lessened, and 
its circumference tumid and swollen. (Fig. 185(3.) The striated appear- 
ance of the iris is measurably effaced by the 
intermediate grooves being leveled up with 
distended vessels and lymph. Ciliary neuralgia 
is present, with some intolerance of light. The 
aqueous humor, instead of maintaining its per- 
fectly transparent character, becomes a little 
dull or cloudy, and there may often be discov- 
ered floating through it minute particles of 
lymph. 
The evils resulting from iritis, wrhen tho 
disease is not promptly subdued, are parenchy- 
matous or plastic infiltration, threads, flakes or 
tufts of lymph, either suspended from tho cir- 
cumference of the pupil or blocking up tho 
opening entirely, and adhesions of the iris’ to 
the capsule of the lens, either by its posterior 
sui’face or by its pupillary border. These ad- 
hesions to the capsule of the crystalline lens are 
influential in provoking repeated attacks of 
iritis. Although the cornea is seldom involved 
in inflammatory accidents attending iritis, except when the origin of the 
latter is of a rheumatic nature, its transparency is occasionally blurred by 
detached fragments of lymph becoming adherent to its inner surface. 
Traumatic iritis may follow operations for cataract, in consequence of some 
injury accidentally received. It may also occur after an iridectomy, or from 
a dislocated lens, or in consequence of damage sustained from a foreign body 
lodged in the eye. It is the serous surface which, as a rule, suffers first in 
traumatic iritis. The inflammation in such cases is liable to extend to tho 
choroid, and to end in suppuration. 
Iritis. 
Fig. 1856. 
Showing vascularity at corneo-sclerotic 
line and irregularity of pupil, with 
patches ot lymph. 222 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
Rheumatic iritis.—An acute attack of rheumatic iritis often comes on after 
exposure to wet, cold, and changeable weather. The peculiarity of the phe- 
nomena attending this variety of disease consists in a precedent neuralgia of 
the supraorbital branch of the fifth pair of nerves, the pain frequently radi- 
ating over the brow, temple, and face. The movements of the eyeball are 
attended with a feeling of soreness, and there is intolerance of light, with 
lachrymation. The vascular zone seen at the circumference of the cornea 
and the numerous fine parallel vessels of the subconjunctival tissue are not 
so bright or so distinct as in traumatic iritis. Rheumatic iritis is sometimes 
ushered in by a chill and other signs of constitutional disturbance; it is 
prone to run a chronic course, and to recur on slight exposure during 
damp weather. 
Syphilitic iritis reveals its origin in the presence of yellow or yellowish-red 
nodules over the surface of the iris. The small masses, or gummata, situ- 
ated in the parenchyma of the iris project from the anterior surface of the 
membrane. The usual vascular zone at the circumference of the cornea will 
be seen in syphilitic iritis, but the distinctness of color will be most notice- 
able at that portion opposite to where the inflammatory products of the iris 
ai’e most marked. 
When iritis develops in children, and there has been no history of injury 
or of an aggravated ophthalmia, it is safe to refer the disease to transmitted 
syphilis. There will bo in almost all cases of syphilitic iritis, whether in 
children or in adults, the external evidences of constitutional contamination 
in other parts of the body. The simultaneous involvement of both irides is 
more common in syphilitic than in rheumatic iritis. 
Treatment.—The two great remedies in iritis are mercury and the iodide 
of potassium. 
The management of a case of traumatic iritis will depend on the character 
of the injury and on the nature of the vulnerating body. When a body like 
a particle of steel, a fragment of a percussion-cap, or a small shot—sub- 
stances which do frequently enter the eye—lodges in the iris, it should be 
removed with a portion of the injured iris. When the inflammation arises 
from a dislocated or cataractous lens, the latter should be extracted. The 
local abstraction of blood, the instillation of atropia, small and frequently- 
repeated doses of mercury, and exclusion of light embrace the other means 
for subduing the inflammation. In the rheumatic form of the disease the 
mercury and iodide of potassium can be administered together. Syrup of 
guaiac, with salicylate of soda, can also be used with benefit. In the S}'ph- 
ilitic variety the mercury should be administered alone, guarded by a little 
opium in order to prevent its running off through the bowels before its 
constitutional action is expended. Half a grain of calomel with one-sixth 
or one-eighth of a grain of opium should be administered every five hours 
until the disease is arrested, care being taken not to carry the alterative to 
the extent of salivation. 
Turpentine, advocated by Carmichael, has not proved satisfactory in my 
practice. 
To avoid the stimulating effects of light, the eyes should be bandaged, or 
the patient confined to a dark room, at least until the acute symptoms have 
subsided. During the whole course of the treatment atropia must be ap- 
plied to the eye (grs. iij-iv, water, fgi), with a view to preserve the patency 
of the pupil, lessen intraocular and vascular tension, secure rest to the mus- 
cles of the iris, prevent its adhesion to adjacent parts, and alleviate pain. 
The diet must be regulated by the necessities of the case. A patient whose 
health is impaired will demand a generous diet, while one with a vigorous 
constitution, and perhaps overfed and overstimulated, must be placed on a 
restricted regimen. It is in the latter class of subjects, and in those who 
sutler from severe ciliary neuralgia, that the local abstraction of blood does 
good : indeed, the instillations of atropia are sometimes powerless to pro- 
duce any marked influence on the pupil until the vascular tension has been TUMORS OF THE IRIS. 
223 
lessened by the use of leeches, natural or artificial. The pain of iritis, so 
common in the evening, and the attendant restlessness, are best relieved and 
sleep procured by the exhibition of anodynes. 
Sequels of Iritis.—After an attack of iritis which has not been detected 
early or not treated with sufficient activity, the pupil may be so occluded 
with a deposit of lymph as to render the patient almost blind. The proper 
remedy after the subsidence of the inflammation is the formation of an arti- 
ficial pupil by an iridectomy. 
The iris, by its pupillary border, or by a more extended surface, is fre- 
quently, after inflammatory attacks, glued to the capsule of the lens,—posterior 
synechia,—thus diminishing the capacity of the posterior chamber. Several 
evils result from this adhesion. The pupil is prevented from dilating, or the 
iris, expanded by the pressure of the aqueous humor, becomes pouched. In 
either condition the irritation provokes subsequent or recurring attacks of 
iritis. The difficulty is to be surmounted only by an iridectomy. 
The morbid growths which implicate the iris are often secondary, be- 
ginning first in the adjacent structures. 
They may be malignant, as carcinoma, sarcoma, and lepra, sometimes 
called tubercle; or non-malignant, as naevi, cysts, and epidermoid growths. 
Tumors of the Iris. 
Carcinoma, whether primary or involving the iris by continuity of tissue, 
appears as one or more small nodules or elevations of a dark color projecting 
from a circumscribed portion of the membrane, the disease gradually infil- 
trating the iris, until all traces of its striated structure are effaced by the 
progress of the growth, which in time fills the entire eyeball. Nothing 
short of enucleation of the ball offers any prospect of relief. 
Sarcoma, like carcinoma, reaches the iris, in most instances, by extension 
from contiguous parts, and in appearance does not materially differ from car- 
cinoma. Both, as they acquire size, tend to produce staphylomatous projec- 
tions of the sclerotica. The remedy consists in extirpating the ball. 
Lepra, which appears to have a geographical distribution, being observed 
chiefly in Brazil and in one or two northern regions, and being often associated 
with constitutional leprosy, resembles sarcoma at the outset. Small nodules 
commence at some point of the iris, usually at the periphery, and extend 
towards the pupil. The growths or nodules will eventually encroach on the 
chambers of the eye until the organ becomes filled with the morbid produc- 
tion. Nothing short of enucleation will effect a cure. 
Nsevi of the iris, like similar growths elsewhere, are congenital. They 
appear as convoluted or tortuous masses of blood-vessels covered with dark 
patches of pigment. Their size is influenced by the position of the head, 
being larger when the latter is allowed to remain pendent for a brief period. 
These nsevi seldom demand surgical interference. 
Cysts of the iris arise either spontaneously or in consequence of violence. 
They originate in the parenchyma of the iris, and have both sessile and 
pedunculated attachments to the iris, with contents sometimes clear and 
limpid, sometimes opaque, and at other times containing sebaceous matter 
and hair. In some instances the contents are the retrogressive products of 
other tumors. 
Another view in regard to the formation of the cyst-wall, that of Wecker, 
is that it is produced by the protrusion of a circumscribed portion of the iris, 
which, gradually increasing, forms at length a spherical or pyriform sac; a 224 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
very plausible explanation when the lesion follows a pre-existing inflamma- 
tion, in which some of the fibres of the iris, in consequence of plastic infil- 
tration, are incapable of yielding, while others, free from the presence of 
the inflammatory tissue, become stretched in the direction of least resist- 
ance. 
When progressive, the remedy is excision of the affected portion of the 
iris. 
OPERATIONS ON THE IRIS. 
Iridectomy.—This operation consists in excising a portion of the iris, and 
is performed to overcome evils incident to inflammatory accidents to the 
cornea, to arrest glaucoma, to lessen the risks attending cataract-extrac- 
tions, to remove foreign bodies or morbid growths, and to overcome the ob- 
stacles to vision in cases of synechia. When the object of an iridectomy is 
to make an artificial pupil or to reopen the old one, so as to admit light, it is 
necessary, before adopting the procedure, to determine the extent to which 
vision is impaired. If no perception of light exists, such as should be evinced 
when the patient faces a window, there is no necessity for the operation. 
If the cornea is opaque over its en- 
tire surface, or if the structure of the 
iris has been disorganized, an iridec- 
tomy is useless. In an inflamed condi- 
tion of the iris the knife must be with- 
held. 
Instruments.—The instruments re- 
quired are—1st, a stop speculum (Fig. 
1857), to keep the eyelids asunder; 2d, 
a pair of fixation forceps (Fig. 1858), 
with which to steady the ball of the 
eye, the teeth being either blunt or 
serrated, so as not to cut through the 
conjunctiva; 3d, two lance-shaped 
knives (Fig. 1859), with which to open the anterior chamber, one straight, the 
other bent at an angle,—the first being suited to operations on the temporal 
Fig. 1857. 
Stop speculum. 
Fig. 1858. 
Fixation forceps. 
side of the cornea, and the other to those performed on the nasal side ; 4th, a 
pair of iris forceps, slightly curved, and with serrated blades (Fig. 18G0), with 
Fig. 1859. 
Lance-shaped knives. 
which to draw the iris through the external opening, and a hook (Fig. 1861), 
which may be used in some cases for the same purpose; and, 5th, two 
Fig. 1860. 
Fig. 1861. 
Iris forceps. 
Iris hook. 
pairs of scissors (Figs. 1862, 1863), one straight, and the other curved on 
the flat. OPERATIONS ON THE IRIS. 
225 
Operation.—The patient, being placed in a recumbent position, in a good 
light, should be etherized. When the anaesthesia is complete, the head is to 
Fig. 1862. 
McClure’s iris scissors. 
be slightly raised and supported on a firm pillow. The lids are next to be 
separated and the speculum adjusted. 
The operator then picks up an ample 
fold of the conjunctiva and subcon- 
junctival tissue with the fixation for- 
ceps directly opposite the point where 
the opening is to be made. Drawing 
the ball a little outward or inward, ac- 
cording as it is contemplated to incise 
the inner or the outer side of the cornea, 
the lance-shaped knife is made to enter 
the sclerotic from half a line to a line 
external to the corneo-sclerotic junc- 
tion, and then, after directing the point 
a little forward, is carried onward into the anterior chamber sufficiently 
far to make an opening of the requisite extent. (Fig. 1864.) This accom- 
plished, the knife is withdrawn slowly, in order that there shall be no sudden 
gush of the aqueous humor, but a gradual escape, thus preventing hemor- 
rhage, which otherwise might follow from the loss of support to the walls of 
the vessels. If the opening is not sufficiently large, it can be increased by 
inclining the edge of the lance-shaped knife against the side of the wound as 
it is withdrawn, or it may be enlarged by the Graefe cataract-knife or by the 
scissors. The discharge of the aqueous humor following the withdrawal of 
the knife will frequently carry the iris into or even through the wound, where 
it can be readily seized with the forceps, drawn out, and cut off on a level with 
the external opening. Should this not occur, the operator, after intrusting the 
fixation forceps to an assistant, introduces the iris forceps closed, or the hook, 
carefully through the wound into the anterior chamber, and, seizing a fold of 
the iris, draws it out through the opening, when it is immediately cut off 
Fig. 1864. 
Fig. 1865. 
Lids separated with the speculum. Puncture made 
with the lance-shaped knife. 
Iris dragged through the wound, and scis- 
sors applied to cut it off. 
with the curved scissors on a plane with the external surface of the eye. 
(Fig. 1865.) The position of the opening made in the iris, and its extent, 
must be determined by the conditions for which the iridectomy is executed. 226 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
If to overcome the evil of an opaque cornea, the opening must be formed 
opposite to a part of the latter which is transparent. When the surgeon is 
at liberty to elect the point for his operation, as in cases where the iridec- 
tomy is done to arrest inflammatory conditions by lessening intraocular 
tension, as in glaucoma, it is desirable, from considerations of personal ap- 
pearance, to make the artificial pupil in the upper semi-circumference of the 
iris, as it will in a great measure be subsequently concealed by the superior 
eyelid. The portion excised from the iris should stop short of the ciliary 
ligament. In cases where the operation is done to remedy adhesions between 
the iris and the lens, it is not necessary to make a large incision through 
either the cornea or the iris. The opening into the anterior chamber, if 
made by a narrow-bladed iridectomy knife, will be quite sufficient to allow 
the introduction of the hook to catch and prolapse the iris. 
In performing iridectomy, operators who are not ambidextrous will be 
compelled to occupy different positions, according to the side of the eye 
opened ; that is, in front, if right-handed, when the anterior chamber of the 
left eye is approached from the temporal side, and behind and above when 
entered from the nasal side. 
Mr. Critchett devised a method of performing iridectomy which he termed 
iridodesis, and which is applicable to cases requiring a change in the position 
of the pupil favorable for the transmission of light through a clear portion 
of an opaque cornea. 
The patient being under the influence of an anaesthetic, the operation is 
performed as follows. The eyelids are to be separated with the spring spec- 
ulum, the ball fixed by the fixation forceps, and the conjunctiva seized on the 
temporal side. While the eye is thus steadied, a puncture is made into the an- 
terior chamber with a broad needle or a narrow-bladed knife, on the nasal side 
of the eorneo-sclerotic line, entering the latter quite close to the ciliary rim 
of the iris. A loop of black silk thread is next laid on the surface of the eye, 
Fig. 1866. 
Canula forceps. 
over the incision, and the iris hook or the canula forceps (Fig. 18G6) passed 
through the loop into the anterior chamber, and a portion of the iris caught, 
between its ciliary attachment and the 
pupil, and drawn out through the ex- 
ternal wound until the pupil occupies 
the proper position, when it is to be 
strangulated by tightening the loop. 
(Fig. 1867.) After making the knot 
secure, the ends of the thread are to be 
cut oft’, one close to the knot and the 
other considerably longer, so as to en- 
able the surgeon to have the iris at 
command. The strangulated portion 
of the iris di-ops otf with the thread 
in the course of two or three days, 
leaving the iris firmly adherent to 
the cicatrix in the cornea. 
Corneal transplantation in cases of 
opacity has proved unsatisfactory. Strawbridge, as a substitute, trephined 
the sclerotic, and covered the opening with conjunctival tissue. 
Fig. 1867. 
Iris drawn through the loop and ready to be strangu- 
lated. AFFECTIONS OF THE CHAMBERS OF THE EYE. 
227 
Iridodialysis. 
The term iridodialysis is employed to designate an operation devised to 
improve the sight in cases of corneal opacity in which a narrow strip of 
unclouded membrane remains near the sclero-corneal junction. An incision 
is made through the cornea with a broad needle in advance of the clear part, 
and the iris seized with the appropriate forceps and carefully torn away 
from its ciliary connection. The margin of the detached fold should then 
be drawn through the external opening and excised. 
AFFECTIONS OF THE CHAMBERS OF THE EYE. 
The chambers of the eye are liable to undergo marked alterations in size. 
In cases of inflammation of the membrane of Hescemet, a large accumula- 
tion of fluid takes place, enlarging the anterior segment of the ball, chiefly 
at the expense of the corneal tissue, which becomes tumid, constituting 
the disease styled hydrophthalmos anterior. The capacity of the anterior 
chamber is always increased whenever the normal resistance offered by the 
lens or by the vitreous humor is lessened or removed, as when the former has 
undergone absorption or has been dislocated, or when the latter has become 
softened. Whatever has a tendency to press the iris forward towards the 
cornea diminishes the depth of the anterior chamber, and, with few excep- 
tions, will correspondingly increase that of the posterior chamber,—hydroph- 
thalmos posterior. Perforating ulcers of the cornea, inflammatory deposits 
on the posterior surface of the iris, and softening of the vitreous humor, act 
in this manner. 
The dropsical accumulations of the eye generally appear during infancy, 
and are often congenital. They are usually progressive, imparting increased 
tension, at least in the eai’ly stage of their history, giving rise to imperfect 
vision, and ultimately destroying the sight. Temporary relief in cases of 
hydrophthalmos will be obtained by the operation of paracentesis oculi. As 
anterior hydrophthalmos tends to create corneal staphyloma, the latter may 
be temporarily arrested by an iridectomy. 
Blood in the Chambers of the Eye follows severe blows upon the ball, 
concussion of the brain, wounds of the ciliary body, and various operations 
practiced upon the eye. Hemorrhage into the chambers may also occur 
from constitutional conditions altogether independent of local violence, as 
in scorbutic disease, in malignant typhus, and as a vicarious dischai’ge when 
the function of menstruation has been suppressed. In traumatic cases the 
crystalline lens will frequently be found displaced. In time the entire 
amount of extravasated blood will be taken up by the absorbents, though 
the traces of the effusion often remain for a long period, interfering somewhat 
with the transparency of the refracting media and lessening the distinctness 
of vision. 
The treatment proper in a case of traumatic haemophthalmos is the use of 
atropia to preserve the pupil, and pledgets wet with cold water and bound 
firmly upon the closed eyelids. The cold water should be withdrawn after 
the first few hours, when all oozing will have ceased, and the dry compress 
and bandage continued. Hemorrhage aidsing from general causes will re- 
quire the use of remedies addressed to the system at large. 
Foreign Bodies, as fragments of steel, fine shot, or small pieces of glass, 
sometimes penetrate the cornea and lodge either in the anterior or posterior 
chamber, or in the substance of the iris. 
It is quite possible that these substances, particularly shot, may remain 
in the eye and become encysted, causing little or no inconvenience; but 
generally they give rise to inflammation of the iris or choroid, which, if not 
promptly arrested, will cause sympathetic trouble in the sound eye. A 228 
DISEASES AND INJURIES OF THE EVE AND ITS APPENDAGES. 
young man wTho, while hunting, received a grain of shot in the eye, has, 
after the lapse of six years, experienced no inconvenience. A lady under my 
care, who had a foreign body enter the eye when a young girl, experienced 
no inconvenience until seventeen years after the accident, when a severe 
sympathetic ophthalmia developed in the uninjured eye and destroyed the 
vision. 
In all cases when the foreign substance can be located (and in doing this 
the ophthalmoscope will prove of great value), no pains should be spared 
to effect its removal. For this purpose it is necessary to open the anterior 
chamber and extract the body with the iridectomy forceps or a scoop. The 
magnet, though considerably overrated, has been successfully employed in 
a number of instances for removing metallic substances from the interior 
of the eye. Some of them, no doubt, could have been extracted with greater 
facility and with less injury to the organ by the forceps. The end of the 
magnet is introduced through an opening made into the anterior chamber, 
and when brought near to the foreign body will draw the latter to itself, if 
within the range of attraction, and thus enable the operator to bring the 
substance to the external wound, where it can be drawn through with a pair 
of forceps. Even bodies buried in the vitreous humor, and recognized by 
the ophthalmoscope, have been thus extracted. In such cases the opening 
may be made through the sclerotic, and the magnet conducted by the most 
direct route to the offending substance. In this manner Dr. Strawbridge, of 
this city, succeeded in extracting a fragment of steel from the vitreous 
humor. 
When the iris has been damaged by a body entering the eye, not only 
should that body be removed, if possible, but an iridectomy will be impera- 
tively required. When the lens has been injured or displaced by any sub- 
stance which enters the eye, it should be extracted without delay. This 
latter accident may not be detected at the time of the injury, when the 
aqueous humor is mingled with blood, but it will not be too late to perform 
the operation after the eye has become sufficiently clear to enable the surgeon 
to distinguish the complication. The instillation of atropia, the exclusion 
of light, and the use of a bandage over the eye, with the local abstraction of 
blood, when the acute 8}7mptoms are marked, constitute the after-treatment. 
When it is found impossible to discover and extract the foreign body, the 
patient should be specifically instructed in regard to the risk of subsequent 
sympathetic irritation in the sound eye, and the necessity in such an event 
of having the diseased or injured organ promptly removed. 
Hydatids.—Occasionally a cysticercus is discovered in the eye. Two cases 
of this nature have been observed in Philadelphia within the last few 3Tears. 
Cases of this kind are most common in Germany. The animal, when visible, 
is ordinarily seen moored to the iris, or floating in the aqueous humor as a 
small bladder or vesicle about the size of a mustard-seed, which will, when 
carefully watched, be noticed to enlarge and contract alternately. The pres- 
ence of hydatids gives rise to slow inflammatory changes in the eye, which, 
unless the animal is extracted, endanger the sight. 
Irido-choroiditis and Irido-cyclitis. 
The vital unity existing between the iris, choroid, and ciliary body renders 
any inflammatory affection which may commence in one of these structures 
liable to extend, through continuity of tissue, to the others. In a large pro- 
portion of cases of inflammation affecting the uveal tract there will have been 
a precedent iritis, the result of which has been either to block up the pupil 
by a plastic membrane or to glue its periphery to the capsule of the lens. 
The resistance offered to the action of the dilating fibres by the lymph oc- 
cupying the pupil, or the closure of the communication between the anterior 
and the posterior chamber of the eye, thus destroying the equilibrium of intra- CHOROIDITIS. 
229 
ocular pressure which results from the fluid of one chamber flowing unin- 
terruptedly into the other, becomes a fixed source of irritation, which reacts 
on the choroid and ciliary body and causes in the latter a habitual congestion 
or fullness of the vessels. Ophthalmia, both syphilitic and sympathetic, is 
also a factor in the causation of irido-choroiditis and irido-cyclitis. 
Symptoms.—The signs which indicate the existence of the inflammation 
under consideration are pericorneal soreness, increased by pressure and by 
rolling the eye, opacity of the vitreous humor, and undue tension of the ball, 
with indistinctness of vision and opacity of the cornea, its inner surface being 
encrusted with inflammatory lymph. In other cases the anterior surface of 
the iris is seen pushed out into little sacs, the result of the combined influence 
of adhesion to the capsule of the lens and the pressure of the aqueous humor 
behind. The color of the iris undergoes a change, becoming grayish or some- 
what green in appearance. The tension of the ball, at first considerable, sub- 
sequently lessens, the aqueous humor loses its transparency and becomes 
cloudy, opacity of the lens and softening of the vitreous follow, and the ves- 
sels of the iris, from mechanical obstruction, become tortuous and varicose. 
There is also detachment of the retina; but this condition is more generally 
present when the inflammation begins primarily in the choroid. During 
these changes there is steadily diminishing vision. 
The inflammatory products seen in irido-choroiditis are not always the 
same. As in other parts of the body, so here, the transudation may be serous 
in its character, or it may be an organizable plastic material attaching the 
surface of the iris to the capsule of the lens or to the cornea, or it may result 
in suppuration. 
Prognosis.—Though always serious, the gravity of a case of irido-choroi- 
ditis and irido-cyclitis will be estimated by the length of time the disease has 
existed, by the character of the products, and by the order of the inflamma- 
tory process, whether from the iris to the choroid and ciliary body or the 
reverse. If preceded by an iritis, the extension of the inflammation can be 
arrested if detected in time. When beginning in the choroid,—a fact which 
may be determined by early opacity of the media of the eye, especially the 
vitreous body, and by detachment of the retina,—the fate of the organ is 
probably sealed; and this probability is increased when the inflammation is 
accompanied by purulent deposits. 
Treatment.—When the disease begins as an iritis, and the latter has 
been followed by posterior synechia, the adhesions being limited and im- 
mature or recent, it is possible in some instances, by tbe repeated use of a 
strong solution of atropia, to tear them loose and release the iris from the 
lens, and thus get rid of an important source of irritation. When this can- 
not be effected, an iridectomy must be performed, and an ample portion of 
the iris excised. 
Choroiditis. 
The choroid membrane, an exceedingly vascular structure, must neces- 
sarily be frequently the seat of inflammatory attacks, either primary or 
secondary. Systematic writers have a classification of choroiditis based on 
the nature of the inflammatory products, as the serous, the plastic, and the 
purulent or suppurative, and also syphilitic. 
Serous Choroiditis, in the absence of the rational signs of inflammation, 
may exist some time without being suspected. No pain is complained of in 
the ball, no unusual sensibility experienced. Neither lachrymation nor in- 
tolerance of light is present. Numerous patches of pigment may be seen scat- 
tered over the choroid, while in certain portions the cells will have lost their 
pigment, at which points the membrane will be white or red. Passing across 
these spots, deprived of coloring-matter, the vessels of the choroid may oc- 
casionally be observed. The vision is imperfect, objects being seen indis- 
tinctly and only in a strong light. In acute cases, when the eye is examined 230 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
with the ophthalmoscope, the cause of the visual defect will become apparent 
by the blurred or cloudy state of the vitreous humor. The horizon of the 
visual field will be contracted or central vision will be impaired according as 
the peripheral portion of the choroid or the macula lutea is involved. Should 
the inflammation extend to the iris, the latter is likely to become attached to 
the capsule of the lens, the aqueous humor loses its transparency, and the 
intraocular tension is increased for a time, though subsequently the reverse 
occurs, the ball becoming softer and useless in consequence of the slow dis- 
organization of the vitreous, and also from structural changes in the lens. 
Treatment.—When recognized early, before extensive structural changes 
have taken place, much may be done to relieve the patient and to improve 
the vision. The eye should be protected against the stimulating influence of 
strong lights. Blood may be taken from the temple by leeches, maintaining 
the advantage gained by the use of atropia and blisters. In order to clear 
up the vitreous body as much as possible, the iodide of potassium, either 
with or without the bichloride of mercury, constitutes one of our most 
effective remedies. If the tension of the ball is well marked, tapping should 
be performed, and, if need be, repeated. When these agencies fail, an iridec- 
tomy can be done, often with great advantage. 
Plastic Choroiditis.—The changes wrought by plastic choroiditis on the 
choroid membrane differ, the dominant ones being the deposition of small 
whitish masses of lymph, 
both on the surface and in 
the parenchyma of the mem- 
brane, with corresponding 
displacements of pigment. 
These exudations may be 
scattered extensively over 
the choroid,—choroiditis dis- 
seminata (Fig. 1868), being 
generally congenital in its or- 
igin, or beginning in infancy; 
or they may be confined 
to more restricted limits, 
each patch being surrounded 
by a collar of thickened pig- 
ment, — choroiditis circum- 
scripta. These little masses 
of exudation, when contig- 
uous to one another, may 
coalesce. Frequently the 
membrane is marked by reg- 
ular and irregular patches 
of different colors,—white, 
dark, and gray. 
The inflammatory changes may extend to the retina (chorio-retinitis), in 
which, over the affected district, the pigment disapppears, leaving an ovoidal 
white expanse running off from the side of the optic nerve. Isolated masses 
of pigment also appear in other portions of the field, as well as on the optic 
disk, the centre of which may be unusually white. (Fig. 1869.) 
Among the sequels of chorio-retinitis is not only atrophy of the choroid, 
but also a corresponding staphyloma. By the aid of the ophthalmoscope 
there will be seen on the macular side of the optic disk, and partly em- 
bracing the latter, a white elongated or ovoidal crescent. The optic disk at 
its centre exhibits an unusually white appearance, and on the side of the 
crescent is bounded by a dark, or more commonly a white, ring (Fig. 1870), 
internal to which localized accumulations of pigment may often be observed. 
A moderate degree of posterior staphyloma often exists in pronounced cases 
Fig. 1868. 
Atrophy of the choroid following choroiditis disseminata: A,arteries 
V, veins; B, optic nerve; Ch, semilunar portion of choroidal atrophy. SUPPURATIVE CHOROIDITIS. 
231 
of myopia, and may remain stationary without damaging the vision. But 
when it follows inflammatory changes in the choroid and retina, the sight 
Fig. 1869. 
Fig. 1870. 
Chorio-retinitis. 
Posterior staphyloma following chorio-retinitis. 
fails, the disk becomes excavated, the ball hardens, and glaucoma super- 
venes. 
In syphilitic choroiditis the ophthalmoscopic revelations answer for the 
most part to those observed in the disseminated variety. 
Treatment.—Much depends on the early recognition of the disease if 
benefit is to be expected from therapeutic agents. The patient must ab- 
stain from using the eyes in reading or writing, and they should be pro- 
tected against strong lights and wind by the use of smoked glasses. When 
the disease assumes the acute form, blood should be taken locally, and after 
the intestinal secretions have been corrected by the administration of a few 
grains of calomel, followed by a gentle aperient, mercury should be given 
in small and frequently-repeated doses, either with or without the iodide 
of potassium. The best form of a mercurial, when administered with the 
potassium, is the bichloride, but when not associated with this salt the blue- 
pill or calomel is to be preferred, and should be pressed to the verge of 
ptyalism, when we may reasonably hope to arrest the progress of the disease 
and not infrequently greatly to improve the patient’s vision. In posterior 
staphyloma following chorio-retinitis, iridectomy alone possesses any power 
to arrest the disease. 
Suppurative Choroiditis is most likely to arise from traumatic causes, as 
when foreign bodies penetrate the eye and lodge in the vitreous humor, or 
after cataract-operations. The disease may follow inflammation of the cerebro- 
spinal meninges, endocarditis, or forms o'f fever, as typhus, typhoid, or 
erysipelas, in which case the immediate excitant of the suppurative inflam- 
mation will probably be embolic plugging of some of the choroidal vessels. 
In cases having a septic or pysemic causation, the disease usually attacks 
both eyes. 
When suppurative choroiditis appears during an attack of inflammation 
of the membranes of the brain, it is probably due to extension by continuity 
of tissue along the course of the optic nerve, as suggested by Borthold. 
Symptoms.—The symptoms of suppurative choroiditis are well pronounced, 
the disease beginning as a severe inflammation of the choroid and extending 
rapidly to the other structures of the eye (panophthalmitis). The pain is 
severe, deep, and throbbing, darting along the supraorbital, infraorbital, and 
frontal branches of the fifth pair of nerves. The eyelids become red, hot, 
and cedematous, and very sensitive to the touch, as is also the ball of the eye. 
The vessels of the conjunctiva and subconjunctival tissues are engorged, 
giving rise to more or less chemosis. On separating the eyelids, should the 232 
cornea still retain its transparency, the aqueous fluid will be found clouded 
and mingled with pus, and the iris carried forward, so as materially to diminish 
the depth of the anterior chamber. The sight is soon lost, at least in acute 
cases of the disease. The cornea, infiltrated with pus, at length sloughs, 
allowing the eye to shrink, or it may resist the destructive changes to a 
remarkable degree, the sclerotic in the mean time giving way, and the ball 
gradually shrinking into a shapeless stump. 
The prognosis in suppurative choroiditis is necessarity unfavorable, the eye 
being in most instances hopelessly destroyed. Nor, indeed, does the evil 
always terminate with a disorganized eyeball: the disease is liable to creep 
back along the nerve-sheaths to the membranes of the brain, and produce 
fatal meningitis. 
Treatment.—This may be considered in two aspects, the preventive and 
the curative. The preventive consists, in cases where a foreign body has 
entered the eye, in extracting it when possible. When the disease is once 
intrenched in the eye, and in its early stage, the use of leeches will be in- 
dicated, in case the patient is young and vigorous. Cold applications should 
also be made, unless they cause an increase of pain, in which event hot ones, 
and of an anodyne character, should be substituted. When the tension and 
throbbing of the ball are great, relief will be obtained from repeated tappings. 
Mercury, recommended by some, unless given before suppuration sets in, 
will do no good, but rather harm. Extirpation of the eyeball, when the 
suppuration becomes general, has been proposed; but the suggestion has 
not been received with general favor, the risk to the brain being too great. 
Pain must be moderated by the use of opiates, and the general strength sup- 
ported with the best nourishment and by tonics and stimulants. 
DISEASES AND INJURIES OF TIIE EYE AND ITS APPENDAGES. 
Tuberculosis of the Choroid.—This affection, first noticed, I believe, by 
Jaeger, has been found to be a common concomitant of pulmonary tuber- 
culosis, as shown by the observations of Manz and Cohnheim; sometimes, 
indeed, choroidal tubercles precede the general disease. The tubercles, when 
fully developed, appear as small nodules projecting from the choroid. The 
pigment over these bodies being partially removed imparts to them a grayish- 
white or a faint red color. The region about the optic disk is the part 
generally elected by these formations, though other portions of the choroid 
are not exempt, particularly the peripheral portion of the membrane. The 
sight will remain unimpaired. Tuberculosis of the choroid frequently exists 
without any extensive choroiditis. 
Coloboma of the choroid occurs with, and also without, a similar condition 
of the iris. There must necessarily be in such cases an arrest of develop- 
ment, a defect in the vision corresponding to the region where the choroid 
is absent,—that is, peripheral vision; though central vision will remain un- 
affected. 
Detachment of the choroid occasionally occurs, and will be readily recog- 
nized by an ophthalmoscopic examination, the membrane being detached from 
the sclera and raised into a spherical eminence projecting into the vitreous 
body, and often accompanied by a like protrusion of the retina. The vessels 
of the retina can be recognized running over the elevation, and those of the 
choroid lying beneath the retina. The exudation, which in many instances 
causes the detachment of the choroid, takes place on the scleral surface of 
the membrane. In order not to confound detachment of the choroid with 
that of the retina, it is only necessary to remember that when the latter 
occurs independently of the former the separated portion presents a plicated, 
wavy appearance, strongly contrasting with the tense, globular form of the 
other. 
The causes which determine detachment of the choroid are inflammatory, 
hemorrhagic, and neoplastic, and often cannot be differentiated in the early TUMORS OF THE CHOROID. 
233 
history of the case. When caused by the first two, the loss of the eye may 
be certainly anticipated, as these effusions excite an irido-choroiditis, with 
disorganization of the vitreous body and wasting of the ball. 
Rupture of the choroid may follow traumatic violence applied to the eye. 
The laceration can take place at any point, from the ciliary processes back- 
ward to the optic nerve, and, as a rule, is more commonly witnessed posteriorly 
than anteriorly. It may be regular or irregular. The effect of such a rent 
in the membrane is an escape of blood, which accumulates, forming a dark 
patch, about the borders of the laceration. The interference with vision 
will depend upon the location of the coagula: when near the macula lutea it 
will necessarily be much greater than when in other parts of the membrane. 
Examined by the ophthalmoscope, the vessels of the retina will often be seen 
unbroken across the rent in the choroid. The clots can also be seen of dif- 
ferent shades as the process of metamorphosis and absorption progresses, 
and when this is complete the sclera may be seen forming the floor of the 
rupture. 
Blood Extravasations in the choroid are occasionally observed altogether 
independent of rupture of the membrane. In these cases a few overstrained 
vessels give way and cause the apoplectic extravasation. The accident can 
be recognized by observing that the vessels which belong to the retina cross 
in front of the clot or clots. 
Treatment.—In both laceration and extravasation time must be the chief 
reliance. Coagula here, as elsewhere, are gradually absorbed, though not 
without leaving serious traces of the damage done in the choroid membrane, 
and followed by impaired vision. While the work of removing the blood is 
proceeding, the eye should be shielded by smoked glasses. 
Colloid Disease of the choroid consists in an aggregation of small, trans- 
parent bodies, variously arranged in files or clusters, surrounded with borders 
of pigment cells and scattered over the choroid at different points. These 
bodies have been regarded, especially by Hulke, as having an inflammatory 
origin; others, as Donders, referred their origin to the fatty and cretaceous 
changes which belong to old age and commence in the nuclei of the pigment 
cells of the choroid. As they are found in persons comparatively young, 
this theory is not tenable. Their true seat is believed by the most careful 
observers to be in the elastic layer, and they are thought to consist of localized 
thickenings of this part of the choroid. The effect of colloid disease on the 
retina becomes in time very marked, causing serious damage to the rods and 
other components of the membrane, which, in the event of the posterior part 
of the choroid being the seat of the disease, will affect central vision. The 
evils lessen, of course, according as these morbid products occupy the ante- 
rior portion of the choroid, in which case the horizon of vision is merely 
narrowed. The disease is not amenable to treatment. 
Ossification of the Choroid.—Among the very rare inflammatory sequences 
of choroiditis is ossification, a notable example of which is recorded by Wolfe, 
in which a bony shell occupied the space between the choroid and the 
retina. 
The neoplastic growths which have been observed affecting the choroid 
membrane are, in a large proportion of cases, melano-sarcomata. The more 
rare varieties are glio-sarcoma, myxo-sarcoma, leuco-sarcoma, cavernous sar- 
coma, and enchondroma. 
The histological elements of these sarcomata consist of round and spindle 
cells, with more or less fibrous tissue. Occasionally an alveolar arrangement 
or disposition of the constituents of the growth exists,—carcinomatous sarcoma. 
Tumors of the Choroid. 234 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
The vascularity of these neoplasms varies, some containing such a predomi- 
nance of blood-vessels as to merit the title of cavernous sarcomata, while in 
others comparatively few vessels exist. 
Sarcomata of the choroid are rarely seen under thirty years of age, are 
confined to one eye, and affect men much more commonly than women. The 
anterior and lateral portions of the choroid are the parts in which these 
growths generally develop. They may exist for a considerable time without 
their presence being suspected. After they attain a certain bulk, marked 
changes occur in the adjacent parts of the eye; the retina becomes detached, 
forming a wrinkled and tremulous sac; peripheral vision is diminished; the 
vitreous humor becomes cloudy and begins to shrink; the crystalline lens 
loses its transparency, and at length becomes opaque; increased tension 
of the globe occurs; the iris is pushed forward, diminishing the antero- 
posterior depth of the anterior chamber, and its pupil either dilated or con- 
tracted and fixed, as when glued by inflammation to the capsule of the lens; 
the aqueous humor grows muddy, and the cornea hazy, while the patient is 
harassed by severe ciliary neuralgia, and all vision is abolished. Various 
intercurrent inflammatory and other accidents will occur while the growth 
is increasing, as irido-choroiditis and irido-cyclitis, hemorrhagic infarctions, 
sloughing of the cornea, and staphylomatous protrusions of the sclerotic. 
Patients may not apply for relief until the media of the eye have become 
dull or opaque, when an ophthalmoscopic examination of the eye is not 
practicable. As long as the sclerotic coat and the cornea remain intact, the 
tumor grows slowly, but when one or both of these give way, and the per- 
ipheral pressure is removed, the increase is rapid. A red, bleeding mass at 
length appears external to the eye, from which a sanious discharge con- 
stantly exudes. 
These sarcomata are malignant, and, although showing little tendency to 
affect the lymph-glands, soon manifest a disposition to implicate the general 
system by metastatic deposits in the internal organs. 
Treatment.—The only hope for a patient suffering from sarcoma of the 
choroid lies in its early recognition and the prompt enucleation of the ball. 
DISEASES OF THE RETINA. 
Congestion. 
Congestion of the retina occurs both as arterial and as venous hyperaemia. 
Arterial congestion is revealed by the patient being unable to use the eye 
for any length of time, especially on subjects requiring an active exercise of 
accommodation. Under such circumstances the vessels of the conjunctiva 
become red, accompanied by a certain degree of intolerance of light and 
lachrymation, and often by flashes or coruscations of light, and by ciliary 
neuralgia. Further confirmation of the congestion will be discovered by an 
ophthalmoscopic examination, in which the color of the optic disk is seen to 
differ but little from that of other portions of the retina, in consequence of 
its increased vascularity, the effect of which is to lessen very markedly the 
natural line of definition between the two, or to render the border of the 
disk indistinct. Numerous vessels come into view which are not visible in 
the sound eye; and as there is, in different individuals, marked difference in 
the color of the fundus, it is well, before deducing any conclusion as to the 
degree of vascularity in the affected eye, to examine the sound organ, so that 
by comparison the true condition may be ascertained. 
Causes.—Retinal congestion is liable to follow any cause tending to invite 
a free flow of blood to the tissues of the eye, the most common being liy- 
permetropia, especially when the defect has not been provided for by suitable 
glasses. Certain occupations predispose to the same condition, as engraving, 
fine sewing, and watch-making. Similar congestions follow exposure of the 
eyes to the dazzling reflection of strong sunlight from white sand, or result 
from too great application to study by artificial light. RETINITIS. 
235 
Venous congestion can be discovered by examining the illuminated fundus 
with the ophthalmoscope. The veins will be seen to be enlarged, tortuous, 
and pulsatile. There is also impairment of the sight. Venous congestion is 
generally due to obstructive causes, such as interfere with the passage of 
the blood towards the cavernous sinus. Thus, tumors and aneurisms, intra- 
ocular or post-orbital, disease of the lungs, and disease of the heart frequently 
produce this condition. 
Treatment.—The management of a case of retinal congestion will depend 
on its cause. If produced by refractive defects, original or acquired, these 
must be corrected by suitable glasses; if it arises from close application to 
study or to certain avocations, rest of the organs must be enforced ; and 
when produced by strong lights, the shade or the smoked glasses should be 
worn, and the brows, temples, and eyelids frequently bathed 'with laudanum 
and water. If the general system is weak, tonics will aid in the work of 
restoration, especially strychnia and iron. 
The relief of venous congestion of the retina will depend altogether on 
the removability of the cause. If it arises from intracranial aneurism, the 
ligation of the primitive carotid may be necessary. In cases of heart disease 
or diseases of other organs, much may be done in the way of palliation by 
regulating the functional operations of these organs. 
Ischaemia. 
Ischaemia of the retina is the absence of a sufficient amount of blood in the 
retinal vessels to sustain the functional activity of the membrane. This 
affection can be recognized by pallor of the optic disk and retina, the vessels, 
both arterial and venous, being scarcely discernible. Both eyes are affected, 
and the patient is entirely blind. In a case under my care, that of a young 
lady who had been much reduced by an attack of pelvic cellulitis, the blind- 
ness continued for four weeks. 
The cause of this empty condition of the vessels in ischaemia can scarcely 
be attributed to a want of power in the heart to force the blood into the re- 
mote arteries, otherwise this affection should be more frequently observed. 
I am disposed to look for the explanation in some j)eculiar condition of the 
vaso-motor nerves or their centres. 
Treatment.—The treatment consists in rest, tonics, stimulants, and a 
strengthening diet, which, if not successful, may be followed either by tap- 
ping the ball or by an iridectomy, in order to lessen intraocular tension and 
thus favor the flow of blood into the vessels of the eye. 
Retinitis. 
Inflammation of the retina may be idiopathic, or symptomatic of disease 
elsewhere, the morbid relations of this membrane being singularly wide and 
varied. For example, we have hemorrhagic retinitis, nephritic or albumi- 
nuric retinitis, diabetic retinitis, syphilitic retinitis, retinitis leucsemica, and 
retinitis pigmentosa. 
The symptoms of retinitis in general may be considered under two heads, 
the rational and the physical. 
The rational signs are obscureness of vision, the patient often complaining 
of a thin, grayish mist or veil being before the eyes, and in the course of 
time of objects appearing in irregular forms and much smaller than they 
really should be. The external appearances of the eye do not differ from 
those of the healthy organ. 
The physical signs of the disease brought to light by the ophthalmoscope 
vary with the nature and location of the inflammatory products; that is to 
say, as the transudation is serous, plastic, or purulent, or is situated on the 
surface or in the parenchyma of the retina. In all there is opacity of a 
grayish color, spread over the retina, slight in the serous and well pro- 236 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
nounced in the parenchymatous and suppurative varieties. The periphery 
of the optic disk becomes somewhat irregular in its outline, loses its sharp 
definition, is swollen, and, in consequence of increased vascularity, its opacity 
is rendered slightly red. The vessels of the retina may be readily seen 
when the infiltrate is superficial, but become invisible when the exudation 
extends into the deeper laminie of the membrane. The arteries of the retina 
exhibit little if any change, but the veins are enlarged and tortuous, and 
describe curves or arches in the substance of the membrane. When the 
inflammation invades the deeper elements of the retina, causing thickening 
and sclerosis of its connective tissue, the optic nerve is liable to participate 
in the disease. Nor are the inflammatory changes limited to the retina. 
Contiguous to the exudative patches in the latter membrane, the choroid 
suffers also, losing its pigment to an extent that renders its vessels quite 
distinct, which, together with other alterations affecting the epithelium and 
stroma of the membrane, constitutes a choroiditis. 
Suppurative retinitis is usually secondary, the disease being a complication 
or a result of a like condition of the choroid and extending to the retina by 
contiguity of tissue. The disease often has a traumatic, pyamiic, or embolic 
origin. The inflammatory products invading, as they do, the nerve-elements 
of the retina, generally produce a disorganization of its structure fatal to 
future vision. 
Hemorrhages in Retinitis. 
Hemorrhage into the retina to some extent is no uncommon occurrence 
in the various forms of retinitis. It may take place altogether independently 
of any inflammatory cause, being a result of cardiac disease, atheroma, 
spasmodic coughs, obstinate vomiting, congestion of the brain, and preg- 
nancy. Considering the subject not as a distinct disease, but as among the 
accidents of retinitis, the appearances presented on an instrumental inspec- 
tion of the eye are, in addition to other changes incident to retinitis, one or 
several red or dark patches and streaks (Fig. 1871) of extravasated blood, com- 
monly in the inner layer of the retina, and 
situated near the macula lutea, the optic 
disk,—which is often much obscured,—or, 
indeed, in any part of the membrane. The 
course of these apoplectic spots, before co- 
agulation takes place, is towards the cho- 
roid, as less resistance is met with in this 
direction. 
The effect of such extravasations on the 
vision depends on the position of the coag- 
ula, sight being most impaired when the 
region of the yellow spot is invaded, and 
least, if at all, when the effused blood is 
seated near the periphery of the membrane. 
Hemorrhage into the retina must be re- 
garded as a very serious occurrence. While 
it is Hue that blood extravasations in this 
membrane are absorbed after a time, as 
elsewhere, yet the damaging effect of such 
clots on a structure so extremely delicate 
as that of the retina is very great and irreparable. 
Treatment.—The treatment required in a case of retinal hemorrhage will 
be that proper in the disease which produced it, and of which the bleeding 
is only a result: it will therefore bo detailed under the different varieties 
o retinitis.. Suffice it to say here that in all cases, whether idiopathic or 
sy mptomatic, the great indication is to remove the cause, or, when this is 
not possible, to lessen the intensity of its action. 
Fig. 1871. 
Hemorrhagic retinitis. The blood extravasa- 
tion seen in spots and in streaks; the optic disk 
greatly obscured; veins quite distinct, but ar- 
teries almost lost from view. RETINITIS NEPHRITICA OR ALBUMINURICA. 
237 
Retinitis Nephritica or Albuminurica. 
The connection between diseases of the eye and Bright’s disease of the 
kidney was known long before the ophthalmoscope came into use,—the 
earliest observer on the subject being Landouzy. 
The appearances disclosed by the ophthalmoscope are so uniformly present 
in the retina in cases of Bright’s disease that the disease can in most cases 
be diagnosed by this instrument alone. These appearances, it is proper to 
say, are not peculiar to Bright’s disease, but may be seen in cases of white 
or of waxy kidney, also in those cases of severe renal congestion which often 
accompany pregnancy or follow scarlatina. 
With the ophthalmoscope, numerous white spots may be seen scattered 
over the fundus, some having an irregular outline, while others are stellated, 
the latter being usually arranged ax*ound the macula lutea. Spots of hemor- 
rhagic extravasation are also present at different points of the membrane. 
Both eyes usually suffer, though not always simultaneously. 
The pathological significance of the peculiar white patches consists in a 
fatty metamorphosis of the cells and con- 
nective components of the retina. (Fig. 
1872.) The stellated or striated appear- 
ance of the patches around the macula 
lutea is the result of sclerosis of the radi- 
ating fibres of the retina. 
In addition to the changes given above, 
and affecting chiefly the granular layer of 
the retina, the other signs common to reti- 
nitis will be seen,—viz., venous congestion 
and opacity of the optic disk, the exudation 
extending forward from the latter towards 
the equator of the retina. 
The effect of these structural changes of 
the retina on the sight is very different 
in individual cases, depending in a great 
measure on the tissue-elements involved, 
being always much less damaged when 
the degeneration is chiefly located in the connective tissue than when it 
implicates the nerve-components of the retina. 
Just in what way the connection between nephritic disease and retinal 
changes of the character described is effected has not been satisfactorily 
determined. By some observers the degeneration is thought to be a result- 
ant of uraemia, as the eyes do not suffer until a decided change has occurred 
in the stnxcture of the kidney, lessening both the quantity of urine and the 
normal amount of urea. The view is at least plausible. Othei-s, noticing 
the frequent coexistence of disease of the right venti'icle of the heart (hyper- 
ti-ophy and dilatation) with that of the kidney, refer the phenomena observed 
in the eye to some pertui’bation of the circulation; but, in opposition to this 
mode of explanation, it may be ui*ged that retinitis albuminurica is often 
seen where no cai’diac disease exists. Certain it is that when a great depu- 
rating organ like the kidney fails to execute its function, the products of 
tissue-metamoi’phosis which continue to circulate in the blood render the 
latter wholly unfit as pabulum for the structure of the body, and may favor 
fatty degeneration. But why the elements of the retina, nervous, fibrous, 
and vascular, should especially suffer I am unable to explain. 
Treatment.—Whatever exei’ts a good effect on the l’enal disease will prove 
useful in mitigating that of the retina. Two emunctories, the intestinal canal 
and the skin, must be made to supplement, as far as possible, the defect of 
the kidneys: hence the value of administering, occasionally, gentle cathar- 
tics and the hot bath. Internally, no remedy compares in value with iron, 
given liberally, either with or without a diuretic. The most reliable prepara- 
Fig. 1872. 
Appearance of the retina in Bright’s disease. 238 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
tion is the tincture of the sesquichloride, alone or in the form of Basham’s 
mixture. 
Diabetic Retinitis. 
A retinitis observed in connection with saccharine urine has been desig- 
nated diabetic retinitis. Its occurrence in cases of diabetes mellitus is by no 
means so constant as in retinitis dux-ing nephritic disease. The appearances 
presented are disseminated white or gray spots of exudation, distinct from 
one another, hemorrhages, both circumscribed and diffused, in the retina, 
and opacities of the vitreous humor. 
The treatment is that adapted to a case of saccharine urine. 
Syphilitic Retinitis. 
Syphilitic retinitis, which is among the secondary and later accidents of 
syphilis, is rarely seen dissociated from inflammation of the choroid. Some 
impairment of vision occurs among the rational signs of the disease, and, 
whether much or little, it is never remedied by glasses. Phosphorescent 
flashes, also, are a frequent accompaniment of the affection. The ophthal- 
moscopic appearances strikingly differ from those present in Bright’s disease. 
Unlike the latter, there are no hemorrhagic patches, and no fatty metamor- 
phosis or sclerosis of the cellular or connective-tissue elements of the retina. 
There is, however, a diffuse inflammatory infiltrate, the cell-portion of which 
becomes developed, at least in part, into connective tissue. The serous and 
fibrinous exudation and the new formation of connective tissue are very 
destructive to the nerve-elements of the retina; and, as these changes con- 
centrate for the most part in the neighborhood of the macula lutea, the vision 
is likely to suffer correspondingly. 
Treatment.—When recognized early, and when the superficial or anterior 
layers of the retina are chiefly implicated, very decided benefit may be 
expected to follow an energetic constitutional coux-se of mercury with iodide 
of potassium. 
Retinitis Lencaemica. 
This form of retinitis, first described byLiebreich, is characterized by pallor 
of the retinal vessels, and also of the optic disk, the boundaries of which are 
indistinct. Hemorrhages appear at various points of the membrane. About 
the macula lutea and around the optic disk are visible, in the retina, numerous 
white patches and round bodies, multiplying anteriorly, and hemmed in by 
red zones. They are seen also along the course of the vessels. The white 
patches consist of sclerosed nerve-fibres, while the round bodies are made up 
of an aggregation of lymphoid corpuscles, the abundance of which constitutes 
the distinguishing peculiarity of the disease. The blood extravasations work 
no small havoc, causing not only atrophy of the nerve-fibres and destruction 
of the ganglionic cells of the retina, but also wasting of the choroid and the 
vitreous humor. The disease attacks both eyes, and is the result of an 
anxemic state of the system. 
The treatment is that proper in a case of ansemia, although permanent 
benefit is not likely to follow medication. 
Retinitis Pigmentosa. 
Retinitis pigmentosa, first described by Ammon, is an affection involving 
all the layers of the retina, and consists in a slowly-progressing connective- 
tissue and pigment-cell proliferation of the entire membrane, with wasting of 
its nerve-elements. 
The disease is most common in males, is often hereditary, and begins at a 
very early period of life; indeed, it may be congenital. Both eyes are attacked 
simultaneously, though occasionally only one suffers. DETACHMENT OF THE RETINA. 
239 
Symptoms.—The earliest rational signs of the disease are night-blindness, 
from torpor of the retina, loss of peripheral and at length of central vision, 
as the region of the macula lutea is crowded, followed by complete blind- 
ness, a result rarely deferred beyond forty years of age. 
The ophthalmoscopic appearances are very characteristic. Masses of black 
pigment are seen scattered over the retina, particularly at the periphery 
and on the under side of the membrane. These local accumulations of pig- 
ment in many places resemble in some respects the bone lacunee and cana- 
liculi (Fig. 1873) of the Haversian system, each consisting of a central mass, 
with radiating and strag- 
gling rays or branches. 
Frequently the pigmenta- 
tion is seen in a linear 
form, as it follows the 
course of the vessels. The 
walls of the latter are 
thickened, though the di- 
ameter of their canals is 
very much less than nor- 
mal. The structural al- 
terations are not limited 
to the retina; the choroid 
becomes thinner and its 
vessels sclerosed; the optic 
disk grows opaque and 
atrophied, and the vitre- 
ous body exhibits mem- 
branous shreds in its sub- 
stance. 
Causes. — Among the 
causes which are believed 
to be potential in the de- 
velopment of the disease 
is the marriage of blood- 
relations. Its occurrence in several members of the same family gives 
importance to the theory of hereditary causation. 
Treatment.—Beyond attention to the general health and protecting the 
eyes against irritants, nothing can be done to cure the disease or to retard 
its progress. 
Fig. 1873. 
Retinitis pigmentosa. 
Detachment or separation of the retina from the choroid may be partial 
or general. It is met with oftencr in one eye than in both, and occurs some- 
times very suddenly, though more frequently gradually. 
The detachment is caused by an effusion of an albuminous fluid, mingled 
with fragments of pigment and lymph-corpuscles, between the retina and 
the choroid. 
Among the rational or subjective signs is some impairment of vision, most 
marked when the central portion of the retina is involved. Objects may be 
seen when the eye is turned in one direction, but are invisible when it is 
moved in another. The patient frequently complains of floating muscse. 
Examined by the ophthalmoscope, little difficulty will be experienced in 
recognizing in well-marked cases the true state of the parts. Once detached, 
the retina falls into plications and floats forward towards the anterior part 
of the eye (Fig. 1874) ; indeed, this may be so marked as to be detected by 
the unaided eye, appearing in the form of a bluish cloud or sac. If the 
examination be made before the detachment is much advanced, wave-like 
undulations of the membrane will be seen. Later on, as the disease pro- 
gresses and the effusion increases, a distinct gray or paste-colored elevation 
Detachment of the Retina. will appear. Occasionally the detached portion of the retina will present 
a brown appearance, indicative of the effusion being mingled with blood, 
the result of hemorrhage. 
By carefully observing the blood- 
vessels of the optic disk, the diagnosis 
will be rendered more certain. These 
will be found, even in the early stage 
of the detachment, to have a dark 
color, to be abruptly turned towards 
the centre of the eye, and to be tortu- 
ous, the bends being abrupt at some 
points and at others serpentine. In 
those portions of the retina which re- 
main in contact with the choroid will 
be seen small white patches, tinged in 
spots with a faint color of red. These 
spots are unlike in their character, 
being in one place made up of lymph, 
while in other places they consist of 
coiled blood-vessels. 
Detachment of the retina is followed 
by softening of the vitreous, and, ulti- 
mately, by destruction of the rods and cones, either by softening or by 
pressure from inflammatory new formation of fibrous tissue. 
Causes.—The causes which determine detachment of the retina are trau- 
matic and inflammatory, also alterations of form in the ball, parasites, and 
morbid growths. 
When produced by traumatism, it is noteworthy that the detachment often 
occurs at a point opposite to that on which the injury has been received. 
Among the inflammatory conditions eventuating in the detachment are 
choroiditis, irido-cyclitis, and neuro-retinitis. 
Most common of all causes is an antero-posterior elongation of the ball, or 
myopia, the retina in such cases, from want of elasticity, being unable to 
stretch with the choroid and sclerotic. The movements of a cystieercus cellu- 
lose may also produce detachment, and so may the growth of a choroid tumor. 
Prognosis.—Detachment of the retina in most instances proves unfavor- 
able. Occasionally the separation reaches a certain point and then remains 
stationary. 
Treatment.—The treatment resolves itself into the medicinal and the 
operative. 
The medicinal consists in enforced rest or confinement of the patient to his 
room, alternating with periods of out-door exercise; the use of a compress 
and bandage over the eye; gentle cathartics; and abstinence from reading, 
writing, etc. The absorption of the effused fluids will be favored by the 
judicious use of a mercurial, which should not be pressed to ptyalism ; also 
by the hypodermic use of pilocarpine. 
Operative treatment has been practiced with some degree of success by 
Hirschberg, Graefe, Bowman, Arlt, Wolfe, and others. 
The operations of Graefe and Bowman consist in establishing a communi- 
cation between the vitreous and the subretinal space, which is effected by 
separating the eyelids with a spring speculum, then holding the ball with 
the fixation forceps in a position to enable the operator to make a puncture 
through the sclerotic, opposite to the detachment, with a knife (Graefe) or a 
lancet-pointed needle (Bowman uses two such simultaneously), with which 
the retina is pierced and divided to some extent. 
Wolfe, after-fixing the ball, the patient being under an anaesthetic, divides 
first the conjunctiva and subconjunctival tissue covering the sclera, and, after 
exposing the latter over the most prominent portion of the detachment, 
pierces the sclerotic, choroid, and retina with a sclerotome, an instrument 
240 
DISEASES AND INJURIES OF TEE EYE AND ITS APPENDAGES. 
Fig. 1874. 
Detachment of the retina. TUMORS OF THE RETINA. 
241 
not materially differing in form from the lancet-shaped needle of Bowman. 
The lips of the wound are then held asunder by delicate hooks, and the fluid 
allowed to escape through the opening thus made, being assisted by gentle 
pressure made on the ball of the eye. Relief in a number of instances 
has doubtless followed these operations, and in a very few cases, it is be- 
lieved, was permanent; oftener, however, the benefit was but temporary, 
and not unfrequently an aggravation of the disease resulted. 
Drainage, by the use of a seton of gold wire introduced through the scle- 
rotic, choroid, and retina, has been practiced by Yon Wecker, but without 
much success. 
Tumors of the Retina. 
The morbid growths which originate in the retina are very limited in 
number: they are fungus liaematodes, or glioma, as described by Yirchow, 
sarcoma, cystoma, and vascular and tubercular formations. 
Glioma is a disease of childhood, commencing in the connective tissue, 
probably in the deep granular layer of the retina. It is made up of small 
round cells, and is extremely rapid in its growth, filling up the eyeball, and 
at length rupturing the sclera, and protruding as a fungoid, bleeding mass of 
granulations between the eyelids, or possibly, should the sclerotic give way 
posteriorly, extending into the orbit. The disease is prone to contaminate 
other organs by metastatic deposits, and also to travel back along the optic 
nerve to the brain. 
The rational symptoms are loss of sight without pain or inflammation, 
dilatation of the pupil, and a bright reflection from the deep part of the 
eye. 
Examined by the ophthalmoscope, the retina will be seen detached, its 
vessels small, tangled, or retiform, and behind them appear small wThite 
patches, which coalesce to form nodules. With the gi'owth of the tumor the 
lens becomes opaque, is pushed forward towards the cornea, and at length 
fills up the chambers of the eye. 
' The diagnosis of glioma is not always an easy task, especially in the early 
history of these growths, as the lens may be advanced and the depth of the 
chambers diminished by the products of an inflammation of the ciliary body 
or choroid: at all events, eyeballs have been enucleated under such circum- 
stances for morbid growths. 
Treatment.—The early and rapid dissemination of the disease renders it 
exceedingly important to institute prompt operative measures. The enucle- 
ation of the ball, with removal of the contents of the orbit, offers the 
only chance of recovery,—a result seldom realised. 
Sarcoma of the retina does not differ materially from round-celled sarcoma 
elsewhere. It is most common in children, is rapid in its growth, and pos- 
sesses a tendency to establish, by transfer, similar growths in other parts of 
the body. Sarcoma of the retina may be secondary to similar disease of the 
choroid. 
The disease may appear without giving rise to any pain or causing any 
unusual alteration in the appearance of the eye, the first recognized symptom 
being the loss of sight, followed by a dilated pupil and a yellowish reflection 
from the fundus of the eye. Left to pursue its course without surgical in- 
terference, the growth projects into the vitreous humor, filling the eye, and 
at length rupturing the sclerotic coat and protruding from the as a foul, 
bleeding mass. 
Treatment.—Early removal of the eye offers the only hope of cure for 
the patient; and even this often fails. 
Cysts of the retina are met with, both single and multiple. There is reason 
to believe that in some instances they have an inflammatory origin. The situ- 242 
ation of these productions varies; they are occasionally observed anteriorly 
or at the junction of the retina with the corpus ciliare, but more commonly 
occur farther back, over the external surface of the membrane. They appear 
as transparent vesicles, and are believed to be made up of a transformation 
of the components of portions of the outer granular layer of the retina into a 
material resembling, if not identical with, colloid matter, inclosed in a wall 
formed from the connective-tissue fibres. 
No treatment, medical or surgical, promises material relief. 
DISEASES AND INJURIES OF THE EYE AND ITS APPEND A OES. 
Vascular growths are also described as among the morbid formations in 
the retina. These appear to spring from the walls of diseased vessels, and 
are finally converted into connective tissue. Examples of such growths are 
seen in glaucomatous eyes. 
Tubercular disease of the retina is almost phenomenal, the disease having 
been witnessed only in one or two instances. 
DISEASES OF THE OPTIC NERVE. 
At one time considerable importance was attached to certain conditions 
observed in the optic nerve, as indicative of cerebral or meningeal disease. 
More extended observation, however, has shown that only when associated 
with other phenomena do they possess any diagnostic value. 
The affections of the optic nerve requiring consideration are neuritis, 
atrophy, hemiopia, amblyopia, and amaurosis. 
Inflammation of the optic nerve is frequently associated with a similar 
condition of the retina (neuro-retinitis). 
In optic neuritis the appearances disclosed by the ophthalmoscope are in- 
creased vascularity, and a certain degree of swelling of the nerve, in which 
the contiguous portions of the retina participate. The effect of this vascular 
engorgement and serous transudation is not only to destroy the normal dark- 
red appearance of the optic disk and render it opaque, but also to diminish its 
peripheral distinctness or definition. As the disease advances and the nerve 
becomes more swollen, from infiltration and new formation of connective-tissue 
elements, the disk becomes striated, and the definition between its margin 
and that of the retina is almost wholly lost, the one passing insensibly into 
the other. In consequence of the swelling of the optic disk, its prominence 
above the plane of the retina is in most instances quite noticeable, and gives 
a curve or bend to the vessels of the retina which are obliged to surmount 
the elevation. The veins are dilated and rendered tortuous in consequence 
of the obstruction to the returning blood-current from the swelling of the 
nerve, especially where it passes through the lamina cribrosa of the sclerotic 
coat, wTiile the arteries are comparatively empty, and small spots of extrava- 
sated blood may also be observed about the border of the disk. 
Inflammation of the optic nerve may commence both within and without 
the eye. When beginning in the disk and traveling back towards the lam- 
ina cribrosa, it constitutes 'papillitis, a term synonymous with the “Stauungs- 
Papillre” of Graefe, the choked disk, and the ascending neuritis of Wells. Ex- 
traocular neuritis (descending neuritis)—for the knowledge of which we are 
indebted to Graefe—is frequently connected with intracranial disease, as 
meningitis and morbid growths. The same relation may be said to exist 
between intracranial disease and papillitis, though in a less degree. In cases 
belonging to this category both nerves are usually implicated, though numer- 
ous exceptions to this rule have been noted. 
Besides the above-mentioned causes, others, as syphilis, pyaemia, typhoid 
fever, violent straining in vomiting, disorders of menstruation, certain exan- 
Optic Neuritis. OPTIC NEURITIS. 
243 
themata, as measles and erysipelas, embolism of the central artery of the 
retina, and intraorbital cellulitis, have been rfecognized as being concerned in 
the production of the disease. 
It is not difficult to understand why the optic nerve should suffer from en- 
gorgement and inflammatory infiltration in cases of disease, both within the 
cranium and within the orbit, especially when such affections act obstruc- 
tively, embarrassing the circulation of the nerve. The unyielding character 
of the cribriform portion of the sclera not allowing of any enlargement 
conduces especially to such obstruction, much in the same way as the stric- 
ture of a strangulated hernia causes the congestion and swelling of the con- 
tents of the sac. The obstruction to the circulation in the optic nerve is not 
due alone to such causes as interfere with the blood entering the cavernous 
sinus, as there are a sufficient number of communications between the great 
central veins of the retina and the upper ophthalmic veins to meet, to some 
extent, such an emergency,—a fact emphasized by Sesemann,—but, as has 
been shown by the elaborate investigations of Schwalbe, to a communication 
between the arachnoid space and the sheath of the optic nerve, by which 
the fluid of the former, from any cause producing intracranial tension, is 
pressed into the latter as a diverticulum. This fluid, as well as that derived 
by transudation from the vessels of the nerve, is detained at the circumfer- 
ence of the optic disk, giving rise to the swollen and raised appearance of the 
latter so often seen in optic neuritis; it may also, if the pressure continues 
unrelieved, pass on into the retina. The tortuous condition of the veins and 
the diminished size of the arteries find their explanation also in the obstruc- 
tion to the flow of the venous blood towards the sinuses and that of the 
arteries towards the papill®. Nor are the inflammatory changes in optic 
neuritis limited to the nerves, as transudation in time takes place into their 
sheaths (peri-neuritis). 
The effect of inflammatory products being poured into the optic nerve is 
to cause atrophy of its nerve-elements, contraction of the visual field, and 
finally loss of function. 
The rational or subjective signs of optic neuritis in its early stages are 
not uniform. Many instances of the disease occur in which no noticeable im- 
pairment of vision exists; generally, however, when the patient applies for 
relief the disease has made considerable progress and the sight is materially 
affected. Sometimes the loss of vision is sudden; at other times there are 
premonitory phenomena, as flashes or brilliant coruscations of light, with 
kaleidoscopic changes of color and forms, double vision, and a sluggish pupil. 
When optic neuritis is developed from intracranial disease there will not un- 
frequently have been a precedent history of vertigo, nausea, derangement of 
the nerves of special sense, and convulsions. 
Optic neuritis presents some ophthalmoscopic appearances not unlike 
those observed in nephritic disease, but may be distinguished from it by an 
examination of the urine. 
Prognosis.—The outlook in a case of optic neuritis is, in most instances, 
very unpromising. The most favorable cases are those in which the onset of 
the disease is sudden and in which the loss of sight is immediate or occurs in 
five or six hours, as in such cases the condition is one of engorgement, and the 
cause of a temporary nature. A favorable termination is also probable when 
the neuritis has a syphilitic causation. In children the prognosis is more 
favorable than in adults. When the disease is secondary to intracranial 
trouble, the danger does not terminate with the loss of vision, but the life 
of the patient is at stake. 
Treatment.—This must be determined by the nature of the cause which 
gives rise to the disease. When the signs of general vascular tension are 
present, the local or even general abstraction of blood will be indicated, 
followed by alterative doses of mercury, with occasional administration of 
bromide of potassium. When the determining cause is referable to disorders 
of the menstrual function, our remedies must be directed to the correction of 244 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
those disorders; when a syphilitic origin, either acquired or transmitted, can 
be detected, full doses of iodide of potassium will be demanded. 
Cases of optic neuritis secondary to brain disease can be met only by 
cerebral and cardiac sedatives, as bromide or iodide of potassium, and tinc- 
ture of aconite or of veratrum viride; also by blisters or setons applied to 
the back of the neck. 
Atrophy of the Optic Nerve. 
Atrophy may commence primarily in the nerve, either from causes which 
rob the latter of a sufficient blood-supply or in consequence of inflammatory 
disease propagated by continuity of tissue from the brain or the spinal cord. 
There is also an atrophy due to the excessive use of alcohol and tobacco, 
to venereal excesses and syphilis, to erysipelas and menstrual derangements, 
and to the poisonous effects of lead. The disease is a frequent accompani- 
ment of ataxy. Nothing, however, constitutes so fruitful a source of atrophy 
as disease of the brain or of the spinal cord. 
Men suffer more frequently than women. Unless the disease follows as a 
result of previous inflammation of the choroid or the retina, both eyes are 
generally affected. 
Symptoms.—The subjective symptoms of optic-nerve atrophy are dimness 
of vision and contraction of the visual field. Strong lights are avoided, and 
the transition from the latter to those more subdued increases the difficulty 
of seeing. Objects appear veiled in a thin haze or fog. The perception of 
colors is lost to some extent, and there follows a loss of central or peripheral 
vision, and afterwards of acuity of sight. 
Examined by the ophthalmoscope, the nerve-disk is seen to have lost its 
faint pink color and to be abnormally opaque, gray, or even white, partic- 
ularly when the nerve-elements have wasted and there has been an increase 
or hypertrophy of connective tissue. The lamina cribrosa becomes distinct, as 
a result of changes in the neurine, giving the spotted appearance or the light 
and dark shades to the disk, and reflecting a bluish-white color. The nerve 
will also be seen to be excavated or concave, its edges, whether regular 
or irregular, being sharply defined and bounded by the dark color of the 
choroid. (Fig. 1875.) With the atrophy of the nerve usually follows that 
of its vessels,—the arteries to a greater 
degree than the veins,—which appear as 
faint lines and render the pallor of the 
papillae more pronounced. This condi- 
tion of the vessels is particularly marked 
in those cases of atrophy which have 
been preceded by choroido-retinitis or 
retinitis. 
The pathological changes which are 
noticed in atrophy, and which have been 
carefully studied by Charcot and others, 
begin sometimes in the nerve-fibres 
(parenchymatous atrophy), which be- 
come grayish white, softened, broken 
down, and shrink away from their 
sheaths. At other times the morbid 
process begins in the connective tissue 
(interstitial atrophy), the hypertrophy 
and sclerosis of which gradually de- 
stroy the nerves by compression. The very common connection between 
atrophy of the optic nerves and disease of the medulla spinalis and of the 
brain should, in all cases of the affection, suggest a careful inquiry into the 
state of the spinal and cerebral centres. 
Prognosis.—The prognosis is far from encouraging. In cases having a 
Fig. 1875. 
Atrophy of tlie optic nerve. AMBLYOPIC AFFECTIONS. 
245 
constitutional causation of a kind amenable to therapeutic agencies, as 
syphilis, rheumatism, and the like, amelioration of the disease may be antici- 
pated ; but, with these exceptions, the resources of the physician merely 
retard the march of the disease. 
Treatment.—In the treatment of atrophy the remedies must be directed 
either to removing the causes concerned in originating or maintaining the 
disease, or to lessening their intensity. The agents which have been found 
to exert the best effects are iodide of potassium, bichloride of mercury, and, 
after a time, strychnia, or a combination of the latter with dilute phosphoric 
acid. These remedies should be pushed with boldness, or until the evidences 
of their constitutional action appear. Phosphate of zinc, nitrate of silver, 
iodide of iron, and other remedies have been recommended, but without any 
sufficient claim upon professional confidence. 
Hemiopia. 
The term hemiopia is of Greek derivation (fyuaos, “half,” and “sight”), 
and signifies half-vision, or a condition in -which similar portions of the visual 
field in the two eyes are destroyed, as well as the perception of colors. 
This affection first became known to the profession in 1841, through Dr. 
Wollaston, who himself suffered from two temporary attacks of the disease. 
When the loss of vision is on the same side of both eyes,—right or left 
halves,—the term homonymous hemiopia has been introduced to express the 
condition; the words temporal and nasal are also employed to designate the 
particular halves of the two retinas involved. The disease may affect one or 
both nerves. 
A patient suffering from hemiopia, whether looking at an object with one 
or with both eyes, sees only one-half. The line of definition which separates 
the visible from the invisible portions of objects falling within the visual field 
is generally sharp, clear, and well defined in homonymous hemiopia, though 
much less distinct in the temporal and nasal forms. 
The explanation of this singular form of blindness depends upon the 
anatomical theory of a semi-decussation of nerve-fibres in the optic chiasm. 
Causes.—The causes of hemiopia are to be sought for within the cranium. 
Cerebral syphilis, hemorrhage, and tuberculosis are among the most common, 
and when affecting the optic nerves or those portions of the brain in con- 
nection with their roots, as the corpora quadrigemina, thalami optici, corpora 
geniculata, or the gray matter of the posterior lobes of the cerebrum, this 
disease may follow. When limited to one side, the cause must necessarily 
be located in the corresponding nerve and anterior to the chiasm. 
Prognosis.—The prognosis is unfavorable. Kecovery is not to be ex- 
pected. 
Treatment.—The remedies which promise an alleviation are iodide of 
potassium and mercury. 
Amblyopic Affections. 
The older writers employed the term amaurosis in a loose sense. With 
them it conveyed no definite idea of lesion, but merely expi’essed the fact 
that the cause of blindness was not discoverable by the eye, or by means 
then at the command of the surgeon. Graefe restricted amblyopic affections 
to those instances of blindness, partial or complete, produced by extraocular 
causes. 
The term amblyopia is applied to cases in which objects are only discovered 
with difficulty; or it may be that the ability to discover is lost, and that 
there remains only the perception of light. In many instances under this 
head the field of vision is not contracted, only the distinctness with which 
objects are seen is lost or diminished. Strabismus is commonly found to 
accompany such cases. 246 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
By amaurosis is meant total loss of vision, the patient not being able 
to distinguish light from darkness. The pupil is often dilated and not re- 
sponsive to light. The countenance is vacant, and the patient walks with 
the head somewhat elevated. When the interior of the eye is examined 
by the ophthalmoscope in these affections, nothing abnormal, either in the 
refracting media or in the tunics of the organ, can be discovered. 
A classification of amblyopic diseases has been based on the various causes 
which produce them. Thus, we have,— 
1. Traumatic amblyopia, in which the visual defect follows violence inflicted 
upon the eye, skull, or spinal column, affecting the fibres of the optic nerve, 
either within the skull or within the orbit, or, it may be, the roots of the 
nerve at some point in the brain. It is no uncommon occurrence to see 
loss of sight or imperfect sight follow fractures involving the anterior cere- 
bral fossa, in which the optic nerve or its commissure is liable to suffer, 
either from rupture of some of its fibres or by pressure from the extravasa- 
tion of blood. 
2. Pathological amblyopia.—Under this head may be included the presence 
of tumors—pressing on the roots of the optic nerves and destroying their 
conductibility—and syphilis; also those cases in which the failure or loss 
of vision occurs from extreme exhaustion following hemorrhages from the 
stomach, lungs, or uterus; or nervous exhaustion from venereal excesses. 
To these may be added cases of epilepsy, protracted vomiting, and headache, 
megrim, retinitis, meningitis, periostitis of the base of the skull, post-ocular 
neuritis, and wasting of the optic nerves, conditions which often give rise to 
irregularities or breaks in the visual field, in which the patient is annoyed 
by spots or scotomata,—central or peripheral; also gray degeneration of the 
posterior and inflammation of the lateral columns of the medulla spinalis. 
The effect of many of these-pathological conditions on the nutrition of the 
optic nerves is such as to produce their atrophy. When following spinal 
injuries, the latter is most probably due to some damage sustained by the 
sympathetic nerve. 
3. Toxic amblyopia.—Under this head come amblyopia and amaurosis from 
tobacco, alcohol, diabetes mellitus, lead, quinine, and uraemia. 
Professional opinion is somewhat divided on tobacco amblyopia, first de- 
scribed by Mackenzie. A number of Continental writers do not believe in its 
existence, the reasons given for their disbelief being based on the infrequency 
of the disease among tobacco-using people, as the Germans, the French, and 
the Turks; while, on the other hand, Critchett, Hutchinson, and others firmly 
believe in the affection, regarding the pathological condition as one form of 
atrophy of the optic nerve. It cannot be denied that among intemperate 
smokers and drinkers there is often seen a failure of vision, characterized by 
an obscuration of sight, as though objects were viewed through a thin veil 
or haze, notwithstanding the field of vision may remain unchanged and the 
perception of colors unimpaired. In the early history of these cases the 
ophthalmoscope reveals nothing more than an undue vascularity and some 
opacity of the optic disk. 
4. Modifications of retinal sensibility constitute another variety of ambly- 
opic blindness, as in hysterical amaurosis from diminished sensibility of the 
retina; also night-blindness, moon-blindness, and snow-blindness from a 
similar cause, the retina having been previously subjected to the intense glare 
of natural or artificial lights. 
Prognosis.—Any opinion as to the future of a case of amblyopia, or amau- 
rosis, should be given with great caution, and only after carefully traversing 
the whole field of possible causation. 
Treatment.—Considered in the order of classification, we have first the 
traumatic variety, in which a hope may be entertained, should the violence 
not have been too intense, that, as the hemorrhagic or inflammatory products 
are absorbed, the vision will improve. 
The attention of the physician in such cases, therefore, should be directed AMBLYOPIC AFFECTIONS. 
247 
to the employment of those remedies which favor absorption, as iodide of 
potassium or small doses of mercury, followod in the course of a few weeks 
by strychnia, in order to wake up the sensibility of the retina. 
In pathological amblyopia the prognosis must be based on the power of 
the physician to remove or modify the cause. If syphilitic, large doses 
of iodide of potassium may be administered with advantage. When from 
extreme exhaustion, the result of hemorrhage or other conditions, tonics, 
especially those in which iron and strychnia form a part, with good blood- 
making food and wine, will be indicated. 
In toxic amblyopia, that, for example, referable to the poisonous influence 
of tobacco and stimulants, it is only necessary for the patient to discard 
smoking and the use of alcohol, and, if the disease is not advanced, recovery 
may be expected. When the ophthalmoscope reveals central scotomata, little 
or no improvement may be anticipated. 
That variety of amblyopia occasionally witnessed as the result of large 
doses of quinine, being most probably congestive in its character, should 
be treated by leeching if it does not disappear with the subsidence of 
cinchonism. 
When the disease arises from the use of certain mineral substances, as lead, 
both eyes are affected, and iodide of potassium constitutes the best remedy; 
when from affections of the kidneys—uraemic—following Bright’s disease, 
scarlet fever, typhoid fever, and diphtheria, the treatment must be directed 
as much as possible to the correction of the renal disease. 
Uraemic amblyopia is generally preceded by headache, dyspnoea, and con- 
vulsions. 
Retinal Anaesthesia exists in eases of night-blindness,—hemeralopia,—in 
which the patient, though seeing well during the day, discerns objects im- 
perfectly and with difficulty towards evening, and perhaps not at all at night. 
The pupil is dilated and somewhat insensible to the stimulus of light, con- 
junctivitis is often present, and there is inability to distinguish certain colors, 
especially blue, red, and violet. In retinitis pigmentosa in which there is 
also night-blindness, the pupil is contracted, a condition which, independently 
of ophthalmoscopic inspection, will serve to distinguish between the two 
affections. Night-blindness affects both eyes, and is frequently accompanied 
by defect in the power of accommodation. 
Hemeralopia depends more on general than on local causes, and is found 
among sailors, soldiers, and other classes of patients who have been exposed 
to hardships and deprived of sufficient food, or of food of a proper quality: 
hence it is frequently the companion of scurvy. 
The treatment best adapted to this form of blindness includes a mixed, 
generous diet, and red wine, together with cod-liver oil, iron, and quinine. 
All strong lights must be avoided, and often it will expedite the cure to ex- 
clude light entirely for eight or ten days, and then gradually accustom the 
eyes to the change from darkness to light. 
Two other affections referable to retinal anaesthesia are snow-blindness and 
day-blindness (nyctalopia),—the former caused by the strong glare from the 
snow, and the latter by sunlight. Almost every one has experienced in some 
degree this kind of blindness when the eyes havo been exposed to the con- 
ditions named. The function of the retina is temporarily suspended or weak- 
ened by the intensity of the stimulus, just as sapid substances of concentrated 
strength or sounds of great power may for a brief period weaken the taste 
or obtund the hearing. A like condition has been experienced by persons 
who have ascended very high mountains, induced, it is thought, by vascular 
congestion of the eye from diminished atmospheric pressure. 
Persons suffering from these forms of blindness have the central field of 
vision tolerably clear, while the periphery is concealed or veiled under a cloud 
or mist. 
In treating cases of this nature it will be necessary to guard the eyes 248 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
against strong lights, natural and artificial, possibly excluding all light, and, 
as in other varieties of central anaesthesia, gradually to accustom the organs 
to the daylight. Cod-liver oil, with tincture of the chloride of iron, may also 
be administered, except when the signs of congestion are present, in which 
case these remedies should bo preceded by the local abstraction of blood and 
by a gentle cathartic. Strychnia, either by the mouth or hypodermically, in 
all cases of obstinate retinal anaesthesia, will be found valuable in arousing 
the membrane from its torpor. 
Hysterical amblyopia constitutes another example of retinal anaesthesia. 
It may be confined to one eye, or may extend to both, and is often incomplete 
or involves one-half of the visual field. Women are more commonly the sub- 
jects of this variety of amblyopia than men, and it is preceded by a condition 
of bad health, or by different emotional phenomena, such as are peculiar to 
hysterical patients. 
Cases of this character are best treated by tonics, antispasmodics, bathing, 
fresh air, and nutritious food, observing also to remove as much as possible 
all causes calculated to excite nervous disturbance. In one case which came 
under my care, the patient, a young lady, was promptly cured by a visit 
from her betrothed. 
Color-Blindness, or Achromatopsia. 
Tlie capacity to appreciate colors has become a subject of practical and 
vital importance. In those occupations, such as railroading and seafaring, 
where, in order to combine safety with speed, it becomes necessary to use 
signals, it is exceedingly important that engineers and others should be 
able clearly to distinguish colors. In 1777 the first papers on the subject 
were published in London by Huddart, but it was not until seventeen years 
later—1794—that the subject assumed its true importance, under the name 
of Daltonism, from the distinguished English chemist, Dalton, who was him- 
self color-blind, and who published a paper on the subject, based on his own 
peculiar sight. Since that time numerous papers and treatises have ap- 
peared, among the authors of which may be mentioned Goethe in 1805 ; 
Professor Wilson, of Edinburgh, in 1853; Holmgren, of Sweden, in 1874; 
Jeffries, of Boston, and Thompson, of Philadelphia, in 1880. 
Typical color-blindness is more common in men than in women, being 
about from three to five per cent, of the former, and two or three per cent, 
of the latter; instances of dullness of color-perception are very much more 
common. 
This form of blindness is in most instances congenital, but sometimes is the 
product of disease, and is bilateral. It most commonly is transmitted 
through the maternal line of antecedents, and particularly where matrimonial 
alliances have been formed between blood-relations. 
It is said by Professor Wilson to be common among persons belonging to 
the Society of Friends. This has been attributed to causes connected with 
intermarriage. If this supposition is correct, the chromatic defect should 
exist among Hebrews, though I know of no observations which have been 
made on this point. Professor Wilson narrates a curious mistake growing 
out of color-blindness, in which a minister of the Society of Friends, in re- 
plenishing his wardrobe, purchased for his wife a bottle-green dress, and for 
himself a coat of scarlet red, instead of the customary drab color. 
The same writer, in an article on color-blindness, alludes to a certain 
peculiarity of expression which betrays the defect. This is described as a 
vacant, sometimes a startled, look, of so marked a character as scarcely to 
escape detection. 
Jeffries, of Boston, has called attention to the same fact, observing that 
the eyes of those so affected have a liquid, slightly suffused appearance, 
looking as though the person was entirely uninterested in what is being said. 
The most common form of color-blindness is that in which red is mistaken SIMULATED BLINDNESS. 
249 
for green, or green for yellow. A distinction must be observed between ab- 
solute blindness for certain colors—as where red is mistaken for black, or 
orange for gray or drab—and mere dullness to perceive color. The dis- 
tinction is well founded, as there are many persons who, though unable to 
recognize faint tints of certain colors, as, for example, red, yet readity per- 
ceive the more brilliant shades of the same color (dyschrornatopsia). 
Landolt has shown that the color-sense of the retina for the appreciation 
of the primary colors—namely, green, red, yellow, blue—in the healthy eye 
is confined within certain limits, blue constituting the horizon of this sense, 
as no color beyond this can be seen. 
Santonin, when pushed to the extent of causing poisonous effects, so modi- 
fies the color-sense that everything presents a yellow tint. 
Acquired color-blindness may proceed from a variety of pathological con- 
ditions, as optic neuritis, syphilitic retinitis, alcoholism, disease of the brain, 
and occasionally uterine disorders. 
Whether or not the seat of the recognition of color is in the retina has not, 
I believe, been clearly ascertained. There are some pathological facts, as, 
for example, the disorganization of a portion of the retina without in any 
way affecting the appreciation of color, which point to some portion of the 
brain as ministering to that office. 
Helmholtz’s theory places the color-perception in three different portions 
of the retina, each answering to a fundamental color, as red, green, violet, 
all intermediate tints being the result of a simultaneous stimulation of the 
different nerve-elements. The discovery of a principle in the retina which 
Bell designates erythropsine, and which in the presence of light is believed to 
form different combinations, constituting color-perception, may yet modify 
our view on this complex and subtile question. 
In testing the color-perception of eyes, a simple method is that of Holm- 
gren, in which colored worsteds of different tints and of different shades of 
the same tints are placed upon a white background before the patient, in 
order that he may discriminate between the colors, or be required to match 
them. A more accurate plan is that in which the person is required to view 
the test-objects through the spectroscope, and then to select from a number 
of colored worsteds the colors which he saw in the instrument. 
Treatment.—For congenital color-blindness no treatment can avail any- 
thing, and when the affection has been induced by disease, the restoration of 
the sense will depend altogether on the removability of the cause. 
Simulated Blindness. 
This kind of malingering is by no means uncommon among soldiers and 
hysterical females. 
In determining the question of binocular total blindness, the pupils should 
be examined, and if found responsive to light, alternately contracting and 
dilating as the latter is allowed to enter the organ or is excluded from it, 
there is reason to believe that the loss of sight is feigned. A cunning patient 
may render the deception more complete by the instillation of atropia into 
the eye. It has been suggested, in order to detect this imposition, that a 
portion of the aqueous humor be drawn off by paracentesis and applied to 
a sound eye. If atropia has been employed, its characteristic effect on the 
pupil will be produced and the fraud exposed. 
Si mulled monocular blindness is more easily detected. Different plans 
are in use for this purpose, of which twro only need be named,—one based on 
the presence of double vision, and the other on the induction of a temporary 
squint. The first method is that of Graefe, in which a prism of ten or fifteen 
degrees, with its base either upward or downward, is placed before the sound 
eye, both being open ; when the patient is asked if the instrument improves 
the sight, should ho say that it produces diplopia he is deceiving, as only 
during the presence of binocular vision could he have the phenomenon of 250 
DISEASES AND INJURIES OF THE EVE AND ITS APPENDAGES. 
double vision. The other plan, that of Yon Welz, is carried into practice by 
placing before one eye a prism of the same degree as that used 
in the Graefe method, with its base either to the temporal or the nasal side 
of the organ. If this is followed by a squint, or if any change takes place 
in the axis of the two eyes after the removal of the prism, there can be no 
doubt that the patient sees with both eyes. 
Embolism of the Central Artery of the Retina. 
Embolism of the central artery of the retina, first recognized by Graefe in 
1858, is among the accidents following disease of the heart and arteries, 
Bright’s disease, pregnancy, and embolic plugging of the vessels of the brain. 
The thrombosis, though almost always occupying the post-ocular portion of 
the artery, has been seen in one of its branches within the retina. 
Symptoms.—Sudden loss of sight, or total blindness, constitutes the first 
symptom of the affection. When examined b}*" the ophthalmoscope, the 
vessels of the retina and the optic disk are seen to be very small and con- 
tracted from the absence of blood, and from the same cause the optic disk is 
usually pale, though not opaque. The veins at some points are well filled, 
and at others are quite small and collapsed. Small masses of thrombi may 
also be detected in the vessels. After fifteen or twenty days a change takes 
place at the termination of the retinal vessels, or in the macula, the latter 
becoming opaque. 
Knapp calls attention to the diagnostic significance of pulsation in the 
retinal arteries as a sign of embolic plugging, alleging that during the first 
week no beating in these vessels could be discovei*ed by making pressure on 
the eyeball when the main or central artery was obstructed. Hemorrhagic 
infarctions are occasionally among the accidents attending plugging of the 
retinal vessels. 
When the embolism is seated in the central or parent trunk of the retinal 
vessels, incurable blindness must follow. 
The term glaucoma at one time had a very wide signification, being applied 
to various morbid states of the eye. After a time it came to be used in a 
more restricted sense, or was applied only to those conditions in which a 
peculiar sea-green color was observed in the pupil: hence its derivation from 
the Greek word ykauxuc; (“green”). It was not until the introduction of the 
ophthalmoscope into ophthalmic medicine that the nature of glaucoma was 
understood or that the word assumed a definite significance. 
The disease affects, for the most part, persons after middle life,—men and 
women alike. There are two forms of the disease, the inflammatory and the 
non-inflammatory. 
Inflammatory glaucoma may be acute or chronic, affecting one or both 
eyes. 
Acute glaucoma.—The acute variety sets in suddenly with ciliary neuralgia, 
the pain affecting the eye, eyebrow, and temple. Very soon there follow 
signs of increased vascularity in the vessels of the conjunctiva and the scle- 
rotic coat, with more or less oedema of the con junctiva and of the eyelids. The 
vision likewise grows dim, progressively or periodically, objects—for example, 
a lighted candle—appearing to be concealed in or seen through a haze and 
tinted with the various prismatic colors and encircled by a red limbos. With 
these signs, and not unfrequently preceding them, there has been a gradual 
receding of the near point of vision,—presbyopia,—in consequence of pressure 
on those branches of the ciliai*y nerves which contain motor filaments and 
energize the muscle of accommodation. There is also increased tension or 
hardness of the eye, easily detected by pressure being made upon the ball 
through the lids, and particularly so when one eye remains unaffected and can 
be used for comparison. The pupil is enlarged and sluggish, and the cornea 
Glaucoma. GLA UCOMA. 
251 
somewhat insensible from the pressure sustained by the ciliary nerves. The 
anterior chamber becomes shallow from the advance of the crystalline lens 
and the iris, and the fundus of the eye obscured by turbidity of the aqueous 
humor and other media of the eye. The lessening of the visual field most 
frequently commences at the nasal side, extending outward towards the tem- 
poral side, until at length the patient finds himself in midnight darkness. The 
opaque condition of the dioptric media renders, in most instances, ophthal- 
moscopic examinations fruitless. It is the contact of the bluish-gray or tur- 
bid aqueous humor with the ordinary senile yellow of the lens which produces 
the peculiar green color belonging to glaucoma. When examination with the 
ophthalmoscope is feasible, and the fundus of the eye can be illuminated suf- 
ficiently for study, the veins of the retina wull be seen to be enlarged, tortuous, 
and probably pulsating, and, as the hardness of the ball increases, pulsation 
in the arteries also becomes evident. The optic disk, early in the commence- 
ment of the disease, exhibits the signs of venous engorgement, being intensely 
red, except at its margin, which is girt about by a white ring having a faintly 
yellow tint, while a pit, depression, or excavation will be detected in the optic 
nerve, over the margin of which may be seen the vessels curving. (Fig. 1876.) 
The phenomena—namely, pain, opacity 
of the dioptric media, and muscular pa- 
resis—which belong to glaucoma are 
such as result from intraocular pressure. 
Chronic inflammatory glaucoma.—When 
the inflammation pursues a chronic 
course, the symptoms already detailed 
as characterizing the acute form of the 
disease creep on so stealthily that often 
serious and hopeless structural changes 
have taken place before the patient 
applies for relief. 
Non-inflammatory glaucoma, or simple 
glaucoma, is that variety in which the 
tension of the ball, not a marked feature, 
and the other symptoms steal on almost 
unobserved, and without any evidences 
whatever of an inflammatory factor. 
Everything on the surface of the eye 
appears healthy, nor are there any ap- 
pearances in the iris or in the refractive media of the eye which disclose the 
mischief already intrenched in the organ. The failure of sight, especially 
for near objects, might readily be referred to advancing years, inasmuch as 
this disease belongs to middle and later life. It will also be observed that 
the tension, unlike that of inflammatory glaucoma, is confined to the pos- 
terior half of the ball and is unattended by any lessening in the depth of 
the anterior chamber. The pupil is slightly dilated; the optic nerve is deeply 
excavated, so that the retinal vessels cannot be seen beyond the margin of 
the chiasm. The optic disk is quite white. The chromatic spectra are absent, 
unless, as may happen, an inflammatory complication sets in. 
Both eyes suffer either simultaneously or with a short interval between 
the two attacks. 
Cases of glaucoma occur in which the loss of sight is sudden, the work of 
a few hours,—glaucoma fulminans. 
Fia. 187G. 
Excavation of the optic nerve in glaucoma. 
Secondary Glaucoma is a term applied to cases in which the ordinary signs 
of glaucoma follow some other affection of the eye, as staphyloma of the cor- 
nea, choroiditis, cyclitis, displacement of the lens, and retinal hemorrhages 
(<glaucoma hemorrhagicum). The introduction of atropia into the eye has, in 
acute cases of glaucoma, and also when intraocular tumors existed, caused 
sudden glaucoma by favoring hemorrhage. 252 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
Etiology.—Various theories have been advanced to explain the proxi- 
mate cause of glaucoma. Heredity constitutes a predisposing cause. Graefe 
believed the primary factor to be choroiditis or irido-choroiditis, in which 
opinion he is joined by Mauthner. Tavignot, Wolfe, Donders, Adamiik, and 
Hutchinson contend for a neurotic causation. Priestly Smith and others in- 
sist on the element of obstruction due to the space of communication be- 
tween the vitreous and the anterior chamber—namely, at the ciliary border 
of the lens—being contracted ; while Jaeger believes that the first link in the 
disease is seated in the optic nerve. 
Those who advocate the nervous theory find in the experiments of Griin- 
hagen, Ilippel, Wegner, and others much to fortify their opinion. Those 
who assume a primary obstructive cause point to the dissections of Knies, 
in which the canal of Fontana was uniformly found obliterated. The 
champions of the nervous doctrine find in a hypersesthesia of the sympa- 
thetic nerve, the motor and regulating nerve of the ocular circulation, a satis- 
factory explanation of the increased accumulation of the fluids of the eye, 
causing the characteristic tension of glaucoma; while others, in common 
with Donders, believe these phenomena to be the sequence of a similar state 
of the fifth pair of nerves. 
As glaucoma appears generally in persons over fifty or sixty years of age, 
it is reasonable to believe that the initial link is one in some way connected 
with senile changes of structure, which are known to give rise to alterations 
in the nutritive changes of tissues elsewhere, ending in inflammation. Such 
changes and the resultant inflammation are quite sufficient to explain the 
close adhesion between the iris, the ciliary body, and the sclero-corneal junc- 
tion,—thus obstructing the canal of Fontana,—and also the increased accu- 
mulation of fluid, as well as of cell-forms, causing ocular tension and opacity 
of the dioptric media. 
Treatment.—Had Graefe contributed nothing else to ophthalmic surgery 
than the discovery that intraocular tension could be lessened by iridectomy, 
his name would be entitled to everlasting remembrance. This operation 
should be done early, particularly in that variety of glaucoma which has 
been described as glaucoma fulminans. In iridectomy a number of ciliary 
nerves are necessarily removed along with the excised portion of the iris, 
and to this fact some writers attribute the diminished intraocular pressure; 
others, as Exner, are disposed to attribute this condition to the removal of a 
number of the minute blood-vessels of the iris, and the consequent transfer of a 
portion of the blood from the arterial to the venous system of the part, directly 
through anastomosing branches, independent of the capillaries. The iridec- 
tomy should be done through the corneo-sclerotic line, or as near the anterior 
free border of the iris as possible, and a large portion of the muscle excised 
up to the ciliary body. Should nothing contra-indicate, the iridectomy should 
be made above, as the evils resulting from a large pupil are somewhat cor- 
rected by the descent of the lid. When the relief is partial, it may be neces- 
sary to repeat the operation on the iris at a place opposite to the first. In 
a few instances iridectomy has aggravated rather than improved the con- 
dition of the eye. The result of iridectomy is sometimes rendered negative 
on account of hemorrhage, yet after the extravasated blood has been ab- 
sorbed—the work generally of four or five weeks—the vision improves and 
the pain disappears. Even in what is called glaucoma absolutum, or in total 
blindness, iridectomy is not contra-indicated, as thereby pain and tension are 
diminished. 
Sclerotomy has been recommended and practiced by De Wecker in certain 
cases of glaucoma, those, for example, in which the disease is just com- 
mencing, as in glaucoma simplex, and where the vision is little impaired. 
The operation is performed by first securing, through the instillation of 
eserine, the contraction of the pupil and then entering a Graefe knife through 
the corneo-sclerotic limbus on one side, and pushing it across the anterior 
chamber and out through a corresponding point on the opposite side, after DISLOCATION OF THE CRYSTALLINE LENS. 
253 
which, by a sawing motion, the blade is made to enlarge the incision to the 
extent of about one-quarter of an inch on each side. The knife, before its 
removal, is then to be turned in such a way as to make the wound gape and 
allow the aqueous humor to escape. The subsequent treatment will be the 
same as that proper after iridectomy. 
A sufficient number of cases have not been recorded to justify the substitu- 
tion of sclerotomy for iridectom}^; in the acute variety of the disease it is 
altogether improper, from the probability of causing cataract. 
Assuming that glaucoma is caused by spasmodic contraction of the ciliary 
muscle, Hancock proposed and performed ciliary myotomy. The opera- 
tion was done by pushing the ordinary cataract-knife through the sclero- 
corneal line, on the outer side of the eye, thus dividing the ciliary body and 
muscle, and entering the vitreous humor. In the early stage of glaucoma 
very decided benefit will often follow the procedure; and even when it has 
failed, I have never seen any evil follow the wound. 
The instillation of a solution of eserine (grs. iv, distilled water, on the 
eye is occasionally resorted to when, from any cause, the patient is either not 
in a condition or is unwilling to have the operation of iridectomy performed. 
The property possessed by this drug of diminishing ocular tension renders 
it applicable to cases of the disease. 
Atropia should not be employed in cases of glaucoma, as the symptoms 
are likely to be aggravated by its use. 
DISEASES OF THE CRYSTALLINE LENS AND ITS CAPSULE. 
The crystalline lens rests in an excavation in the anterior face of the vit- 
reous body, and is held in position principally by the suspensory ligament. 
The lens changes its form at different periods of life: at first, in the infant, 
approaching in form a spherical figure, it becomes more and more flattened 
as age advances. The density of the lens increases from the circumference 
to the centre or nucleus. It is inclosed in a capsule of elastic homogeneous 
substance, which not only surrounds the lens, but has a vital union with it, 
there being a layer of epithelium between the lens and the capsule, which is 
subservient both to the growth and the nutrition of the former. Both capsule 
and lens in health are transparent, without any shade of color, in the young, 
but as age advances the lens begins to exhibit a faint yellow hue. 
Congenital Absence of the crystalline lens, except as occurring through 
some morbid process during intra-uterine life, is not mentioned by writers 
on ophthalmic surgery. 
Dislocation of the Lens may be complete or incomplete, congenital or the 
result of disease or traumatism. The various positions occupied by the lens 
when displaced are in the posterior chamber, in the pupil, in the anterior 
chamber, buried in the vitreous body, and, in rare cases, under the conjunctiva, 
having passed through a rent in the sclerotic. When not wholly unseated, 
the lens sometimes is seen to swing about, though still moored to the ciliary 
body by a few threads of tissue. 
Symptoms.—The discovery of a luxated lens is not a matter of difficulty. 
The body may be seen with the unaided eye floating in the aqueous humor, 
or, if not, can readily be detected by the ophthalmoscope. The refraction 
also is changed. 
Treatment.—When the lens occupies the anterior chamber, it should be 
extracted through an incision made in the cornea by the Graefe or Beer’s 
knife. The only difficulty likely to be encountered is the tendency in the 
body to recede through the pupil into the posterior chamber. When this is 
the case, it may become necessary to oppose the retrograde motion by a cat- 
aract-needle passed through the posterior chamber forward through the 
pupil and thrust into the substance of the lens, resisting its recession and 254 
DISEASES AND INJURIES OF TIIE EYE AND ITS APPENDAGES. 
favoring the extraction. Cases of incomplete luxation, in which the lens 
remains in the posterior chamber, require no operation unless irritation is 
developed in the eye. The defect in refraction which arises can be materially 
corrected by proper or astigmatic glasses. 
Cataract. 
The word cataract is of Greek origin (from xarafiaaaeiv,“ to flow quickly”), 
based on the supposition entertained by the old writers that the disease was 
due to an effusion of a watery fluid posterior to the pupil. 
Cataract is defined to bo an opacity of the crystalline lens, of its capsule, or 
of both: hence the terms capsular, lenticular, and capsulo-lenticular cataract. 
Causes.—Anything interfering with the nutrition of the lens may be 
regarded as a cause of cataract. These changes in nutrition are often too 
obscure to be recognized. They are sometimes primary, that is, beginning 
in the crystalline lens, and sometimes secondary to inflammatory, senile, or 
other alterations in contiguous structures. The nutrition of the lens being 
affected through the vitreous body and the aqueous humor, whatever alters 
the constitution of the latter or the structure of the former must inter- 
fere with the nutrition of the lens. Under the head of causation may be 
noticed,— 
1. Senility.—A very large proportion of all cataracts are met with after fifty 
years of age, and are connected with changes which belong to advancing 
years, as defective circulation, atheroma, etc. Of 512 patients with mature 
or hard catai'acts, the average age I find to be fifty-five years. 
2. Traumatism.—Penetrating wounds of the eyes, either from entering the 
capsule or by damaging the iris or choroid, contusions of the ball, and in- 
tense, concentrated vibrations transmitted through the walls of the orbit by 
injuries to the head, frequently produce cataract from inflammatory results. 
These contusions and vibrations are often sufficient to rupture the capsule, 
allowing the aqueous humor to enter the substance of the lens, and causing 
its opacity. 
Besides the above causes, cataracts are known to follow the presence of 
saccharine urine. Of 438 persons operated on for cataract in the Azimgurh 
Hospital, India, 2 suffered from diabetes. Meyer mentions cases in which 
the cataract seems to have been connected with ergotism, and Rothmund 
others (infantile) apparently depending on dense scaly disease of the skin. 
It is by no means clear that either ergot or ichthyosis has any such deter- 
mining influence. I am not aware that among all the phenomena attending 
ergotism, collected by the French when investigating the subject of gangrene 
following the use of diseased rye, cataract was once observed. 
Various terms are employed in the description of cataracts : 1st, stationary 
and advancing cataracts, suggested by the progress of the opacity; 2d, hard 
and soft, based on the property of density; 3d, central and cortical, according 
as the nuclear or the peripheral portion is involved (Fig. 1877) ; 4th, mature and 
immature, as the opacity includes the peripheral or the 
cortical substance, or when the latter partly or wholly 
retains its transparency; 5th, simple and complicated, 
the former when the lens alone of the structures of 
the eye is diseased, and the latter when it is con- 
nected with other affections of the organ; 6th, posterior 
polar and antero-capsular, the first when the vitreous 
aspect of the lens is opaque, the second when there is 
cloudiness of the anterior capsule or of the anterior 
lens-substance : the first condition is often asssociated 
with inflammatory changes of the choroid and retina; 7th, conical cataract, 
in which the nuclear portion of the lens assumes a pyramidal form; 8th, 
lamellar, sometimes called zonular or congenital, from a portion of the sub- 
stance of the lens between the nuclear and the cortical portion being opaque. 
Fig. 1877. 
Cortical cataract. CATARACT. 
255 
This opacity does not extend to the periphery of the lens, and consequently 
may not materially disturb the vision, except in compelling the patient to 
hold objects very near the eye, a habit which in time may render the indi- 
vidual myopic. Congenital cataract is often associated with involuntary 
muscular movements of the eyelids, with amblyopia, and with oscillating 
eyeballs (nystagmus), conditions unfavorable for and often forbidding opera- 
tions, the cataract being complicated by inflammation of the choroid or 
retina. Fre}Ter reports in 512 cases of cataract only 1 case congenital. 9th. 
Another variety of cataract, capsular, is thought by some writers, as Muller 
and Schweigger, to have no existence. They allege that the primary changes 
which produce the opacity begin between the lens and the capsule, the latter 
not participating in the morbid process. Those who entertain this view 
believe that the real opacity is made up of layers of a dense substance 
behind the capsule, the adhesion of which to the latter conveys the im- 
pression of the disease being capsular. Nevertheless, there are other 
authorities, equally respectable, who recognize, and on sufficient grounds, 
capsular cataract as a primary affection. That this variety of catai’act is 
frequently consecutive to inflammatory disease of the iris and choroid ad- 
mits of no doubt; so common is this connection that a prominent surgeon, 
when the opacity of the capsule is found to exist, never undertakes an opera- 
tion before subjecting the eye to a most critical examination, in order to 
ascertain if any such complication exists. 10th. Still another variety is 
the capsulo-lenticular, a term which sufficiently explains itself, the disease 
involving both the lens and its capsule. 
Symptoms.—Among the earliest signs of cataract is dimness or indistinct- 
ness of vision, increased by looking at objects in a strong light: hence pa- 
tients laboring under the affection, when reading letters, are wont to turn the 
back to the window admitting the sunlight, a position which favors the dila- 
tation of the pupil and exposes the peripheral portion of the lens to the light. 
When the cataract is well formed, its presence can generally be detected by 
the unaided eye, the pupil being occupied by a grayish-white body, which is 
the diseased lens. To discover cataract in its early stages or incipiency the 
use of the ophthalmoscope is necessary. The examination will be facili- 
tated by previously dilating the pupil with atropia. The mh*ror only is 
to be used, either by oblique or direct illumination. In the event of any 
opacity existing in the lens, it will be detected. The observer must not for- 
get, while studying the interior of the eye, those cloudy changes in the lens- 
structure which are incident to advanced life, and which counterfeit, to some 
extent, the opacity of cataract. The diagnosis will often be rendered more 
certain by supplementing the mirror with'a convex lens held between the 
ophthalmoscope and the observer, and under a moderate light. The ap- 
pearances thus disclosed vary with the nature of the cataract. 
Cortical cataract.—In the cortical variety numerous gray or dark stripes 
or lines w'ill be seen running from the periphery of the lens, where the 
change commences, towards the centre, and, when fully formed or ripe, pre- 
senting a bluish or opalescent appearance. This variety of cataract rapidly 
advances to maturity. When binocular and in young subjects, the ex- 
istence of saccharine urine may bo suspected. 
Nuclear cataract, which is the form most common to aged persons, presents 
a yellow or amber color, and has a very hard or firm consistence. The cor- 
tical portion is not exempt from the morbid process, but gradually changes 
from translucency to opacity, though never becoming so hard as tho nuclear 
portion. As in cortical cataract, the stripes or lines are seen to run from 
the circumference towards the centre of the lens. The progress of nuclear 
cataracts is in many instances quite slow, occupying sometimes several years 
before their maturity is attained. Their relative density can be approxi- 
mately determined by noting the color and the form of the opacities, being 
for the most part soft when, in addition to the deep opacity, the color is 
steel-gray and the opacities in spots and widely disseminated. 256 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
Lamellar cataract, as already stated, is usually congenital, and when ex- 
amined by the ophthalmoscope the opacity of the cortical substance of the 
lens is seen to be uniform, having a gray color. The nucleus retains its trans- 
parency, the chief opacity of the cortical portion being in those laminae next 
to the nucleus, while the more superficial ones remain sufficiently free to 
admit of the transmission of light. Dark stripes and specks may also be 
present, especially when the disease is advancing. 
Traumatic cataract, or cataract resulting from external injury, usually 
forms rapidly, depending, of course, on the extent of the damage to the 
capsule. When the opening in the latter is large, a portion of the lens-struc- 
ture may escape and cause inflammation in the adjoining parts of the eye; 
or the aqueous humor, entering the rent, may cause swelling of the lens, 
and produce much irritation from pressure. The admission of the aqueous 
humor within the capsule will occasionally effect the solution of the lens, 
leaving only a small, shapeless, dark, or mottled mass at the bottom of the 
posterior chamber; or, if only partly absorbed, the capsule will, in adapt- 
ing itself to the diminished size of the lens-substance, become wrinkled and 
thickened. When the opening into the capsule is very small, it some- 
times heals up, leaving only a very slight opacity answering to the cicatrix. 
The danger to the eye in traumatic cataract is greater in the aged than in 
the young. 
Capsular cataract, or that form of cataract in which there is a new forma- 
tion between the capsule and the lens, which new material is prone to undergo 
a cretaceous transformation, frequently has its origin in some inflammatory 
state of the choroid or in an irido-choroiditis. An opacity of the anterior 
face of the capsule may also exist from traumatism, or as a sequel of a 
perforating ulcer of the cornea, in which the lens is swept forward by the 
escape of the aqueous humor, until it comes in contact with the cornea. 
The reaccumulation of the fluid, as the ulcer heals, presses the lens back 
again into its place, but the damage sustained by the capsule remains, and is 
likely to induce structural alterations of the adjacent cortical portions of the 
lens. Capsular cataracts often exhibit a chalk-white appearance. 
Before the introduction of the ophthalmoscope into ophthalmic surgery, 
the catoptric test wras resorted to for the discovery of cataract. When a lighted 
taper is moved before a sound eye, three images will be seen, two erect and 
one inverted. One of the former is reflected from the cornea, and the other 
from the anterior part of the lens; the last, or the inverted image, is re- 
flected from the concave posterior surface of the lens or capsule. (Fig. 
Fig. 1878. 
Illustration of the catoptric test: A, cornea; B, anterior surface of the lens; C, 
anterior surface of the posterior face of the lens; D, candle; 1, anterior erect image 
seen on the cornea; 2, erect image on the front of the lens; 3, middle and inverted 
image formed by the posterior face of the lens. 
1878.) "When the lens has become opaque, the inverted image is wanting, 
and after a time the upright one is reflected from its anterior surface. 
This is the explanation of the catoptric test. 
Treatment.—Drugs possess no power to retard the progress or to cause 
the absorption of a cataraetous lens. It is probable that the disease may be CATARACT. 
257 
hastened by disorders of the digestive apparatus, or by agencies which dis- 
turb the orderly operations of the body; consequently it will be proper to 
correct any derangements of the system which may be present; to effect 
which, attention must be given to the diet, exercise, exposure, and habits of 
the patient. The cure of cataract can be accomplished only by operative 
measures, and before these are described it will be proper to determine what 
conditions contra-indicate a resort to operation. 
1. When the vitreous humor is abnormally soft,—a sign of intraocular in- 
flammation, especially of choroiditis,—nothing favorable can be expected from 
an operation. The same may be said when there is a tremulous iris, another 
evidence of a softened viti’eous. 
2. Feeble health is also a bar to operation, predisposing, as it does, to 
sloughing of the cornea or to low forms of inflammation of the internal 
tunics of the organ. The experience of Freyer* in a series of 512 opera- 
tions for catai-act, in which the patients could not be selected, establishes 
beyond question the favorable influence of general good health, the failures 
being 24.5 per cent. The same operator has shown the influence of tem- 
perature on the ratio of success. Of 296 operations done in the cool season 
of India, 84 per cent, had excellent vision ; while of 210 operations performed 
during the warm season, less than 64 per cent, had good vision. The ordi- 
nary causes of failure are iritis, simple and plastic, irido-choroiditis and cy- 
clitis, softened vitreous, sloughing of the cornea, suppuration, etc. In such 
cases the constitution must, by diet, food, and proper surroundings, be restored 
to a reasonable degree of vigor before the removal of the diseased lens is 
attempted. 
3. A severe chronic cough forbids operative interference, as it not only dis- 
turbs the regular circulation of the eye, but renders it impossible to secure 
that absolute quiet which is so necessary to recovery. 
4. An abnormally hard or glaucomatous ball is unsuited to the knife or the 
needle; indeed, any imperfection in the perception of light, or any contrac- 
tion in the field of vision, should awaken the suspicion of other lesions besides 
that of an opaque lens. These unfavorable conditions can be discovered 
best by placing the patient in a dark room and exposing the eyes to the light 
of a candle or lamp which is moved in different directions. Failure to per- 
ceive and to follow the light means, in all probability, retinal disease, and 
indicates the case to be unsuited for the knife. Even though there is a 
perception of light, if the field of vision is narrowed in any direction the 
situation is not altered. Much may be learned by noting the direction in 
which the vision is defective: thus, in commencing glaucoma or in disease 
of the optic nerve it is usually on the nasal, or the temporal side; if above 
or below, it indicates retinal detachment. 
5. The existence of an acute conjunctivitis, of a sclerotitis,—rheumatic or 
otherwise,—of lachrymal obstruction, or of fistula, renders an operation out 
of the question until the complication has been removed by treatment. 
Operations.—In all operations for the cure of cataract the object is to get 
rid of the opaque lens. This is done by extraction, solution, or reclination. 
Extraction.—According to Bbazes, the extraction of cataract was performed 
by surgeons about the end of the third and the beginning of the fourth cen- 
tury. The first well-authenticated instance of extraction, however, does not 
date beyond 1707, when the operation was done by St. Ives. Thirty-eight 
years later the method was practically formulated by another French sur- 
geon, named Daviel, to whom belongs the honor of placing on a substantial 
basis this process of removing an opaque lens. The original operation of 
Daviel has undergone various modifications in the hands of modern surgeons. 
As originally performed, the corneal flap was large and the pupil not interfered 
with. One of the great obstacles encountered in the operation was the diffi- 
culty of bringing the lens through the small aperture of the pupil, and, even 
in the hands of those trained to great delicacy and adroitness of manipulation, 
* London Lancet, August 30, 1879, vol. ii. pp. 313, 347. 258 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
the iris was often injured in the process and the eye lost. The discovery by 
Graefe that glaucoma can be cured or arrested in its progress by excising a 
portion of the iris, led the way to the introduction of iridectomy by Des- 
marres, in 1856, as a very important part of the process of extraction. This 
iridectomy, following the example of Mooren, was performed by some sur- 
geons two or three weeks before, and by others at the time of the extraction. 
To facilitate the extraction of the lens, Waldau invented a spoon-shaped in- 
strument, which, after the incision through the cornea, the enlargement of 
the pupil by iridectomy, and the laceration of the capsule, was introduced 
through the wound and carried behind the lens and used as a scoop. This 
scoop has undergone various modifications by Critchett, Bowman, and others. 
The instrument is made of different materials, as metal, bone, hard rubber, 
tortoise-shell, and wire, and of different shapes. (Big. 1879.) 
Fig. 1879. 
Spoons for extracting the lens. 
Jacobson’s plan consisted in forming a flap at the corneo-scleral line, followed 
by an iridectomy, which was done sometimes before and at other times after 
the extraction of the lens. This method had few advocates, and consequently 
fell into disuse. 
Linear extraction.—Travers, in 1814, resorted to a simple linear incision, 
not exceeding one-fourth of the corneal circumference, and through this ex- 
tracted the lens, either entire or in installments, by means of a curette. In 
his earlier operations by this plan, Travers first displaced the lens into the 
anterior chamber and then made the incision in the cornea. 
The operation of Adolph Weber may also be considered one of linear extrac- 
tion, the opening into the anterior chamber being made close to the corneo- 
scleral line with a broad, lance-shaped knife, the capsule lacerated by a double 
hook below and on each side, and the lens brought out by pressure on the 
ball below, while the posterior lip of the wound is pressed back by a curette. 
Modified linear extraction.—In 1865, Graefe introduced an operation for the 
extraction of cataract, termed the modified linear, in which the cornea was 
incised very near the peripheral insertion of the iris by a very narrow knife, 
the iris drawn out and a portion excised, and, after opening the capsule, 
the lens was coaxed out by pressure and counter-pressure made on the 
sclerotic and the cornea, or, in case of very hard cataracts, was removed 
by a hook. By this method the flap is exchanged for a linear incision. This 
operation has undergone various modifications in the hands of later surgeons, 
especially Wecker, Taylor, and Wolfe. 
Liebreich and Lebrun have each devised methods of operating, wThich 
do not materially differ, and which they assert avoid the evils both of the 
old flap and of the modified linear plan of Graefe, admitting of the extraction 
of the lens without either a preliminary iridectomy or the use of a scoop 
or hook, and without risk to the vitreous body. By both operations the in- 
cision is limited to the cornea,—that of Liebreich to the lower half, and 
slightly curved, with the convexity downward; and that of Lebrun to the 
upper half, with the convexity upward. In the latter operation the obliquity 
of the cut and the extent of the curve form a very short flap of the cornea, 
while in the former little or no flap is made. A slight difference also exists 
in the points of puncture and contra-puncture between the two methods,— 
the incision of Liebreich entering the sclerotic close to its junction with the 
cornea and passing out at a corresponding point on the opposite side, while 
that of Lebrun is restricted to the cornea. The knife used by both is one 
similar to that of Graefe, though smaller and more delicate. 
These operations, from their simplicity and ease of execution alone, it CATARACT. 
259 
might be supposed would necessarily enlist the interest of surgeons; and yet 
they are not very frequently employed. For, while the advantages claimed 
for these methods are well founded, there are certain attending evils which, 
in some measure, outweigh the anticipated good; for example, the liability 
to prolapse of the iris, its adhesion to the wound, and the numerous in- 
flammatory sequels which follow the accident. The delivery of the lens, 
moreover, may be greatly embarrassed by this prolapse, and in the event 
of the edges of the wound being tardy in uniting or becoming inflamed, 
there would probably follow an unfortunately-located opacity of the cor- 
nea, with such alterations in the curvature of the latter as to cause some 
vice of refraction. 
Conditions for and against operations for cataract.—1. In senile cataract an 
operation should be deferred until the lens is mature. For obvious reasons, 
when it is attempted too early, a portion of the soft cortical substance peels 
off during extraction through the sides of the wound, and under the action 
of the aqueous humor swells and becomes an irritant, causing inflammation by 
contact with the iris, ciliary body, or capsule. The exception to this rule is 
in cases where the lens shows a tendency to undergo fatty or calcareous de- 
generation, changes which might render a clean extraction difficult, if not 
impossible. 
2. The necessity for an operation upon a patient having a cataract in one 
eye, the other being sound, is questionable. It is proper to say that sur- 
geons differ on this point, some advocating interference on the ground that 
if the operation is successful, of which there is a strong probability under 
modern methods, the field of vision will be enlarged by the removal of the 
lens. The possibility of failure, however, cannot be denied, and in such an 
event the danger to the sound eye from sympathetic disease is considerable. 
3. Operations promise no good when the patient has no perception or 
very defective perception of light, indicating disease of the retina or of the 
optic nerve. In like manner the operation is contra-indicated when the visual 
field is contracted. If the upper or lower half of the field is found absent, 
it implies a detachment of the retina, and when the contraction is lateral, 
there is in all probability disease of the optic nerve. 
Perception of light can be conveniently tested by placing a luminous object, 
as a lighted taper or candle, some ten or twelve feet in front of the patient. 
If the object is not perceived, or only very faintly recognized, a suspicion 
of intraocular disease may be entertained, and a careful examination of 
the organ should be made. 
4. In cases of binocular cataract, synchronous operations should not, as 
a rule, be practiced. The proper course is to extract the lens which is most 
mature, and some time after recovery remove that of the other eye. In 
aged persons who have undergone a successful operation on one eye, it is not 
wise to insist on a similar procedui’e for the other. 
5. No extraction is proper during an acute inflammation of the conjunctiva, 
or of the other tunics of the eye; nor should the operation be made when 
there is present on the side of the diseased eye lachrymal epiphora or a 
fistula. All such complications must be removed by appropriate treatment 
before the removal of the lens is attempted. 
6. Preternatural softness or hardness of the eyeball is a condition un- 
favorable to extraction, as indicating antecedent inflammatory changes of 
structure. 
7. The association of cataract with saccharine urine (diabetic cataract) 
is not favorable for operation. 
8. The existence of an acute or a bad chronic cough, tubercular, bronchial, 
or catarrhal, or, indeed, any considerable impairment of the general health, 
forbids an extraction. 
Operation by flap extraction.—By this method the incision is limited to the 
cornea, and may be made either above or below, the operations differing very 
little in facility of execution, the latter perhaps being the easier of the two. 260 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
The instruments required are—1st, a Beer’s knife (Fig. 1880), with which to 
make the section of the cornea; this knife has undergone several modifica- 
Fig. 1880. 
Beer’s knife, two forms. 
tions, none of which, in my judgment, have materially improved the instru- 
ment ; 2d, a pair of rat-toothed forceps, with which to fix the eye; 3d, a 
cystotome (Fig. 1881), to divide the capsule; 4th, a curette, sometimes com- 
Fig. 1881. 
Cystotome. 
bined with a cystotome (Fig. 1882), for making pressure on the eyeball in 
order to direct the lens towards the place of exit and to coax out fragments 
Pig.1882. 
Curette and cystotome combined. 
of the cortical substance which may become detached, or coagula of blood, and 
to adjust with accuracy the edges of the corneal flap; 5th, a pair of blunt- 
pointed scissors, and also a blunt-pointed knife (Fig. 1883), for enlarging the 
Pig. 1883. 
wound in cases where the incision by the knife has not been sufficiently large 
to admit of the easy exit of the lens. 
Preparation of the patient.—It is desirable that a patient who is to be the 
subject of an extraction should, dui-ing the twenty-four hours preceding the 
operation, remain quietly in his room or ward; that his diet be plain, unirri- 
tating, and somewhat restricted, and that the bowels be freely moved by an 
aperient. 
At the time of the operation the patient should be placed in the recumbent 
position on a narrow table, and before a good light, preferably from the north, 
the pupil having been previously dilated by atropia. 
The administration of an anaesthetic must be determined by the composure 
and self-command of the person who is to undergo operation. Far better that 
one should not be employed. The operation is not a painful one, and a few 
words of assurance from the surgeon will generally remove any timidity which 
may be experienced and restore the tranquillity of the patient. The objec- 
tion to the use of anaesthetics is the vomiting which may ensue. Derby, of 
Boston, to settle the question of administering or withholding an anaesthetic 
in this operation, furnishes the results of two hundred cases of extraction. 
One hundred patients were operated on while under an anaesthetic, with eight 
losses; the second hundred without an anaesthetic, and with only a single loss. 
The operator takes his position either in front of or behind the patient, accord- 
'Blunt-pointed knife for enlarging corneal incision. CATARACT. 
261 
ing as he is able to use only one hand or employs both with equal readiness. 
Assuming that the eye to be operated on is the right one, and that the flap is 
to be made above, the surgeon, if he stands in front of the patient, seizes the 
conjunctiva and subconjunctival tissue, immediately below the cornea, with 
the fixation forceps, at the same time directing an assistant to raise the upper 
eyelid, either with the index and middle fingers or by the elevator. (Fig. 
1884.) Should the operator stand behind the patient’s head, he will himself 
command the upper lid, 
while the assistant stead- 
ies the ball with the fixa- 
tion forceps. After the 
operator, by experience, 
has acquired the neces- 
sary manual dexterity, 
he may lay aside the fix- 
ation forceps, and prevent the rolling inward of the eye by the gentle pressure 
of a finger against the nasal side of the sclerotic. Some surgeons employ 
the spring speculum (see Fig. 1864) for separating the lids. The instrument 
should be constructed and applied so as not to press against the ball of the 
eye. The eye being fixed, the operator, taking the knife in his right hand, 
and resting the little and ring fingers on the temple of the patient, enters the 
point of the instrument at the outer side of the equator of the cornea, and 
just within the junction of the latter with the sclerotic, and carries the knife 
steadily but slowly across the anterior chamber in front of the iris, making 
a counter-puncture at a corresponding opposite point, and completing the flap 
by the onward progress of the knife. (Fig. 1885.) In executing this part 
of the operation care must be observed 
not to lateralize the knife, a movement 
which would wedge the sides of the 
cut asunder, allow the aqueous humor 
to escape, and probably complicate 
the procedure by a prolapse of the 
iris. The secret of making this cut 
properly consists in maintaining the 
knife in a plane parallel with the iris, 
pressing its back against the pos- 
terior border of the cut, and keeping 
the eye directed on the point where 
it is desired to make the counter- 
puncture. If there remains a small 
bridge of corneal tissue undivided 
after the knife has been carried on- 
ward, the section can be completed 
by imparting a sawing motion to the 
knife, or by inclining its edge slightly 
forward as it is withdrawn from heel to point. 
This constitutes the first stage of the extraction, on the completion ol 
which the fixation forceps must be removed and the upper lid be released 
from the fingers. During the execution of this stage, and at its termination, 
the courage and self-possession of the patient will be sustained by a few as- 
suring words from the operator, as, “ Steady, very steady; you are behaving 
admirably,” or some similar phrase. 
A few moments’ rest, and the surgeon proceeds to the second step in the 
operation, namely, that of dividing the capsule and releasing the lens from 
its bed. In doing this, the upper lid is again to be gently raised from the eye, 
and the patient directed to look downward, after which the cystotome is to 
be carefully introduced through the wound, with its back downward. As 
soon as the edge of the pupil has been passed, the instrument is to be turned 
so as to bring its point or edge against the front of the capsule, the division 
Fig. 1884. 
Palpebral elevator. 
Fig. 1885. 
Cutting the corneal flap by the upper section. 262 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
of which is effected by moving the cystotome once or twice upward and 
downward, after which it is to be turned on the flat and withdrawn with the 
back upward, and with the same care as was exercised in its introduction. 
This part of the operation is to be done with precision and delicacy, other- 
wise there will be danger of toppling the lens over into the bottom of the 
posterior chamber, or of burying it in the vitreous humor. 
The third step consists in the delivery of the lens. The patient is again 
directed to look downward, and in this position of the organ the surgeon 
makes a moderate degree of pressure on the lower eyelid with the curette, 
while at the same time counter-pressure is cautiously applied to the ball 
above with the extremity of a finger, thus compelling the lens to pass through 
the pupil into the anterior chamber, and to move with its edge or equator 
towards, and glide through, the wound. (Fig. 1886). A little practice will 
soon confer the necessary adroitness in 
applying the pressure, especially that 
by the curette, which should be back- 
ward and upward, so as to force the 
lens in the desired direction. At this 
part of the process it may happen that 
the lens, in passing through, leaves a 
portion of the softened cortical sub- 
stance between the lips of the incision 
or in the anterior chamber; or, if the 
section has been too restricted, the lens 
may become impacted in the wound. 
In either case the curette again comes 
into use. In order to free the edges of 
the incision of the softened lens-sub- 
stance, or to float the latter out of the 
anterior chamber, the instrument 
should be insinuated into the wound, 
and one of its edges pressed a little 
away from the other, when the particles will make their exit, boime on the 
aqueous humor, which now flows towards the external opening. An impacted 
lens can be extracted either by the curette, the forceps, or the blunt hook. 
Should the lens not leave its bed and advance towards the wound, it will be 
because the capsule has not been sufficiently divided, in which event the 
cystotome should be reintroduced and a more extensive incision made, after 
which the manipulatory procedure must be repeated. It is not unusual to 
see the lens and capsule come out together, and should portions of the latter 
be discovered floating in the aqueous humor, they can be readily extracted 
by the iris forceps or hook. 
The extraction having been completed, the operator proceeds to the dress- 
ing. The edges of the wound are accurately adjusted and smoothed down 
by the curette, and the patient directed to close the eyelids gently. In 
this last act it is well to notice that, in descending, the upper lid does not 
catch on the edge of the flap and displace or turn it down. When satisfied 
that all is right, both eyelids are closed and secured by a few strips of thin 
plaster, like that made from the peritoneum of the bullock; over this is 
applied a compress, consisting of two thicknesses of soft patent lint or of 
charpie, a piece of soft old linen being interposed between the latter and the 
eyelids, and the whole made secure by a few turns of a light binocular band- 
age. In adjusting the bandage, care is to be observed that it is neither too 
tightly nor too loosely applied, the pressure being such as to cause no discom- 
fort to the patient. The patient is next placed in bed, in a room where the 
light is partially excluded, and entire quiet enjoined. During the first two 
or three days and nights succeeding the operation the patient should be care- 
fully watched, so that he shall not unconsciously in his sleep interfere with 
the dressing. 
Fig. 1886. 
Compelling the exit of the lens. CATARACT. 
263 
Generally after the dressing the patient will experience some heat, smart- 
ing, or gritty feeling in the eye, but these, the result of friction, usually pass 
away after the lapse of six or seven hours. Should these symptoms be at all 
severe, or render the individual nervous, it will not be amiss to administer a 
small amount of morphia hypodermically or otherwise. Unless the patient 
experiences some very decided uneasiness, the bandage should not be removed 
sooner than thirty-six or forty hours following the operation, at which time 
the roller bandage and compresses should be taken off and the condition of 
the parts carefully examined. If the secretion is very moderate, it may be 
accepted as a favorable sign, and, after brushing away the moisture from the 
edges of the lids, using for the purpose a camel’s-hair brush dipped in warm 
water, a fresh compress and bandage should be applied, with the same care 
as in the original dressing. This procedure is to be repeated each succeeding 
day, and, after cleansing away the pasty secretions which accumulate, the com- 
fort of the patient will be enhanced by smearing over the eyelashes and along 
the edges of the lids a little vaseline or cold cream, which serves to prevent the 
adhesion of the latter and favors the escape of the tears. During this time 
the eyelids are not to be opened nor the eye exposed, unless some untoward 
or urgent symptoms appear. After the second day, when the union of the 
wound has taken place, a few drops of a solution of atropia (grs. ij to f“3i water) 
maybe insinuated between the angle of the lids: this is to be repeated daily, 
or even oftener, if it is deemed necessary. The bandage should be kept on 
the eyes for ten or twelve days, during four of which the patient must be 
confined to bed, and the eye not exposed earlier than the fifth day. After 
the removal of the dressing it will be necessary to protect the eye by the use 
of a shade, at the same time keeping the room somewhat dark. These pre- 
cautions are to be observed for seven or eight days longer, when at the end 
of two weeks the presumption is that the patient can be allowed to walk out, 
and may be discharged as cured, though the shade should not be laid aside 
for several days later. Occasionally a slight conjunctivitis lingers about the 
eye for some time after the wound in the cornea has cicatrized. This will 
be removed by the occasional use of astringent collyria. 
The diet after extraction must be regulated by the constitutional vigor 
and habits of the patient. For the first three days it should consist for the 
most part of milk and beef-tea. Solid food requiring mastication must be 
avoided, as the motion of the jaws is unfavorable to that perfect rest of the 
head and face which is so conducive to the process of healing. After the 
above period, animal food may be taken once a day, but it should be scraped 
into a pulp, so as to avoid the necessity for much chewing. At the same time 
cream-toast, eggs, and an occasional cup of tea can be allowed. Stimulants 
in moderation must not be withheld from patients who have been habituated 
to their use. It must not be forgotten that cataract is generally a disease of 
advanced life, when the vital powers have passed the meridian and demand 
support. 
Complications.—Not every case, however, proceeds in so favorable a man- 
ner. It may be that the discharge of tears, or a inuco-purulent secretion, 
becomes copious and the eye painful, accompanied by oedematous lids and a' 
feeling of roughness on the ball of the eye. The existence of these phe- 
nomena requires that the dressing be removed and the condition of the organ 
ascertained. The disturbance may be due to iritis, to prolapse of the iris, or 
to commencing suppuration of the ball. 
Iritis.—If iritis is the cause, it will probably be found that the inflammation 
has been provoked either by injury inflicted during the extraction or by some 
softened lens-substance which has remained behind, in which event, after 
separating the lids and exposing the eye to daylight or candle-light, the 
aqueous humor will be found cloudy, the color of the iris changed, its pupil 
contracted, and the conjunctiva chemosed. This complication rarely occurs 
earlier than the fourth or fifth day after the operation, and should be com- 
bated by the local abstraction of blood, the instillation of a strong solution 264 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
of atropia(grs. iij, water, fSi), and the administration of calomel in quarter- 
grain doses every three or four hours, which should not be pressed to the 
degree of causing tenderness of the gums : to prevent its purgative effect, it 
should be guarded by an occasional small dose of opium. 
Prolapse of the iris.—It may be discovered when the upper lid is raised 
that the corneal wound has opened and the iris prolapsed, causing the pro- 
fuse lachrymation, muco-purulent discharge, and swollen eyelids. 
The management of such an accident must be determined by the extent 
of the prolapse. It is useless to attempt the reduction of the protruding 
structure, and if the portion of iris which has slipped through the wound in 
the cornea is large, it will be proper to draw it out slightly with the forceps, 
so as to break up any slight adhesion which may have taken place, and clip 
it off with the scissors. The subsequent application of a strong solution of 
atropia to the eye maj7 relieve the wound of the intruder. When the pro- 
lapse is small, the lids should be closed and supported by a thin compress and 
roller drawn with moderate firmness. If the healing progresses, the iris 
will become consolidated with the cicatrix and the protruded part remain 
distended into a little sac or vesicle filled with the aqueous humor, which, 
being punctured from time to time, ultimately shrivels up to a level with the 
cicatrix. An iris thus tied to the cornea is likely to suffer from repeated 
attacks of inflammation, which may extend to the choroid and other portions 
of the eye, and demand at an early day an iridectomy, either to release the 
iris from its abnormal attachment or to establish a new pupil. 
Suppuration.—The most unfortunate complication, however, is suppura- 
tion, which, commencing in the sides of the wound, extends between the 
laminje of the cornea, destroying its transparency, and at length involves 
the other tunics of the eye in the general devastation. Whether the de- 
structive process begins primarily in the cornea, or originates in the iris and 
extends to the cornea, is not certainly known. The latter course would 
seem to be the more likely one, in view of the susceptibility of the iris to 
take on inflammation. 
The occurrence of suppuration is announced by swollen eyelids, a copious, 
thick, purulent discharge, and severe, often intolerable pain, accompanied by 
rigors and other constitutional disturbance. Only in broken-down constitu- 
tions does the condition exist with severe pain. 
The treatment of suppuration of the eye will sometimes, when early and 
perseveringly applied, result in the preservation of a portion of the cornea 
sufficiently transparent for the transmission of light, though too often the 
inflammatory process terminates onl}r when the contents of the eye have 
been destroyed, leaving a withered and collapsed stump, the remains of the 
former ball. 
The introduction of antiseptic liquids, as the bichloride of mercury (one 
to ten thousand), and the use of similar dressings, should lessen the tendency 
to suppurative accidents. The system will require tonics, good food, and 
probably the use of stimulants. Hot fomentations over the eye, of water 
alone, or of a decoction of chamomile-flowers, will give comfort. Pressure 
•by compress and bandage over the eye will be useful, by supporting the 
blood-vessels. 
Extraction by the lower flap is said to be more easily accomplished than by 
the upper section, just described: on this account it has been suggested that 
the beginner select this method (Fig. 1887) until, after a few operations, he 
has acquired the necessary manual tact and self-command. The difference 
in facility of execution, however, I do not regard as of sufficient moment to 
render this course necessary. Indeed, I think both plans should be practiced, 
as there are circumstances which often render one section better than the 
other. For example, an opacity of the upper portion of the cornea, in an 
eye with a cataractous lens, will necessitate the making of a lower flap. A 
lower flap is not likely to be displaced by the movements of the lids, an 
accident to which the operation by an upper flap is exposed. CATARACT. 
265 
Linear extraction.—This operation, the product of the fertile brain of 
Graefe, has furnished the basis for a number of ingenious and now popular 
methods for the removal of a cata- 
ractous lens. It is true that the ex- 
traction of an opaque lens through 
a linear wound had, as early as 
1811, been practiced by Gibson, and 
still later by Travers,—only, how- 
ever, in cases of soft cataract. 
Gibson introduced the plan in or- 
der to get rid of a very slowly 
disappearing lens, which had been 
previously treated by tbe needle; 
while, with more boldness, Travers, 
after lacerating the capsule, tilted 
the whole lens into the anterior 
chamber, and then coaxed it through a linear cut in the margin of the cornea. 
These operators did not, however, foresee the full importance or the extended 
application of their methods; indeed, they passed into disuse, until revived 
by Graefe and by Bowman, the former of whom has formulated the details 
of the operation with great minuteness. 
The pupil is first dilated with atropia, after which the eyelids are to be sepa- 
rated by a spring speculum, the patient having been previously placed under 
the influence of chloroform. With a lancet-shaped or iridectomy knife an 
opening is made two and a half lines in extent through the cornea, on its 
outer side, and a line from the sclerotic. After the withdrawal of the knife 
a cystotome is introduced through the opening, the capsule divided, and the 
lens extracted by the curette. In using the latter instrument, the delivery 
of the lens will be materially assisted if, while the inner side of the ball is 
pressed with a finger, the wound is made to gape, by pressing the sclerotic 
side of the corneal incision with the curette. This operation was adapted 
chiefly to the removal of cortical cataracts. In cases of senile cataract with 
a hard nucleus, the smallness of the incision through which the lens was com- 
pelled to pass exposed the iris to injury, and often left behind a quantity 
of soft cortical substance, which gave rise to serious irritation. Graefe was 
quick to perceive this, and subsequently modified the method, introducing 
what is now known as modified linear extraction. In performing this opera- 
tion, the eye is fixed by seizing the conjunctiva with the fixation forceps, 
close to the middle of the lower margin of the cornea, after which tbe point 
of a very sharp, narrow-bladed knife (Fig. 1888) is pushed into the cornea 
at the corneo-sclerotic line (temporal side) 
and carried onward and downward until 
opposite the pupil, when the point is to be 
raised by depressing the handle of the in- 
strument, and the counter-puncture made 
directly opposite the point of entrance. In 
completing the incision, as much of the 
wound as possible should be made on the 
inner side, by pressing the anterior part of the blade towards the temporal 
side, while the knife is at the same time pushed onward as far as possible. 
By this manoeuvre the heel of the knife fills the wound so completely as to 
prevent the escape of the aqueous humor, and also prolapse of the iris. The last 
stage of the incision consists in dividing the remaining bridge of corneal tissue 
on the outer side as the knife is withdrawn, in doing which the edge is in- 
clined a little forward, in order not to approach too near to the ciliary liga- 
ment, and at the same time to form a little flap of conjunctiva. The cut 
embraces about one-quarter of the circumference of the cornea. (Fig. 1889.) 
A portion of the iris is then drawn out with forceps or hook (Fig. 1890) 
and excised with the scissors. 
Fig. 1887. 
Lower flap section of the cornea. 
Fig. 1888. 
Graefe knife, two patterns. 266 
DISEASES AND INJURIES OF THE EVE AND ITS APPENDAGES. 
The capsule is next lacerated freely with the cystotome, and a scoop is 
introduced through the wound and slid gently down the posterior surface 
of the lens, after which the latter is carefully 
brought out. Should any of the cortical 
substance of the lens remain, the lids may 
be closed and gently rubbed, then separated, 
and the fragments coaxed out by the curette, 
or brought out with the scoop. 
In his later improvement of the linear 
method Graefe abandoned the scoop, using 
instead a vulcanite curette, which, after 
steadying the eye by picking up the con- 
junctiva at the inner and lower part of the 
ball with the fixation forceps, he applied 
immediately against the lower margin of 
the cornea, and pressed backward and up- 
ward. By this manipulation the upper edge 
of the lens is made to advance towards the 
wound, and then, by making the pressure directly backward, to engage in 
the wound, after which its expulsion is easily effected by sliding the curette 
upward over the cornea. 
Waldau’s operation.—The operation known as Waldau’s did not differ from 
the linear method, as first practiced by Graefe, except in the removal of the 
lens, whether hard or soft, by means of a spoon or scoop, somewhat differ- 
ently constructed from that of Graefe, and through an incision more re- 
stricted, being less than one-fourth the circumference of the cornea, neither 
of which could be regarded in the light of an improvement, as both pecu- 
liarities subjected the eye to injury from bruising, and from the retention of 
some remains of the lens. 
The scoop has undergone several modifications by English, German, and 
American operators, dictated by personal experience and taste; but as the oper- 
ation of extraction is more carefully studied and the cases multiply, the effect 
has been to lessen very much the enthusiasm of surgeons for these instruments. 
Mooren's method—The peculiarity of this plan of operation consists in 
making a preliminary iridectomy a few weeks (about three) before the ex 
traction. The object is to diminish the risks to the cornea, by lessening the 
extent of the operation. 
Liebreich's method.—As in the various operations described the incisions are 
all peripheral, some wholly within the cornea, some at the corneo-scleral line, 
and others commencing in the sclerotic, there is always some risk of escape 
of the vitreous humor, especially when a little softened. To obviate this acci- 
dent, and at the same time to leave the iris intact, Liebreich introduced a new 
operation, in which the incision lies wholly in the 
cornea, except where the knife enters and passes 
out, points which are over the sclera. The cut 
is made wTith a Graefe knife in the lower half of 
the cornea, and has a slight curve (convexity 
downward), which is made by the edge of the 
blade after the puncture and counter-puncture 
are made, being turned forward and downward 
(Fig. 1891) as it is withdrawn. After the cor- 
neal section has been completed, the capsule is 
opened and the lens started towards the wound 
by the conjoined pressure of a curette against 
the lower margin of the cornea and the finger 
of the operator, who, while holding the upper 
lid, makes pressure on the upper portion of the cornea. This pressure, made 
with unequal degrees by the curette and fingers, causes the wound to gape, 
and the lens to escape. 
Fig. 1889. 
Different positions of the knife in making the 
corneal incision. 
Fig. 1890. 
Iris hook. 
Fig. 1891. 
Liebreich’s incision. CATARACT. 
267 
The method of Wolfe, of Glasgow.—This surgeon describes a plan of operation 
for which he claims several advantages. Like Mooren, he performs a prelim- 
inary iridectomy. The section of the eornea is an upward and peripheral 
one, made by a Graefe knife, and to the extent of a millimetre more than 
one-third of the circumference. As the knife is withdrawn the capsule is 
cut, and a small bridge of corneal tissue left undivided. The speculum, with 
which the eyelids are held apart, is next removed. To be sure that the 
capsule has been divided, he introduces a cystotome and draws it across the 
front of the lens, and with the same instrument tilts or hooks it forward, 
some degree of pressure at the same time being made on the ball. As soon 
as the lens comes towards the wound, the small uncut bridge of the cornea is 
divided with a blunt knife, when by making pressure on the lower part of the 
ball and through the superior lid on the upper part, so as to cause the wound 
to gape, the lens is forced out. The advantages claimed by the operator for 
this procedure are the formation of a pupil exact in position and in form, 
and not liable to prolapse at the time of extraction; little liability of the 
vitreous humor to escape in consequence of the small bridge of corneal tissue 
being allowed to remain unsevered until late in the operation; and facility 
in the removal of the lens, there being no blood in the anterior chamber 
to conceal this body from view while being extracted. 
Secondary Cataract. 
The term secondary cataract is used to designate a condition in which an 
overmature lenticular cataract is followed by thickening of its capsule; or 
when after the extraction of a cataractous lens the capsule assumes a pli- 
cated or wrinkled form; or when some of the debris of the lens is left behind 
during an extraction and becomes fastened to the capsule; or when retro- 
gressive changes commence in the lens, leaving it a shrunken, shapeless 
mass. 
Treatment.—If secondary cataract follows an operation for extraction, 
no attempt should be made for twelve or fifteen months to get rid of the 
body by operation. When the time arrives for interference,—that is, after 
the eye has recovered thoroughly from the effects of precedent treatment, 
—the surgeon, after separating the lids with a speculum, can proceed to in- 
troduce a cataract-needle through the cornea and onward into the capsule, 
lacerating the latter in various directions. Should it glide away from the 
instrument or refuse to yield, a second ndedle should follow the first (the 
plan of Bowman), inserted through the nasal side of the cornea, and, these 
being made to penetrate the membrane, its disorganization can be effected 
either by employing one of the instruments to fix the obstructing body, while 
the other is busied with its laceration, or by using both needles at the 
same time in twisting and tearing the cataract to pieces. Cases may be en- 
countered where the membrane is so tough that the needles fail to effect its 
reduction without exerting a force which might damage the iris or the vitre- 
ous, especially where adhesions between these parts exist. Better success 
will follow the use of the canula forceps of Desmarres. (See Fig. 1866.) This 
instrument, with the delicate scissors attached, being introduced through a 
puncture in the cornea, can be used effectively in cutting the membrane to 
pieces. With the forceps attached to this canula the fragments can be seized 
and extracted. When the lens has undergone cretaceous degeneration, 
the capsule in such cases being corrugated, it is feasible, though not un- 
attended with danger, to extract the cataract by means of a hook introduced 
through a peripheral opening in the cornea made with a spear-shaped 
keratotome. 
In dealing with these secondary cataracts, Agnew,. of New York, occa- 
sionally uses a stop-needle, which he passes into the membrane, and, while 
holding it securely, makes a linear incision through the periphery of the 
cornea. Through this wound he next passes a sharp-pointed hook, which is 268 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
made to enter the same opening (Fig. 1892), and, after tearing the membrane 
apart, he either extracts it after it is wound around the hook, while the latter 
is rotated, or, if adhesions render this 
unsafe, enlarges the opening by the con- 
joined action of the two instruments, and 
allows it to remain. It may happen that 
the artificial pupil made in the iris, in con- 
sequence of inflammation, becomes occluded 
by lymph, thus preventing the entrance of 
light. Under these circumstances a new 
pupil must be made. This is accomplished 
by fh*st making a small peripheral linear 
incision through the lower portion of the 
cornea and onward through the iris, and 
then, introducing the canula scissors, or 
the scissors forceps (Fig. 1893), into the 
opening, and passing one blade behind 
and the other in front of the iris, cutting 
out a triangular piece of the membrane. 
After these operations the same care is necessary to guard against inflam- 
matory accidents, as after the 
usual cataract-extraction,—name- 
ly, closing the eyes with com- 
press and bandage, the daily use 
of atropia, and, in case pain, 
heat, and undue lachrymation 
arise, the employment of com- 
presses wet with cold water, laid 
over the eye. 
Treatment by division, or discis- 
sion.—The object contemplated by 
discission is to secure the absorp- 
tion of the lens by opening the 
capsule and breaking up, to some extent, the anterior portion of the lens and 
allowing the aqueous humor to come in contact with its substance. The 
operation, at one time very popular, is at present restricted for the most 
part to cases of congenital cataract in children, or to soft cortical cataracts 
of young subjects. The operation is not suited to senile cataracts. In such 
cases the lens is too hard to be disposed of rapidly by the solvent power of 
the aqueous humor, under which it becomes swollen, and in this state is 
liable to act as a foreign body, giving rise to iritis or ii*ido-cyclitis. 
A single operation may suffice for the cure of a soft cataract, especially 
in veiy young patients, but in hard or senile cataract the operation not 
unfrequently requires to be repeated several times. 
The instruments employed for division or dis- 
cission are the needle, straight or curved, and the 
Hays knife. The needle must be very delicately 
fashioned, having a round stem and a spear-shaped 
extremity, with sharp cutting edges running back 
about one-eighth of an inch. The stem should be 
furnished with a shoulder, and supported on a 
good-sized handle. (Fig. 1894.) The knife devised 
by the late Dr. Hays, of Philadelphia (Fig. 1895), 
has a cutting edge about a quarter of an inch 
in length, and is capable of doing effective work 
when brought into contact with the lens. In 
both the needle and the knife it is important that 
the stems of the instruments shall accurately fill up the opening, in order to 
prevent the escape of the aqueous humor. 
Fig. 1892. 
Agnew’s method of lacerating the membrane of 
secondary cataract. 
Fig. 1893. 
Scissors forceps (Strawbridge’s). 
Fig. 1894. 
Cataract-needles. 
Fig. 1895. 
Hays knife, natural size. CATARACT. 
269 
Discission is accomplished in two ways, either through the sclerotic 
(scleronyxis) or through the cornea (keratonyxis). 
Discission through the sclerotic.—The pupil is to be dilated a short time before 
the operation, and, if the patient is a child, it will be proper, in order to avoid 
resistance or other movements which might embarrass the manipulations, to 
administer an anaesthetic, or the arms may be pinioned to the body by means 
of a broad bandage. The eyelids are either to be separated by a spring spec- 
ulum, or the upper lid may be raised by an assistant with an elevator, while 
the operator depresses tho lower lid with the index and middle fingers, and at 
the same time, by pressing against the ball, pi-events the latter from rolling. 
When the spring speculum is used for separating the eyelids, the surgeon 
may control the movements of the ball with the fixation forceps, as in the 
operation by extraction. The needle or Hays knife is now passed through 
the sclerotic, about one line and a half behind the cornea, on the temporal 
side, the cutting edge—if the knife is employed—looking upward. The 
puncture being made, the point of the instrument is turned a trifle forward 
and carried onward, through the posterior chamber, between the lens and 
the posterior face of the iris, until it reaches the nasal side of the pupil. 
In executing this part of the operation the utmost care must be observed not 
to puncture the lens or to wound the ciliary body. Should the latter occur, 
the needle must be withdrawn until free from the lens, and again pushed on- 
ward towards the objective point. This step successfully accomplished, the 
next is to attack the lens. In doing this the needle must be rotated so as to 
bring the cutting edge of the instrument exactly over the equator of the lens. 
It only remains now to incise or to lacerate the capsule at one or more points 
by withdrawing the needle or knife, while the edge is pressed against the lens. 
As soon as this has been accomplished, the instrument is to be again rotated 
so as to bring it, while being withdrawn, into the same position as when 
making the puncture of entrance. The division of the capsule allows the 
aqueous humor to come in contact with and penetrate the substance of the 
lens, when the work of solution and absorption begins. After some time, 
when all irritation consequent on the procedure has passed over and the 
process of absorption ceased, the operation can be repeated. From five to 
six weeks is the period generally required to elapse between the operations. 
The error often committed consists in endeavoring to accomplish too much 
by breaking up the lens-substance with undue freedom, the swelling of which, 
or the displacement of its fragments, is likely to provoke dangerous irrita- 
tion and inflammation in the eye. During the treatment the iris must be 
kept dilated by atropia, in order to prevent it from coming in contact with 
the debris of the lens. 
The accidents possible in discission are displacement of the lens and injury 
to the iris, followed by iritis. Should the first happen, a peripheral linear 
incision of the cornea should be made and the lens extracted at once, either 
with or without iridectomy, according to circumstances. 
Declination, or couching.—Declination, at one time practiced to some extent, 
is so generally followed by destructive changes in the vitreous body and by 
slow subacute inflammation of the iris and the choroid, that a very large 
percentage of eyes operated on by this plan are ultimately lost. Except for 
its historical interest, the operation might with great propriety be omitted 
from surgical writings. 
In reclination a needle is introduced through the sclerotic into the pos- 
terior chamber, and the opaque lens displaced from its bed and buried in the 
substance of the vitreous, below the axis of vision, where it is allowed to 
remain without undergoing absorption. The immediate result of this opera- 
tion, introducing the patient almost instantaneously from darkness into light, 
is very brilliant, but the after-effects soon rob the method of its charm. 
Suction, or aspiration.—The removal of a soft cataractous lens by aspira- 
tion may be accomplished either by the instrument of Teale or by that of 
Bowman. The first consists of a glass tube having a smooth, round, blunt- 270 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
pointed curette at one end and a rubber tube with a glass mouth-piece at the 
other end. (Fig. 1896.) In using this instrument, after full dilatation of 
the pupil, a puncture is made with a spear-pointed needle through the cornea, 
Fig. 1896. 
Teale’s auction instrument. 
opposite the margin of the dilated pupil. The capsule of the lens being next 
divided, the point of the curette is introduced through the puncture in the 
cornea and carried onward through the pupil into the substance of the lens. 
Placing the glass tube in his mouth, the surgeon can now, by gentle suction, 
draw the soft opaque contents of the capsule into the instrument. 
Bowman’s instrument differs from Teale’s in that the suction is effected 
by means of a syringe attached to a fine tubular nozzle. The nozzle is in- 
troduced through an opening in the cornea and the capsule of the lens, made 
by a broad needle, similar to the one used by Toale. The operation of suc- 
tion is not a modern one, but was in use among the Persians as early as the 
fourth century. Those whoso names are associated with it in more recent 
times are Langier and Desmarres, both of whom appear to have abandoned 
the method as unsatisfactory. 
From practical experience I am unable to speak positively in regard to the 
exact place which suction should occupy among the various methods for re- 
moving cataracts, as I have performed the operation only twice. Estimating 
its value, however, by the conditions which are said by the friends of the suc- 
tion plan to call for its use, I am disposed to believe the sphere of its usefulness 
is by no means an extensive one. Very soft or liquid cataracts are the only 
variety to which the aspirating apparatus is suited, and these can be easily 
disposed of, with less danger than will be likely to follow the use of suction 
instruments in the hands of ordinary operators, either by dividing the cap- 
sule and allowing the aqueous humor to penetrate the lens-substance, or by 
making a small linear opening in the cornea. There are some, however, 
who, rather than introduce curette and scissors into the eye, employ the suc- 
tion method for removing detached fragments of a broken lens which remain 
in the eye after extraction by the flap or by the linear plan of operation. 
Treatment of lamellar, zonular, or congenital cataract.—In lamellar 
cataract the opacity, as already explained, does not extend to the periphery 
of the lens,—a fact readily established by dilating the pupil, when, the clear 
part of the crystalline body being exposed to the rays of light, vision will be 
distinct. Such cataracts are best treated by discission, an operation which 
may be performed with comparative safety in very young infants. These 
needle operations will probably have to be repeated. The first operation 
should be limited to opening the capsule for the admission of the aqueous 
humor, and in the second, done several weeks later, the lens-substance should 
be incised in different directions, but no portion displaced. In adults the 
operation of iridectomy or that of iridesis is sometimes performed without 
disturbing the lens. When the opacity approaches so near to the periphery 
as to exclude the light, linear extraction will be necessary. 
Treatment of traumatic cataract.—The management of traumatic cata- 
ract must be determined by the peculiarities of the case. When the capsule 
has been opened and the lens damaged by the vulnerating body, so long as 
no inflammatory symptoms develop no interference will be necessary, except 
to keep the pupil well dilated. In time the cataract will be absorbed. Not so, 
however, when signs of inflammation appear, or when the lens becomes swmllen, 
or when a foreign body can be recognized buried in the substance of the lens. CATARACT. 
271 
Under any of these circumstances extraction should be promptly performed, 
accompanied by an iridectomy, particularly when the lens is voluminous. 
Should the foreign body, after the removal of the lens, be left behind, or 
be found buried in the vitreous humor, a careful watch must be maintained 
in anticipation of a sympathetic ophthalmia arising in the sound eye at some 
future time, near or remote, in which event the diseased ball should be 
promptly enucleated. 
General results of cataract-operations.—The following tables of cataract-op- 
erations, which have been collected by Dr. Baum, enable me to present, first, 
a comparison of ditferent plans of operating ; second, the results of extraction 
after Graefe’s linear method and its modification; third, the results of all 
methods of extraction; fourth, the results obtained by a limited number of 
operators. 
Table I.—Comparison of Methods. 
Operator. 
Year. 
Cases. 
Loss. 
Deferences. 
Discission. 
49 
2, or 4 per cent. 
p. 433. 
Boston City Hospital 
June 1,1864, to 
50 
3, or 6 per cent. 
Med. and Surg. Bepts. of Hosp., 1st S., 
June 1, 1869. 
p. 373. 
99 
5, or 4.95 per cent. 
Scoop. 
6 
Ophth. Hosp. Bepts., 1876-79, p. 374. 
tober 31, 1876. 
Boston City Hospital 
1864-69. 
12 
3, or 25 per cent. 
Hosp. Bepts., 1st S., p. 373. 
18 
3, or 16.66 per cent. 
Streatfield’s Method. 
Moorfields Hospital 
11 mos., 1876. 
17 
Ophth. Hosp. Bepts., 1876-79, p. 374. 
Lebrun’s Method. 
(Brussels.) 
Moorfields Hospital 
11 mos., 1876. 
17 
1, or 5.7 per cent. 
Hosp. Bepts., 1876-79, p. 374. 
1 
1874. 
6 
“ ‘ 44 ' 1874, p. 264. 
24 
1, or 4.17 per cent. 
Wolfe’s Method. 
J. B. Wolfe 
107 
4, or 3.73 per cent. 
Lancet (Lond.), January 6, 1868, p. 715. 
Liebreich’s Method. 
C. K. Agnew 
1874. 
21 
4, or 19 per ceirt. 
Trans. Amer. Ophth. Soc., 1874, p. 264. 
Linear Extraction. 
Knapp 
1862-79. 
41 
3, or 7.3 per cent. 
Trans. Amer. Med. Assoc., vol. xxx. p. 
433. 
Pagenstecher’s Extraction in Capsule. 
Pagenstecher and Bro.... 
117 
3, or 2.56 per cent. 
Arch. Ophth. (N. Y.), vol. x. p. 152. 
Jacobson’s Method. 
(Much the same as Pagenstecher’s 
He recommended a large segment of the iris.) 
Greifswald Hospital 
October, 1873, to 
97 
4, or 4.01 per cent. 
Arch. Ophth. (N. Y.), vol. x. p. 121. 
June, 1880. 
Weber's Method. 
(By lancet-shaped knife. No iridectomy.) 
Arlt and assistants 
1872-73. 
95 
6, or 6.3 per cent. 
Graefe and Saemisch, Handb., August, 
1874, vol. iii. p. 315. 
Knapp 
4)^yrs.,tol873. 
13 
1, or 7.7 per cent. 
Trans. Amer. Ophth. Soc., 1873, p. 60. 
108 
7, or 6.48 per cent. 
Flap Extraction. 
1874. 
6 
Boston City Hospital 
1864-69. 
206 
19, or 9.22 per cent. 
Hosp. Bepts., 1st S., p. 373. 
Knapp. 
1862 to 1879. 
140 
19, or 13.5 per cent. 
Trans. Amer. Med. Assoc., vol. xxx. p. 
433. 
1 
433. 
353 
38, or 10.765 per cent. 272 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
There are compared in the above table 1002 operations for cataract by 
eleven different methods. To make the comparison just, the number of 
cases under the different heads should be more equal than it was possible to 
make them; but, even with this admission, the remarkable number of failures 
in scoop and in flap extractions, as compared with other plans, is very sug- 
gestive. 
Table II.—Results of Linear Cataract-Extraction and its Modification. 
Cases. 
Complete 
success. 
Partial 
success. 
Failures. 
References. 
916 
789 
69 
68 
Trans. Amer. Med. Assoc., vol. xxx. p. 443. 
164 
109 
12 
13 
Ibidem. 
1075 
900 
114 
61 
Graefe and Saemisch, Handb., vol. iii. p. 315. 
200 
178 
6 
16 
llrit. and Kur. Med.-Chir. Rev., January, 1873, p. 196. 
218 
181 
15 
22 
Boston City Hosp. Repts., 1st S., p. 373. * 
107 
94 
9 
4 
Lancet (Lond ), January 6, 1868, p. 715. 
150 
115 
24 
11 
Med.-Chir. Trans. (Lond.), vol. lxii. p. 347. 
179 
160 
11 
8 
Trans. Sled. Soc. Penna., 1875, p. 545. 
77 
66 
10 
1 
Brit. Med. Jour., July 9, 1881, p. 43. 
18 
16 
2 
Atlanta Med. and Surg. Jour., 1874, p. 330. 
346 
335 
4 
7 
Internet. Med. Cong. (Lond.), 1881, vol. iii. p. 14. 
17 
13 
4 
Trans. Med Assoc. Ga., 1880, p. 193. 
12 
8 
4 
Boston Med. and Surg. Jour., vol. xciii. p. 520. 
3449 
2964 
268 
217 
or 
or 
or 
85.94 per cent. 
7.77 per cent. 
6.29 per cent. 
The results in some of the following cases were unknown: 
Unknown. 
506 
342 
40 
Ill 
13 
Lancet (Lond.), August, 1879, pp. 313, 347. 
146 
74 
53 
13 
6 
Moorfields Hosp. Repts., 1876-79, p.374. 
118 
91 
13 
11 
3 
Trans. Amer. Ophth. Assoc., 1874, p. 264. 
1369 
650 
298 
17 
404 
Guy's Hosp. Repts., 1870-78, inclusive. 
2139 
1157 
404 
152 
426 
Adding the totals in both tables, we have 
5588 
4121 
672 
369 
426 
or 
or 
or 
or 
73.75 per cent. 
12.03 per cent. 
6.6 per cent. 
7.62 per cent. 
The above table comprises a record of 5588 cases of cataract-extraction 
made by the Graefe linear method and its modifications, the failures amount- 
ing to only 6.6 per cent. 
Table III.—All Methods of Cataract-Extraction combined. 
Cases. 
Success. 
Failure. 
Eeferences. 
3,449 
3,232 
217 
See Table II., above. 
18,734 
17,176 
1558 
Noyes’s Tables, Trass. Amer. Ophth. Soc., 1879, after deducting cases 
already recorded. 
97 
93 
4 
Arch. Ophth. (N. Y.), 1881, vol. x. p. 121. 
117 
111 
6 
“ “ “ “ p. 152. 
22,397 
20,612 
or 
92.03 per cent. 
1785 
or 
7.97 per cent. 
The preceding table shows an analysis of 22,397 cases of cataract-extraction 
by all the methods combined, with the exceedingly low percentage of failures 
of 7.97 per cent. 
Dr. Noyes, of New York, lias tabulated 20,755 operations for cataract, 
10,094 being flap extractions, with a loss of 1067, or 10.57 per cent,, and DISEASES OF THE VITREOUS HUMOR. 
273 
10,661 linear extractions with its modifications, the loss being 621, or 5.82 
per cent. 
Table IV.—Graeff Modified Linear Extraction, by Seven Operators. 
Operators. 
Year. 
Cases. 
Loss. 
References. 
130 
735 
105 
200 
77 
6 
16 
9, or 6.9 per cent. 
45, or 6.1 per cent. 
12, or 8.22 per cent. 
7, or 3.5 per cent. 
1, or 1.3 per cent. 
Trans. Amer. Med. Assoc., vol. xxx. p. 433. 
Ophth. Hosp. Repts., 1876-79, p. 374. 
Brit, and For. Med.-Chir. Rev., January, 
1873, p. 196. 
Brit. Med. Jour., July 9, 1881, vol. ii. p. 43. 
Louisville Med. News, 1881, vol.xi. p. 50. 
Boston Med. and Surg. Jour., vol. xciii. p. 
520. 
1862-79. 
11 mos., to Octo- 
ber 31, 1876. 
1868-73. 
1879 and 1880. 
Moorfields Hospital.. 
1269 
74, or 5.83 per cent. 
But the most extraordinary showing of successes attending the extraction of 
cataract by the modified Graefe plan is that made by Dr. Derby, of Boston,— 
namely, 100 operations executed without ether, with only a single failure. 
In view of the information thus brought together as to the results of cat- 
aract-extraction by the best methods, it is no exaggeration to say that these 
operations are among the most successful in the whole range of surgery, and 
that there is no single man in our profession better entitled to a place in 
history than Graefe, whose masterly mind and hand opened the way to 
success. 
DISEASES OF THE VITREOUS HUMOR. 
Hyalitis. 
There was at one time a difference of opinion among writers in regard to 
the existence of hyalitis. It was thought that the vitreous body, having 
neither blood-vessels nor nerves, could not be the subject of inflammation; 
but the same mode of reasoning would exclude some of the cartilages and 
also the cornea from participating in inflammatory changes, when we know 
very well that they are susceptible to such processes. Modern pathology has 
shown that the proliferating and other cell changes which belong to the phe- 
nomena of inflammation, though not independent of the blood, occur at a 
considerable distance from the blood-vessels. Inflammation of the vitreous 
body is now a recognized affection, chiefly owing to the observations of 
Virchow and of Weber. The disease is generally secondary to a pre-existing 
retinitis or choroido-retinitis, but may be primary, as when a foreign body is 
lodged in the humor. No doubt the fatal complications which frequently 
followed the old practice of depressing for cataract—when the lens was 
thrust into the vitreous body—began as a hyalitis. 
The inflammatory changes noticed in hyalitis consist in proliferation of the 
cells of the vitreous body, followed by fatty changes, giving rise to opacity, 
and to suppuration, serous transudation, and liquefaction. Occasionally a new 
formation of connective tissue is observed. Among the phenomena disclosed 
by the ophthalmoscope in hyalitis, under the most favorable circumstances, 
as when a foreign body, such as a piece of steel, a fragment of a gun-cap, or 
some other substance, is lodged in the vitreous humor, is a dull, hazy, and 
gray opacity, first seen about the vulnerating body and along its track, which 
ultimately spreads through the humor and changes to a cream color or to a 
lighter gray, according as the degeneration is in the direction of suppuration 
or in that of connective-tissue formation. These changes, especially in trau- 
matic hyalitis, do not progress far without implicating the adjoining tunics 
of the eye in inflammation and its consequences, and in this way concealing 
the vitreous body from further observation. The terminations of hyalitis in 
suppuration, liquefaction, or connective-tissue formation necessarily produce 
such other disorganization in the eye as to destroy vision. DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
Treatment.—When byalitis supervenes on the presence of a foreign body, 
extraction of the offending substance is of the first importance. This can 
sometimes be accomplished, if the body can be located by the ophthalmoscope, 
by sclerotomy,—an operation described under “Foreign bodies in the eye,”— 
or by first removing the lens, as in the operation for cataract, by an incision 
through the cornea, and in this way gaining access to the vitreous humor. 
When the extraction cannot be effected, the inflammatory evils must be com- 
bated by the local abstraction of blood and by small doses of calomel fre- 
quently repeated. If the eyeball becomes disorganized, its removal will be a 
prudential measure, in view of the ifisk of subsequent trouble in the sound eye. 
Hemorrhage sometimes takes place into the vitreous humor as the result 
of violence inflicted upon the eye, or from any cause in wThich the vessels 
of the choroid are overstrained and give way. The accident may be recog- 
nized by the ophthalmoscope, when the extravasation is not too extensive, 
by the light-red appeai'ance of the fundus of the eye. Loss of sight after 
an accident of this nature is usually sudden, any light which may still be 
perceived giving the impression of a red haze or cloud hanging over the 
eye. 
The evils resulting from hemorrhage into the viti’eous are not limited to 
this humor. The retina is liable to become detached, particularly when 
there is a rupture of the vessels at the posterior part of the choroid, where 
the connection between the latter membrane and the retina is slight. 
Treatment.—Time and the use of antiphlogistics and sorbefacients, as 
iodide of potassium and mercury, are the means on which the physician 
must rely for the gradual absorption of the extravasated blood. 
Opacities of the vitreous humor may be divided into two classes, those 
having a foreign or extei’nal origin and those which arise within the vitreous 
itself. Among the former are hemorrhage, plastic and purulent matters, the 
products of inflammation of the sclerotic and choroid, foreign bodies, and 
cysticerci. Opacities from internal causes are such as result from degenera- 
tive changes commencing in the substance of the vitreous humor. 
Yitreous opacities are usually detectable by the aid of the ophthalmoscope, 
through which they appear as small gray spots or white filaments and mem- 
branes, straight or curved, and with regular or irregular borders. Masses of 
pigment, crystals of hminatin and cholestei'in, the residue of old blood-extrav- 
asations, are also detected in the vitreous humor. These cholesterin crystals 
are remarkable on account of the appearance which they give to the vitreous 
humor when seen through the ophthalmoscope, making it resemble myriads 
of brilliant yellow particles in a state of constant agitation. Scotomata of 
the choroid will often simulate vitreous opacities. These opacities are par- 
ticularly annoying to the patient, who complains of dark specks moving 
before the eyes, which he endeavors to avoid by looking at objects in dif- 
fei’ent directions. 
Treatment.—This must be based on a knowledge of the true cause of the 
opacity: if it arises from hemorrhage, the remedies must be those already 
described under that head ; if from inflammatory causes originating outside 
of the vitreous, as in sclero-choroiditis, an antiphlogistic treatment should be 
adopted, as rest, local blood-letting, and mercury. After the acute symptoms 
have subsided, the absorption may be favored by the local use of electricity. 
When the opacity is dense and membranous, Graefe advises its laceration 
with a fine needle, which, in addition to hastening absorption, has the ad- 
vantage of somewhat improving the sight, in consequence of the opening 
made by the instrument. 
Cysticercus.—The presence of a cysticercus is regarded as peculiarly dan- 
gerous to the eye. The occurrence of this entozoon in the vitreous is very 
unusual: when detected by the aid of the ophthalmoscope, it appears as a ANOMALIES OF ACCOMMODATION. 
275 
circular or flask-shaped vesicle, varying in color from pale blue to green. 
When the animal is alive, the movements of the head are perceptible: it is 
first protruded and then retracted, each movement being attended with an 
undulatory one of the body. These parasites are thought to develop beneath 
the retina and subsequently to make their way into the vitreous body. 
When an operation becomes necessary, the same procedure is to be adopted 
as for the extraction of foreign bodies in the vitreous,—namely, section of the 
cornea, iridectomy, and removal of the lens,—afterwards breaking through 
the hyaloid membrane with a fine blunt hook and floating out the cysticercus 
by gentle pressure on the ball. 
Muscae Volitantes—Myodesopia. 
Muscm are sometimes mistaken for opacities of the vitreous. These spec- 
tra, however well they may imitate such opacities, are physiological, not 
pathological phenomena. The muscae are seen to float before the eyes, rising 
and falling, and resembling strings of beads, filaments, circles, etc. They 
are always increased, particularly with myopic persons, by looking at a 
white wall or at white sand, or at any brilliantly-illuminated object, as the 
sun or an electric light. 
Their explanation is to he found in the presence of granules and threads in 
the vitreous so infinitely small as not to be detected by the ophthalmoscope. 
Muscae are liable to appear from overtaxing the eye and from disorders 
both of the digestive and nervous systems. As the source of these objects 
is not always in the vitreous, Listing has devised an experiment by which 
their locality may be determined. A piece of card-board should be pierced 
with a pin-bole and held before the eye of the patient, and if the muscae, when 
the card is moved upward and downward, move in the same direction, they 
are situated in the anterior chamber; but if they move in the opposite direc- 
tion, they lie in the posterior chamber, or behind the pupil. 
Relief from muscae can only be obtained by searching for and removing 
the cause, which, on inquiry, will generally be found to be some intemperance 
in eating, drinking, smoking, or study. 
Anomalies of Accommodation. 
The power possessed by the eye of adjusting itself for near and remote 
vision is called its accommodation. The nearest point to which this power 
can be exerted, or at which distinct vision is possible, is distinguished as the 
near point (the punctum pro.rimum), expressed by the symbol P, and the 
farthest point (punctum remotum) by the symbol R. The distance between 
these two points, the extremes of vision, constitutes the range of accom- 
modation, and is expressed by the formula I = i— i. As R is at an infinite 
distance, the symbol go is often used to express it. The distance between 
P and R, being the range of accommodation, will bo represented by a lens 
whose refractive power is I, the power of a lens being in inverse proportion 
to its focal distance. Monocular accommodation is a trifle greater than 
binocular. 
Accommodation is effected by the ciliary muscle, whose function is to in- 
crease the curvature, or convexity,'of the lens, thus increasing its refractive 
power. When the latter has attained its maximum, the muscle is in an active 
state of contraction and the eye adjusted for the near point ; and when the 
refraction is at a minimum, the muscle is in a condition of relaxation and the 
eye adjusted to the remote point. 
The anomalies resulting from defects in the physiological action of the 
ciliary muscle are,— 
1. Paresis or weakness of the ciliary muscle, indicated by inability to read 
for any length of time without experiencing fatigue and perhaps pain in the 
eye, with indistinctness of vision. This condition is likely to follow any ex- 276 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
hausting disease, as typhoid fever. It is often met with among females whose 
health has been damaged by protracted uterine disease and faulty digestion. 
Treatment.—As the paresis is only a symptom of a constitutional condi- 
tion, it will be most judiciously treated by improving the strength of the 
general system, through the combined agency of iron, strychnia, quinia, and 
cod-liver oil, with a diet rich in the plastic elements of nutrition, and with a 
change of air. As in some instances there is a complication involving the 
refraction, it will be proper to examine for any error of the kind, and, in case 
it is present, to make the necessary correction. It may occasionally bo found 
advantageous, for the purpose of reading, to allow the patient to wear weak 
convex glasses. 
2. Paralysis of the ciliary muscle, and also of the muscles of the ball, is 
frequently witnessed after diphtheria, and in the course of constitutional 
syphilis, and from the peculiar action of certain mydriaties. Intense appli- 
cation to books, or to fine work, may produce a similar loss of muscular 
power; as may also morbid conditions, central or peripheral, affecting the 
third nerve. 
Treatment.—Time, in most cases, is the great remedy, the nerve-power 
being restored with returning health. When the paralysis is referable to 
syphilitic poison, benefit will be derived from the use of iodide of potassium. 
Iron and strychnia, the former by improving the condition of the blood, and 
the latter through its stimulating effect on the nervous system, will bo 
productive of good. The local use of Calabar bean, eserine, and pilocarpine 
has received the commendation of some ophthalmologists. 
3. Spasm of the ciliary muscle may be suspected when in a hitherto em- 
metropic eye there is disposition to hold work or reading-matter close to the 
eye, followed by pain, redness of the conjunctiva, and lachrymation. It is met 
with both in hypermetropic and in myopic subjects. It is among the phe- 
nomena which crop out in strumous ophthalmia, wThere there is great intol- 
erance to light; and it may be reflex from a similar condition of the orbicularis 
palpebrarum muscles. It is sometimes among the earliest manifestations 
of sympathetic ophthalmia. In fine, it may coexist with any defect in the 
accommodation or refraction of the eye. 
As the symptoms already given are not peculiar to spasm of the ciliary 
muscle, it will be necessary to seek for other and more decisive signs of its 
existence. These are furnished partly by the ophthalmoscope, and partly 
by the use of convex glasses and prisms so combined as to suspend the neces- 
sity for any accommodative effort. Some importance has been attached to 
the varying changes in the refraction which occur in spasm while the fundus 
is being inspected, the details at one moment being clearly defined, and a 
few moments afterwards being fading and indistinct. 
Treatment.—The treatment consists in paralyzing the ciliary muscle by 
strong solutions of atropia frequently applied to the eye (gr. ij to fgss) and 
continued for one or several days. In obstinate cases of spasm, when other 
means have failed, paracentesis of the ball will afford prompt relief, the 
muscle relaxing with the diminished tension which follows the operation. 
When the spasm of accommodation is connected with feeble health, a 
course of tonic medicine, with good diet and pure air, will contribute greatly 
to correct the trouble. In all cases the refraction should be carefully studied, 
and, if‘ at fault, must receive the necessary correction before a cure can be 
effected. 
Presbyopia. 
Very early in life, even before puberty, there commences a recession of the 
near point of vision, in consequence of which small letters or other objects 
require to be removed a little farther from the eye in order to be seen with 
normal The change is so gradual that no inconvenience is experi- 
enced until about forty-five years of age, when the individual finds himself 
unconsciously holding the book which he may be reading at a greater distance REFRACTION. 
277 
from the eyes, or carrying the head back in order to make out the letters with 
distinctness, and these efforts may be attended with irritation and smarting 
of the eyes, particularly when the illumination is not strong or when using 
gas-light. This early alteration in the eye-accommodation is not due to any 
imperfection in the refractive power of the crystalline lens, but probably to 
an increase in the hardness of its structure, in consequence of which its 
curvatui*e responds less readily to the contraction of the ciliary muscles. 
At forty years of age and upward the refractive power of the lens is dimin- 
ished from a permanent alteration of form, becoming less convex, and its 
focal distance being necessarily increased. As time moves on and the 
meridian of life is passed, say at about fifty-five or sixty, not only has the 
near point receded, but also the remote point. 
Presbyopia is therefore one of the conditions inseparable from advancing 
years, rather than an error of refraction. So regular and uniform is this 
recession of the near point with advancing life that Donders has, with con- 
siderable accuracy, constructed a scale by which the degree of its progress 
is measured by the age of the individual. Landolt gives one showing the 
progress every five years up to sixty. In this calculation the near point, or 
that which stands for unity, is assumed to be eight inches. 
Presbyopia affects not only the emmetropic but also the myopic and the 
hypermetropic eye; indeed, the latter sometimes appears as a result of an 
advanced stage of presbyopia. 
Treatment.—Far-sighted persons should be allowed glasses as soon as 
they find it difficult to read ordinary print without holding it, say sixteen 
inches distant from the eye, or when fine work cannot be done without a 
sensible effort or strain of the accommodation. Convex glasses will be de- 
manded to restore the requisite distinctness of vision. To find the strength 
of the glass required, it will be necessary to assume some definite number for 
the near point. This, of course, varies in different individuals. If eight 
inches be taken as the standard, and the presbyopia is found to measure 
twice that number, or sixteen, that being the near point at which No. 8 can 
be read, the presbyopia is one-sixteenth, and we have, therefore, to supply a 
sixteen-inch convex glass to restore the vision to its original acuity. For 
if P = 16 inches, it follows that Pr = i — tV = tV 
There are individuals who dispense with glasses even until far advanced in 
life. Such persons have in most instances been near-sighted or possess very 
small pupils. Others, again, after wearing convex glasses for their presbyopia 
until late in life, find themselves able to lay them aside, and can read quite 
well by the unaided eye. This constitutes what is called “ second sight.” 
This remarkable phenomenon is attributed by some writers to a cataractous 
change in the lens, in which the convexity of the latter is increased by 
swelling. 
Refraction. 
The eye is an optical instrument. The condition necessary to correct un- 
aided vision is that the retina shall be so related to the dioptric or refractive 
media that parallel rays entering the 
organ, when the accommodation is at 
rest, shall form an image at the proper 
focus on the retina. (Fig. 1897.) An 
eye thus constituted is said to be emme- 
tropic, a word formed from the Greek 
words u><p, “the eye,” and t/xfierpot;, 
“maintaining proper measure.” When 
the principal focus lies in front of the 
retina, the eye is termed myopic (plow, 
“ to close,” and d>4>, “ the eye”); and 
wThen the focus is placed behind the retina, it is said to be hypermetropic. When 
from some irregularity in the curvature of portions of the dioptric appa- 
Fia. 1897. 
Emmetropic eye. DISEASES AND INJURIES OF TIIE EYE AND ITS APPENDAGES. 
ratus the rays of light from a single point cannot converge again to a single 
point or focus, the eye is called astigmatic (a privative, and “ a point”). 
These different anomalies of refraction all depend upon an anatomical im- 
perfection in the construction of the eye, which may be congenital, acquired, 
or pathological. For example, the myopic eye lias either an extraordinary 
antero-posterior depth or length of axis, or refracting media of too high 
power. The hypermetropic eye is just the reverse: its antero-posterior axis 
is abnormally short, or the refraction of too low power. In the case of. the 
astigmatic eye, the imperfect refraction is due to abnormal curvature of the 
cornea in one or more of its meridians. 
Myopia. 
In myopia the principal focal point for parallel rays coming from an infi- 
nite distance is placed in front of the retina. rIhe form of the hall is elon- 
gated or ellipsoidal, chiefly at the ex- 
pense of its posterior half (Fig. 1898); 
or, as in axial myopia, the prolonga- 
tion may be limited to a small region 
around the optic nerve. The projec- 
tion of the sclerotic coat is so marked 
in many of these cases that it is dis- 
tinguished as posterior staphyloma. 
Besides this elongation of the antero- 
posterior axis of the ball, a similar 
defect in the refraction may arise 
from causes which increase the curvature of the cornea, or increase the 
refractive index of the lens. 
The eyes of persons who are myopic often appear unusually prominent, 
having a large palpebral fissure. In looking at distinct objects (the punctum 
remotum) the orbicularis palpebrarum muscle is called into active contrac- 
tion, so as to lessen the aperture between the lids, and, consequently, the 
amount of light admitted into the eye. Even then the individual has an 
inquiring expression, indicative of indistinctness and uncertainty of vision. 
"When viewing near objects, for example, letters, the book is held close to the 
eyes, the punctum proximum being that which enables the eye to bring the 
most divergent rays to the proper focus. 
Myopia runs in families, and is, consequently, congenital and hereditary. 
That the anomaly may be acquired is also true, as it is caused by those oc- 
cupations or studies which, either from defective light or position, demand a 
constant exercise of the accommodation for near objects. The effect of this on 
the of school-children in developing myopia has been well shown by the 
observations of Cohn, Erismann, Bisley, and others, extending over many 
thousands of children. Near-sightedness was found to increase in proportion 
to the imperfect illumination and bad arrangement of their seats and desks. 
During this early period of life, when the tissues of the eye are plastic and 
the circulation full and active, it is entirely reasonable to suppose that such 
influences, keeping the organ constantly overdosed with blood, would neces- 
sarily result in posterior yielding of the sclera and other tunics of the eye. 
Spasm of the muscle of accommodation, arising from long-continued action, 
is also shown by Dobrowolsky to be instrumental in causing a similar condi- 
tion of the refraction and a similar congestion of the organ. 
Aside from the rational signs which belong to myopia, the defect can be 
diagnosed by the use of the ophthalmoscope. With this object in view, let 
the observer examine the eye of a person supposed to be myopic with the 
mirror alone, or in the erect image, and it will be found that the notable 
features of the fundus can be seen at a distance from the eye, and also that 
by fixing the sight on some single object on the eye-ground, and then moving 
the head to one side, the image will be seen to move in the opposite direction. 
The prognosis in a case of myopia is ordinarily favorable; that is, when it 
Fig. 1898. 
Myopia.—Bays converging to a focus anterior to the 
retina. HYPERMETROPIA. 
279 
is not rapidly progressive. It is common for the short-sightedness to in- 
crease up to about the age of twenty-five and then become stationary. 
When, however, the affection continues to increase rapidly, there is reason 
to be anxious, as under such circumstances it is often associated with inflam- 
mation of the choroid and sclerotic. 
Treatment.—In the treatment of myopia it is necessary first to determine 
its degree, and then to supply the proper glasses for its correction. Each eye 
should be tested separately. 
Place before the patient the test-types, and ascertain the greatest distance 
at which No. 1 can be read. (Fig. 1899.) If the point r (punctum remo- 
tum) is six inches, the formula for his myopia will be M = i. Theoretically, 
therefore, it is only necessary to sup- 
ply a concave lens having a focus 
of six inches. This, by imparting 
to parallel rays the same degree of 
divergence as though they started 
from a point six inches distant, will 
enable the person to see at an infinite 
distance, or enable him to read type 
XX at the distance of twenty feet. 
Having thus far corrected the error 
of refraction, the next point is to de- 
termine the weakest lens with which 
the person can read No. XX distinctly at the distance of twenty feet; and if 
this is found to be a concave lens, seven inches, the formula will be V = -f, and 
the vision will be restored to V = |£, or to whatever may be its normal acuity. 
Generally a patient with myopia should not use glasses for near work, as 
reading or writing, but only for distant vision; and this rule is especially to 
be observed in the higher and progressive degrees of the affection, when it is 
not improbable that congestive or inflammatory changes may be threatening 
the organ. In reading or studying, myopic persons should neither allow 
the head to hang down, nor lean over the object of attention. 
Fig. 1899. 
Diagram showing the effect of the concave lens on par- 
allel rays, causing them to diverge sufficiently on enter- 
ing the eye to reach the proper focal points through the 
refraction of the dioptric apparatus within the eye. 
Hypermetropia. 
Hypermetropia is that anatomical imperfection in the form of the eye in 
which the visual axis is too short antero-posteriorly, or in which the retina 
is in front of the focus of the dioptric system. 
Besides this shallowness of the eye, hypermetropia may be caused by a low 
refractive power of its dioptric combination ; by an unduly flattened cornea 
or crystalline lens; or by either displacement or congenital absence of the 
latter. The defect is almost always congenital. In a state of rest, parallel 
rays are not united upon the retina, but are brought to a focus behind it: 
hence an eye thus constituted is incapable of seeing distinctly any object, 
remote or near at hand, without an effort of accommodation. This fact will 
explain the unusual development of the ciliary muscle which belongs to the 
hypermetropic eye. A hypermetropic 
eye is usually smaller and flatter than 
the emmetropic organ. (Fig. 1900.) 
Notwithstanding hypermetropes may 
work or follow the ordinary occupa- 
tions of life without even being sensible 
of any defect, yet, when the health has 
been shattered by disease, or on too long 
and close application to some calling 
which requires the fixed attention of 
the eyes, the constant exercise of the 
accommodation necessary to vision is liable eventually to exhaust the power 
of the muscle and to impair the sight. The earliest evidence of such a state 
Fig. 1900. 
Focus in the hypermetropic eye. 280 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
will be some indistinctness of vision experienced after the eyes have been 
used for a short time: the letters, for example, when reading, at first distinct, 
at length run together, or the print becomes blurred. This, after closing the 
eyes and waiting a few moments, may pass away, but only to retui-n on a 
renewal of the cause. The term asthenopia, which is really nothing more 
than a degree of hypermetropia, is often applied to this condition. There is 
also some feeling of fatigue or uneasiness experienced in the ball of the eye, 
and this may at length culminate in supraorbital pain or perhaps headache. 
The symbol for hypermetropia is H, and the formula for expressing its 
degree is a fraction the numerator of which is 1 and the denominator the 
focal length of the convex lens necessary to give an acuity of vision |~§-. For 
example, if the hypermetropia required for its correction a convex lens of ten 
inches, it would be formulated II = . The difficulty in securing a tem- 
porary relaxation of the accommo- 
dation in hypermetropia, in conse- 
quence of the long and constant 
activity of the ciliary muscle, tends 
to conceal, to some extent, its exact 
measurement when the patient is 
under examination. This undeter- 
mined factor—latent hypermetropia, as 
it is called—can only be satisfactorily 
ascertained and neutralized by the 
use of atropia, and, after the accom- 
modation is suspended in this manner, the patient should be supplied with 
the strongest convex glasses necessary for good vision. 
Hypermetropia requires for its relief convex glasses, which, by increasing 
the refraction, bring the rays of light to the proper focus on the retina. 
(Fig. 1901.) 
Fig. 1901. 
Effect of a double convex lens In correcting hypermetropia. 
Astigmatism. 
Astigmatism consists in an asymmetric curvature of some portion of the 
dioptric surfaces, by which the refraction is so changed that rays of light 
proceeding from a given point are not concentrated at a focal point on the 
retina. The word is a Greek derivative (a privative, and <nly/ia, “ a point”). 
For our knowledge of this anomaly of refraction we are indebted to Thomas 
Young, who, in 1793, was led to the investigation of the subject from being 
himself troubled with this irregularity of refraction. 
Astigmatism, though occasionally acquired, is generally either congenital 
or hereditary. 
That the subject of astigmatism may be properly understood, it may be 
stated that the meridians of the eye, spoken of by physicists, are supposed 
or imaginary lines on a spherical surface, which pass through the poles of the 
latter. The two poles of the eye pass, one in a vertical and the other in a 
horizontal direction; the former dividing the eye into an external and an 
internal half, or hemisphere, called the vertical meridian, and the latter into 
an upper and a lower half, or hemisphere, named the horizontal meridian. 
Even in emmetropic eyes the curvature varies in the different meridians, 
and consequently there must be a similar asymmetry of the refraction. The 
vertical meridian having a shorter radius than the horizontal meridian, its 
curvature will be greater; for the same reason its refractive power will be 
greater and its focal distance shorter than those of the horizontal meridian. 
It follows from these premises that rays of light falling upon meridians of 
different curvatures are brought to different foci; in other words, that those 
which fall on the meridian the curvature of which has the shortest radius 
will be soonest converged to a focus. It results, therefore, from the operation 
of these laws, that, in an eye with a dioptric system so formed as to destroy 
the unity of the focal point of all rays on the retina, circles of diffusion will 
exist, interfering with distinct vision. ASTIGMATISM. 
281 
There are two kinds of astigmatism, the regular and the irregular. The 
first depends on an abnormal curve of the dioptric media, notably the 
cornea, sometimes the lens; the latter, upon some inflammatory deposit or 
some peculiarity of conformation in one or other of the same structures. 
As the first form alone admits of correction, we shall describe it only. 
Diagnosis.—The rational signs of astigmatism are indistinctness of vision 
and inability either to read small type or to continue at fine work for a con- 
siderable length of time, frequently accompanied by headache and sometimes 
nausea. There are, however, certain tests employed which place the diag- 
nosis beyond any doubt. As this anomaly is not unfrequently associated 
with myopia or hypermetropia, especially the latter, according to Donders, 
it will be necessary to proceed with caution. First, the visual acuity should 
be tested without glasses, by placing the types of Snellen before the patient. 
If unable to read No. XX at the usual distance of twenty feet, a trial must 
be made, with a view to bring the vision up to this standard, by placing 
alternately before the eyes different concave or convex spherical lenses. 
If unsuccessful in this, the existence of a complicated astigmatism may be 
suspected, and we next proceed to determine the fact. 
Place the patient at the distance of sixteen feet before a black screen 
having a small round aperture in it. If the patient is astigmatic, the hole 
will not appear round, but somewhat oblong. Not only does this test reveal 
the existence of the anomaly in question, but its meridian, the long axis of 
the luminous figure being either horizontal or vertical,—horizontal when the 
greatest curvature is in the vertical meridian, if the accommodation is for 
the farther point, and vertical if adjusted for a nearer point. 
Another and more accurate test, that of Dr. Green, consists in placing be- 
fore the person to be examined, at the distance of twenty feet, a card on 
which a number of radii of a circle are arranged in groups of three, each 
line of the series having 
the same thickness as 
those used in forming 
No. XX. (Fig. 1902.) 
If now one eye is 
closed, and the patient 
is able to make out 
the different horizontal 
and vertical lines with 
equal distinctness, he 
is probably not astig- 
matic. Before decid- 
ing positively, how- 
ever, let concave and 
convex spherical lenses 
be tried, with a view 
to correcting any myo- 
pia or hypermetropia 
which might possibly 
be present; and if the 
result is the same, the 
first opinion is corrob- 
orated,—namely, that 
the anomaly of astig- 
matism is not present. 
If, on the other 
hand, the lines in one direction appear distinct, and those in another indis- 
tinct, the patient is astigmatic, the meridian being in the direction of the 
highest refraction, or in the course of the line which is seen with the greatest 
distinctness. 
Another form of test-card, belonging to the Green series, is one re- 
Fig. 1902. 
Green’s astigmatic diagram. 282 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
sembling a clock-face, at the circumference of which are figures correspond- 
ing to the hours, by reference to which the prominent lines can be indicated. 
(Fig. 1903). The patient, having on the spherical glasses, is required to look 
at the card and say whether the ra- 
diating lines are all equally distinct 
from circumference to centre. If not, 
let him designate the ones most dis- 
tinct, their number, and whether the 
corresponding lines on the opposite 
side are equally distinct. The error 
will be determined by the number of 
lines which can be clearly seen being 
inconsiderable: if as many as seven 
or eight appear distinct, the direc- 
tion to compare corresponding dis- 
tinct lines on the two sides of the 
centre is important, for if these are 
not equally distinct it implies that 
the astigmatism is irregular, and 
therefore not susceptible of being 
entirely corrected. 
The surgeon now proceeds to de- 
termine the nature of the astigma- 
tism, whether myopic or hyperme- 
tropic. This is effected by placing in a stenopaic cjdinder a very weak 
concave lens, and if the lines in the different meridians become distinctly 
visible, the case is ono of myopic astigmatism. If, on the other hand, the 
distinctness of the different lines is obtained only by introducing into the 
apparatus a strong convex lens, the case is one of hypermetropic astigma- 
tism. To correct the anomaly, it only remains to select either the concave 
or the convex cylindrical lens, according as the astigmatism is myopic or 
hypermetropic, so as to render the vision distinct for all the different lines. 
A word of explanation in reference to the stenopaic apparatus will be 
proper here. This consists of a cylinder of metal, wood, or even pasteboard, 
open at one end and closed at the other. The open end is for the eye of the 
patient; the other extremity has a very narrow slit, to admit the rays of 
light in one direction only, the width of which can be increased or dimin- 
ished at pleasure. The diameter of the cylinder should be such as will per- 
mit the introduction of trial cylindrical lenses. 
As the refraction of the two eyes may differ, and as it is desirable to give 
the patient binocular vision, each eye should be separately tested, in oi'der to 
determine the true value of its refraction, and then by the proper combina- 
tion of concave or convex lenses with cylindrical ones the anomalies in the 
refraction of the two organs can be corrected. To attain accuracy in these 
examinations it will always be necessary to paralyze the accommodation. 
Astigmatism has been divided into several varieties : 1st. Simple, when tho 
eye is astigmatic in one meridian and emmetropic in the other. Under this 
general head are two divisions, simple myopic and simple hypermetropic, 
based upon tho existence of myopia or hypermetropia in the astigmatic me- 
ridian. 2d. Compound, when tho anomaly exists in both meridians, only 
varying in degree. Under this head are two complications, subdivided into 
the myopic and the hypermetropic. 3d. Mixed, the two meridians being 
unlike in their refraction, one myopic and the other hypermetropic. 
Treatment.—Tho treatment adapted to these varieties of astigmatism in 
general ma}T be stated as follows : For the first, or simple variety, cylindrical 
glasses having their axes perpendicular to the astigmatic meridian are re- 
quired ; for the second, or compound variety, glasses with unlike surfaces, 
spherical on one side and cylindrical on the other; and for mixed astigmatism, 
double cylindrical glasses, their axes being at right angles to each other. 
Fig. 1903. 
Green’s astigmatic card. ASTIGMATISM. 
Dr. Thompson, of Philadelphia, has devised a very ingenious appliance for 
discovering astigmatism. It is formed of four thin metal plates, pierced by 
fifteen holes: stout card-board will answer the same purpose. Referring to 
the cut (Fig. 1904), the relation of the 
plates to one another and the position 
of the holes will be understood. 
The room being darkened, the patient 
is placed about sixteen or eighteen feet 
from the flame of a candle or lighted 
gas-jet. Taking the optometer, he looks 
at the light through the hole No. 1, and 
■while doing so moves the screen ac- 
tively before the eye. If the refraction 
and the antero-posterior axis of the eye 
are normal, the light will not move, but 
if the organ is ametropic, it will move 
with each movement of the optometer. 
Looking through the holes marked 2, 
the light, to an eye with normal refrac- 
tion, will remain single, but will be mul- 
tiple to an abnormal one. When the 
light which passes through the two 
openings at No. 3 is seen, it gives the 
impression, if the eye is ametropic, 
of coming from two circles situated at the screen and overlapping each 
other. There is also with the instrument a slide of a red color, which can 
be placed over either opening at pleasure, imparting a similar color to the 
transmitted light. If the refraction is abnormal, the light where the circles 
overlap will be seen as two lights. Placing now the rod glass over the 
opening on the right side, if the light on that side exhibits a crimson-red 
color, it reveals a condition of myopia, while if it becomes colored on the left 
side, it shows a condition of hypermetropia. 
The two holes No. 4 are designed for the purpose of determining the de- 
gree of defective refraction independently of the glasses, which is done by 
measuring the apparent distance between the two lights as they are seen by 
an astigmatic eye. The subjoined table furnishes the degree of ametropia 
set over against the distance between the lights: 
283 
Fig. 1904. 
1, a single hole 1 nun. in diameter; 2, holes 
mm. In diameter; 3, two holes 3 mm. apart and ]Z 
mm. in diameter; 4, two holes 4 mm. apart and 2 
mm. in diameter. 
Distance of lights apart. 
Degree of ametropia. 
1 inch 
A 
1 “ 
H “ 
= 
2 inches 
= 
3 “ 
= 
4 “ 
i 
Distance of lights apart. 
Degree of ametropia. 
5 inches 
= 
vh 
6 
U 
= 
vh 
7 
(( 
= 
t 
8 
a 
= 
9 
(( 
= 
A 
10 
(( 
= 
Another simple device well adapted for ascertaining the degree of merid- 
ional astigmatism is a disk ten inches in diameter, japanned or painted black, 
with a hole in the centre one-fourth of an inch in diameter, and having on 
its face a number of white lines one inch apart. (Fig. 1905.) This disk is 
attached by a pivot to a candlestick, in which a short piece of lighted candle 
is to be placed. The patient, standing or seated behind the instrument, looks 
steadily at the point of light shining through the central aperture. If 
astigmatic, two points of light will bo seen. Now, by counting the lines 
between the lights, both the number and the distance (one inch) from each 
other are learned. It is only necessary to rotate the disk to determine any 
meridian of the astigmatism. 
Some ophthalmologists prefer the apparatus of Javal for detecting and 
correcting astigmatism. It consists of a piece of card-board on which are 
described two circles side by side, the distance between the centres of the 
two circles equalling the distance between the two eyes. On the face of one 284 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
of these card-boards (Fig. 1906) a number of radiating lines are drawn from 
the centre to the circumference; around the latter are placed figures, from 
Fig. 1905. 
Astigmatic disk. 
Javal apparatus for discovering and correcting astigmatism. 
I to XII, precisely as on the dial-face of a clock or The other card- 
board has a number of squares, corresponding in position and number to the 
figures on the first. These cards are mounted on a stand, having a number 
of concave and convex spherical lenses adapted to myopia and hyper- 
metropia. Behind these lenses are mounted a number of cylindrical ones, 
so arranged that they can be used singly or in combination with the others 
and can be rotated on a pivot at pleasure. On trial, if the lines of vision 
are parallel, the two circles will be blended into one image, with the radiating 
lines in its centre and the figures at its periphery. To determine the diam- 
eter of the greatest refraction, let the circles next be slowly moved away 
from the eye until all the lines on the dial become indistinct, save one, the 
direction of which will be indicated by the figures at the circumference of 
the circle, answering exactly to the meridian of highest refraction. This 
ascertained, the correction of the astigmatism is effected by rotating the 
series of cylindrical lenses until the proper glass comes before the eye, wrhich 
corrects the refractive anomaly. Having made the correction for one eye, 
the other eye is to be similarly treated, by merely shifting the lenses to the 
opposite side and rotating them as in the first instance. If there is reason 
to believe that in these experiments the accommodation is not wholly 
relaxed, it may be necessary to paralyze* the ciliary muscle in order to 
obtain greater accuracy. 
Astigmatism may also be determined by an ophthalmoscopic examination 
of the eye, both by the direct and the inverted-image methods. If the former 
is employed, and the case is one of simple astigmatism, the optic disk will 
be seen to be elongated in a certain direction, and this elongation answers to 
the meridian having the greatest curvature or refractive power. If the in- 
verted-image method is selected, the elongation of the disk will be seen run- 
ning in a direction the reverse of that observed by the direct plan ; that is 
to say, if to the eye of the observer the elongation of the disk appears to lie 
in the vertical position when examined in the erect image, it will bo seen 
horizontally in the inverted image. 
Enucleation of the Eyeball. 
Excision of the eyeball is rendered necessary on account of morbid growths, 
foreign bodies, and sympathetic ophthalmia. It is desirable, when its extir- 
pation is required, that the cellular and muscular portions which encapsulate 
the ball shall be allowed to remain, unless these are involved in the disease ENUCLEATION OF THE EYEBALL. 
285 
for which the operation is performed. When this course is adopted, the 
method is one, properly speaking, of enucleation, for which we are indebted 
to Bonnet and Ferral. 
Operation.—The patient being placed upon the back and etherized, with 
the head somewhat elevated on a pillow, and protected by a piece of rubber 
cloth, the lids are to be held apart with a speculum. The surgeon, taking his 
stand behind the patient, steadies the eye with a pair of forceps, and divides 
the conjunctiva around the entire circumference of the ball, a short distance 
behind the corneo-sclerotic junction, with a pair of bent scissors, one of the 
blades being blunt-pointed. Picking up the subconjunctival tissue, he next 
snips it with the scissors, and, introducing a blunt hook through the open- 
ing, raises and divides the tendon of the underlying muscle. Treating 
the remaining recti muscles in a similar manner (Fig. 1907), the operator 
then seizes with a volsellum for- 
ceps or a tenaculum the front of 
the eye, and, drawing the ball 
forward, passes a pair of strong 
scissors, curved on the flat, with 
the blades closed, down the inner 
or the outer side of the orbit, 
close along the side of the scle- 
rotic, until the optic nerve is 
reached, when the blades are to 
be separated and the nerve sev- 
ered close to the ball. 
The hemorrhage which follows 
the removal of the ball, though 
free for a few moments, rarely 
continues for any length of time, 
notwithstanding that the ophthal- 
mic artery, necessarily cut in the 
operation, is a tolerably large ves- 
sel. Should the bleeding, however, 
seem disposed to continue, it will 
be controlled by douching the orbit with cold water squeezed from a sponge, 
or by a stream of water, not too forcible, from the nozzle of a syringe. 
After the hemorrhage ceases, the gap in the conjunctiva should be closed 
by two or three silk sutures, leaving sufficient space between them for the 
escape of any blood or inflammatory products which may collect in the 
sac beneath. If the enucleation is done while the tissues of the eye are in 
a state of active inflammation, it will be best to omit the sutures, in order 
to allow of the free escape of any vitiated accumulations. The remaining 
part of the dressing will consist of a pledget of lint, wet with cold wrater, 
laid over the closed eyelids and tightly secured in place by a few turns of 
a roller. The water-dressing should be repeated after the first twelve hours 
thrice daily until after the lapse of six or seven days, when it need not be 
renewed oftener than once or twice during the day. In the course of twelve 
or fourteen days the wound will usually be found healed. 
The only complication which may possibly follow the operation of enucle- 
ation is inflammation and suppuration of the connective tissue of the orbit, 
in which event warm dressings must be substituted for the cold ones, keeping 
the parts sufficiently open to allow the escape of pus, and wmshing them out 
once or twice daily with a solution of permanganate of potash. 
Enucleation is not the operation to be performed in cases where the tis- 
sues external to the ball are involved in disease. Under these circumstances 
the freest exposure of the contents of the orbit should be made by dividing 
the palpebral commissures, and then, after dragging the eye forward with a 
volsellum, dissecting out with the knife and the scissors the contents of the 
orbit. 
Fig. 1907. 
Lids separated with the speculum, conjunctiva and subcon- 
junctival tissue divided, and the tendons of the recti muscles 
exposed, one of which is raised on a strabismus hook, with the 
blades of the scissors passed beneath and ready to cut the 
tendon. 286 
DISEASES AND INJURIES OF THE EYE AND ITS APPENDAGES. 
The Use of Artificial Eyes. 
As the loss of an eye entails a very serious deformity, it is desirable to fur- 
nish the artificial substitute as soon as may be consistent with comfort and 
safety to the patient. Usually six or seven weeks are required after enucle- 
tion before cicatrization becomes complete, and earlier than this it would be 
obviously improper to attempt the use of an artificial eye. The time for in- 
serting the latter will depend altogether on the conditions which existed be- 
fore, or which necessitated the enucleation. If the removal of the diseased ball 
was performed on account of sympathetic ophthalmia, no artificial substitute 
should be allowed for several months, or at least until some time after the 
disappearance of all signs of irritation in the sound organ. Indifference to 
this point may defeat the very object for which the extraction was made, by 
keeping up the irritation, or by recalling it after it had disappeared. In cases 
where the eye has been lost by burns from molten metal, quick-lime, or other 
foreign substances, a preparatory operation will often be required before the 
artificial eye can be introduced, in consequence of adhesions of the lids to the 
disorganized stump or ball. In such cases it will be necessary to introduce 
either the eye or some substitute for it immediately after the division of the 
adventitious bands, in order to prevent them from contracting their original 
attachments. 
Artificial eyes are made from enamel, highly polished, and in shape re- 
semble segments of a sphere. The selection of an eye requires the personal 
presence of the individual who is to wear it, in order that in size and color 
it shall correspond to the natural oi’gan. Artificial eyes should be removed 
at night, placed in a cup of water, and replaced in the morning. By the 
observance of this rule not only will the eye last longer, but it will be worn 
with more comfort. 
Introducing the eye.—With the palmar surface of the hand resting over the 
eyebrow, let the upper lid be raised by the middle and ring fingers; with 
the other hand slip the upper edge of the artificial eye beneath the elevated 
eyelid, at the same time allowing the latter to drop by removing the fingers: 
it only remains to depress the lower lid with the free hand in order to direct 
the lower border of the eye into its place. 
Removing the eye.—While the lower lid is drawn down with two fingers of 
one hand, with the other hand insinuate the end of a probe or a knitting-needle 
beneath the lower margin of the artificial eye and raise it forward, when it 
will slip out. This manipulation should be effected while leaning over a bed, 
a cushion, or some soft substance, as the eye, being brittle, would readily 
break should it fall on any hard material. CHAPTER XXX. 
DISEASES AND INJURIES OF THE EAR. 
GENERAL RULES TO BE OBSERVED IN EXAMINING THE EAR. 
The examination of a patient who is the subject of aural disease should be 
conducted in a methodical manner. As the ear is a part of the body, and 
as many of its affections are more or less intimately related to constitutional 
conditions, it is impossible to ignore the latter if the patient is to have the 
fullest benefit of the resources at the command of the surgeon. In outlining 
a plan which shall serve to guide the practitioner, the following order may 
be pursued: 1st, note the name of the patient, a point which is essential if, 
as is often done, a record of cases is kept; 2d, ascertain the age and occupa- 
tion, either of which may furnish a clue for unraveling the obscurities con- 
nected with the ear disease; 3d, inquire regarding hereditary and family 
influences, since deafness frequently results from transmitted vices of blood or 
of special organization, and sometimes runs in certain families ; 4th, find out, 
if possible, the duration of the disease, and the circumstances attending its 
origin; whether it has arisen without any appreciable cause; whether it has 
come on suddenly or gradually, or has followed scarlatina, measles, small-pox, 
diphtheria, typhoid fever, malarial fever, nasal or post-nasal catarrh, sore 
throat, intracranial disease, or traumatic violence; 5th, inquire about any 
antecedent discharges and their character,—whether purulent or sanious, 
odorless or offensive,—and whether such discharges have been preceded or 
followed by pain or earache. 
In the case of adults it will be necessary to carry the inquiry into the con- 
duct and personal habits, and also to learn if there exists any constitutional 
diathesis which might be likely to have a bearing on the local disease. It is 
not, of course, deemed necessary that in ever}' trifling affection of the ear so 
formal a plan of procedure should be observed, but only where the importance 
of the case is of a nature to demand a critical analysis. Having made the 
preliminary inquiries indicated, the surgeon next proceeds to consider the 
character of the phenomena present at the time of consultation. Under this 
head, the important points to be inquired into are the following: 
1. The acuity of hearing.—There are several ways of testing the acuteness 
of hearing,—namely, by the watch, the voice, the tuning-fork, and the click of 
the nails. All of these are open to objection, inasmuch as there is no uniform- 
ity in the tick of watches and no absolute similarity in the volume and the 
distinctness of voices. The click of the nails might be selected with propriety 
as a common test, being very much the same by whomsoever made. The 
sound is produced by scratching together the nails of the thumb and the ring 
finger. I find that the noise thus made can be heard at the distance of forty 
feet by most persons who appear to have normal acuteness of hearing. The 
watch, which is so commonly and conveniently used, should be placed suffi- 
ciently close to the ear under examination (the other being closed) to be dis- 
tinctly heard, and then slowly removed from the head in a direction corre- 
sponding to the longitudinal axis of the auditory canal until the tick can no 
longer be heard. The point where it ceases to be recognized is then to be 
noted in inches or feet. Some prefer adopting the reverse order of testing; 
that is, by holding the watch beyond the limits at which the tick can be heard 
by the patient, and then gradually lessening the distance until the point is 288 
DISEASES AND INJURIES OF THE EAR. 
reached where it can be heard. With young children more difficulty will be 
experienced in reaching a correct result, in consequence of their inability to 
concentrate the attention on the experiment; and they may be too young 
correctly to understand or to communicate their sensations. The examiner, 
therefore, will be compelled to draw his conclusions as to the amount of hear- 
ing by holding the watch, unnoticed, a short distance from the ear, while 
the head of the little patient is averted, and noting if the click attracts atten- 
tion ; or the end may be attained by producing slight sounds with the tuning- 
fork while the head of the child is in a position in which the source of the 
sound cannot be seen. Not only is it necessary to test the hearing by holding 
the watch at different distances, which may be called the intermediate test, 
but, if no sound can be recognized, the time-piece should be placed in contact 
with the head,—the mediate method. In doing this, the watch should be ap- 
plied to the auricle, over the mastoid process of the temporal bone, over the 
temple, upon the zygoma, or between the teeth. An experiment of this kind 
will, when the waves of sound are not transmitted to the internal ear by 
the’route of the auditory canal, determine to some extent the integrity of the 
auditory nerve; the bones which surround and inclose the organ of hearing 
being by this experiment made the lines of communication, partly through 
the air of the tympanic cavity, between the labyrinth and the external 
world. 
In employing the voice-test, the words shotdd be spoken first in the ordi- 
nary conversational tone, and then in a greater or less volume, even to a 
whisper, according as the hearing is found to be dull or reasonably acute. 
Conversation should be carried on while the back and the face of the patient 
are alternately turned towards the examiner, as often individuals are able to 
determine by the movements of the lips what is being spoken, when, were 
the ears alone relied on. they would fail to understand. 
Some persons are able to hear, with a reasonable degree of ease, ordinary 
conversation in a railroad-car, or in a manufactory, when the noise is consider- 
able, better than in a perfectly quiet room,—the noise in the first instance 
acting as a stimulus to the muscles of the ossicles, and thus transmitting 
to the labyrinth an influence which seems to impart an increased degree 
of functional activity to the special nerve of hearing. Indeed, the effect 
of loud and confused noises on the acuity of hearing must be accepted as 
a factor in estimating the acoustic state of the organ. Thus, persons who 
work in boiler-shops, or in other manufactories where the noises are loud, 
confused, and discordant, do not hear common conversation in a quiet room 
as keenly as persons of most other occupations. The hearing can be edu- 
cated far above the ordinary standard by occupation and by necessity. The 
leader of an orchestra will detect a discordant note among the multitude of 
instrumental sounds, which would pass unobserved even by a fairly good 
musical ear. The heai'ing power of the North American Indian, ever on the 
alert for the approach of danger, detects sounds which are never perceived 
by the ordinary ear. 
There is an obtuseness of hearing in some persons which may be consid- 
ered as wholly fictitious, and which depends entirely on want of attention, or 
proceeds from habits of abstraction. 
There is also an apparent defect in the hearing of some individuals for 
particular sounds; apparent, I say, because it is to be referred to a par- 
ticular state of the mental consciousness rather than to any disorder of the 
acoustic organ. A miller, accustomed to the rattle of the hopper, might 
pass a flour-mill without being able afterwards, if interrogated, to say 
whether the machinery was in operation or not. Living for a number of years 
where the sound of forges was constantly heard, day and night, the writer, 
if asked whether the hammers were in operation at any hour except the one 
when the question was propounded, would have been unable to answer from 
any recollection of having heard their ponderous strokes. It would be de- 
sirable to have some universal standard established for normal hearing, one RULES TO BE OBSERVED IN EXAMINING THE EAR. 
289 
which, like V = in ophthalmology, would represent a general fact or fixed 
quantity. 
The tuning-fork.—This instrument, first intelligently employed by Luca>, 
is indispensable in tho investigation of certain cases of deafness. It can be 
used in two ways,—either removed from or in contact with the head. (Fig. 
1908.) By the first method, it will constitute a test for the relative hear- 
Fig. 1908. 
ing capacity of the two ears, that being the stronger in which the perception 
of sound continues longer to be heard. The instrument, when practically 
employed, is placed either on the top of the head or against the middle in- 
cisors of the two jaws. The information communicated by the tuning-fork 
is of the greatest value. 
If the external meatus or auditory canal is closed, the sound of the tuning- 
fork, when placed in the positions already named, will be materially increased 
over that heard when the external ear is left unobstructed,—a fact which 
is taken advantage of in diagnosing any obstruction in the external auditory 
canal, as the presence of impacted wax, polypus, a foreign body, epithelial 
accumulations, or inflammatory swelling in the canal. The same is true 
if the obstruction is located in the cavity of the tympanum. The sound is, 
with rare exceptions, always louder in the obstructed ear. 
When no disease exists in the external ear, and the sound of the tuning- 
fork is heard louder on the same side, some accumulation, mucous or other, 
may be inferred as being in the tympanic cavity. Should a patient in a case 
of deafness on one side hear the vibrations of the tuning-fork more plainly 
on the opposite side, nervous deafness may be assumed for the ear sensible of 
the less degree of sound. That there are exceptions to these rules is true, 
but they are so unfrequent as not to invalidate the general law. In regard 
to the philosophy of the test, or the reason why sounds transmitted from the 
bones of the head to the tympanum and labyrinth should be heard with 
greatest intensity in an ear the outer portion of which is in some way ob- 
structed, we may say that it is believed to be due to the reflection of the 
waves of sound from the membrana tympani and their projection upon the 
auditory nerve. 
Some of the cases exceptional to the general law above stated may be 
explained as follows: it may be that in addition to peripheral obstruction, 
or to a catarrh of the middle ear, there is some disease of its labyrinth, in 
consequence of wdiich the perception of sounds in the affected ear is im- 
paired, and hence they are more strongly realized in the healthy organ. It 
has happened in cases of this very kind that, as the catarrhal condition 
improved and the labyrinth became relieved, the old law again asserted 
itself, and the sounds of the tuning-fork were heard louder in the unsound 
ear. 
Any cause interfering with the physiological action of the chain of bones, 
and of course with the external or outward transmission of the waves of 
sound, would cause the tuning-fork to be heard better on the sound side. 
When, in consequence of an opening in the membrana tympani, the cavities 
of the tympanum and the external auditory canal become continuous, the 
increased resonance from the magnified air-chamber acting on the labyrinth 
might be expected to render the note of the tuning-fork more distinct. 
Yon Conta, of Weimar, has proposed that the tuning-fork be used in all 
cases for determining the hearing distance. Ilis plan is to transmit the 
Tuning-fork. 290 
DISEASES AND INJURIES OF THE EAR. 
waves of sound from the tuning-fork to the ear through an elastic tube, one 
end of which is placed in the external auditory meatus and the other in 
contact with the instrument. The time, noted by the watch, between the 
application of the fork to the tube and the last vibration of sound heard by 
the patient represents the measure of hearing. 
Luc©, of Berlin, has also invented an apparatus, which he terms the inter- 
ference otoscope, and which consists of a glass and a rubber tube, with a tuning- 
fork and a resonator. Of its practical value I am unable to speak. 
Pain.—In all acute inflammatory affections of the ear, pain, more or less 
severe, is experienced. Especially is this the case when the inflammation is 
seated in the external auditory canal or in the membrana tympani. So in- 
tense is the suffering in some cases of this nature that the strongest persons 
lose all self-control. Children frequently suffer for days together agonizing 
pain from the formation of a furunculus in the ear, without the seat of 
the disease being suspected. The movements of these little ones, which to 
the eye of a sagacious physician are often as significant as spoken words, 
should always be noted when the evidence of pain is present. The sudden 
carrying of the hand to the side of the head or to tho ear, and the petulant 
pulling of the hair, constitute the sign-language of pain in the auditory canal, 
the drum of the ear, or the cavity of the tympanum. The pain characterizing 
inflammatory conditions of the internal ear is dull and throbbing rather than 
acute. 
In all chronic cases of ear disease the occurrence of acute pain should 
awaken the suspicions of the surgeon, especially if ushered in by rigors, 
nausea, and vomiting, indicating, as it often does, intracranial trouble. 
The operation of washing the ear, though very simple, is often very rudely 
executed. It is one frequently required in order to remove accumulations of 
inspissated cerumen, foreign bodies, or purulent secretions. The instruments 
employed for the purpose are a hard-rubber syringe, with a well-rounded 
nozzle, and holding not less than from four to six ounces of fluid (Fig. 1909), 
Syringing or Washing the External Auditory Canal. 
Fia. 1909. 
Rubber syringe for the ear. 
a basin to supply the water required, and a bowl or a tin cup to receive the 
refluent fluid. 
The patient, seated on a chair or stool, holds the bowl or tin vessel close 
up under tbe lobe of the ear. The surgeon, holding with one hand the 
auricle upward and backward in order to straighten the canal, with the other 
inserts the nozzle of the syringe into the meatus and discharges its contents 
steadily and continuously. (Fig. 1910.) In executing this last act the column 
of water should be directed along the upper wall of the auditory canal, where 
it will strike the drum-head at a point where the impact will be less sensibly 
felt, and where the deflection of the current will be somewhat parallel with 
the inclination of the drum-head. 
It is desirable not only that the patient should be seated during the process 
of syringing, but also that he should not too suddenly arise after the opera- 
tion is over, as the vertigo which sometimes follows would render the footing 
insecure. When syringing the ears of a very sensitive or timid person, 
it is well to prepare the patient for the peculiar sensations accompanying SYRINGING THE EXTERNAL AUDITORY CANAL. 
291 
the inflow of the liquid, by directing the stream for a short time upon the 
concha. 
Another apparatus for cleansing the external auditory canal is the fountain- 
Tig. 1910. 
Syringing the ear. 
douche, consisting of a flexible soft-rubber tube tipped with a delicate 
ivory nozzle. (Fig. 1911.) The bag, supplied with warm water, is to be sus- 
pended at a convenient distance above 
the bead, the nozzle introduced into 
the meatus, and the liquid allowed to 
flow by raising a little stop-ratchet 
attached to the tube, the escaping 
fluid-being received in a vessel placed 
under the lobe of the ear, as in the 
use of the syringe. 
A simple and cheap contrivance 
Fig. 1911. 
FlO. 1912. 
Fountain-syringe for the ear. 
Clark’s ear douche. 
for washing out the external auditory canal is the ear douche of Clark. 
(Fig. 1912.) It consists of a tin or glass vessel, having a flexible tube, tipped 
with an ivory or rubber nozzle, attached close to its bottom. 292 
DISEASES AND INJURIES OF THE EAR. 
Examination of the External Auditory Canal and Membrane of the Tympanum 
Having measured the hearing power of the patient, the next step is the 
examination of the external auditory canal and the membrane of the tym- 
panum. This can often be effected without the aid of instruments, the ex- 
amination requiring only that the person shall be placed in a favorable light, 
while the auricle is raised upward and carried a little backward in order to 
straighten the curves in the canal. In this way inflammatory swelling, puru- 
lent discharges, foreign bodies, accumulations of inspissated wax, or polypus, 
can be readily detected. When, however, a critical examination of the canal 
or of the membrana tym- 
pani becomes necessary, 
resort must be had to 
instrumental appliances. 
The illumination of the 
external ear is effected 
by means of the aural 
speculum, of which there 
are different kinds. The 
funnel-shaped one of Gru- 
ber or the conical one 
of Wilde (Fig. 1913) an- 
swers in most cases every purpose. Three or four sizes will be quite suf- 
ficient to correspond to the different capacities of the cartilaginous canal. 
A glass speculum will be found of value when it is necessary to introduce 
acids or other potent caustics into the ear. The value of the speculum has 
been immensely enhanced by the addition of a concave mirror (Fig. 1914) 
Fig. 1913. 
Wilde’s ear speculum. 
Fig. 1914. 
Concave mirror. 
for reflecting and concentrating the light upon the deeper portion of the 
auditory canal. The first application of the reflector for illuminating the ex- 
ternal ear was made, it is believed, by Hoffmann, of Westphalia, in the year 
1841, though its moi’e general use among the profession is largely due to the 
labors of Yon Troeltsch, some thirteen years later. 
In using the otoscope, sunlight will be found much more satisfactory than 
gas- or lamp-light. The patient, if an adult, may sit or stand, as may be 
found convenient, but always in a position which shall enable the observer 
most satisfactorily to reflect the light into the organ. A very convenient 
position is that in which the patient sits and the surgeon stands. By 
one not entirely familiar with the anatomical peculiarities of the cartilagi- 
nous part of the ear, some little embarrassment may be experienced in in- 
troducing the speculum into the cavity of the canal. It must he remembered 
that the latter is not a straight tube. At the meatus it looks forward, farther 
in it winds backward, and finally it turns slightly upward. In looking into the 
meatus, therefore, the eye cannot penetrate deeply, but usually sees only a 
small portion of the anterior wall of the tube. This disposition of the audi- EXAMINATION OF THE AUDITORY CANAL. 
293 
tory canal, and the strong growth of stiff* hairs which guard the meatus, like 
the irregularities of the nasal fossae, are well calculated to intercept dust and 
other foreign matters which come in contact with these parts. To introduce 
the speculum without injury to the delicate cutaneous lining of the tube, the 
cartilaginous portion of the canal must be straightened by simply seizing 
the upper part of the auricle and raising and pulling it backward, when the 
instrument can be inserted and carried well inward through the meatus. 
In children the external auditory canal is small, and this, taken in connec- 
tion with their timidity, requires that the utmost gentleness and adroitness 
be observed in inserting the speculum. When the latter has been properly 
placed, it is to be held between the thumb and finger of one hand, while the 
light is thrown into the canal by the mirror held in the other. (Fig. 1915.) 
Fig. 1915. 
Examination of the ear by speculum and lens. 
In order that the parts shall be brought under observation in detail, it will 
often be required, before using the speculum, to remove from the sides of the 
canal particles of wax, or accumulations of detached epithelium or purulent 
matter. This can be accomplished by the syringe or by little pledgets of ab- 
sorbent cotton rolled on the end of a probe. ‘The probe which I prefer for this 
purpose, and indeed for all manipulations within the external auditory canal 
requiring the use of such an instrument, is one which is rendered flexible 
by being spiral a short distance from the extremity. (Fig. 1916.) When it 
Fig.1916. 
Ear probe. 
is necessary to have one hand free, as in making topical applications, securing 
morbid growths, or performing other operations, the hand-mirror must be 
substituted by one having an elastic sti’ap attached, by means of which the 
glass can be secured to the forehead (Fig. 1917), and then it will be found 
most convenient for the surgeon to sit. 
To secure the advantage of both eyes in operating on the ear, or in 
studying the details of the membrane, Dr. Di Eossi has devised a binocu- 
lar otoscope, which promises to be a useful addition to our instrumental 
resources. 
When artificial light is employed for illuminating the ear, the speculum 
of Toynbee may be used. This apparatus consists of a cylinder containing 
two lenses, with a funnel-shaped tube attached to its side (Fig. 1918), into 294 
DISEASES AND INJURIES OF THE EAR. 
which the light is concentrated from a lamp with a bull’s-eye attachment. 
Fig. 1918. 
Fig. 1917. 
Forehead-mirror. 
Toynbee speculum. 
Weber, in using artificial light, or even sunlight, for aural examinations, 
Fig. 1919. 
Weber reflector for the ear. 
lias designed for tlie purpose an apparatus the parts of which are a mirror APPEARANCE OF THE MEMBRANA TYMPANI. 
295 
or reflector, with a speculum and lens supported on a piece of metal with 
two branches. (Fig. 1919.) 
Not the least important structure which is brought into view in an oto- 
scopic examination of the ear will be the drum-head, or the membrana tym- 
pani, and the observer must be familiar wTith its normal appearance in order 
to be able to recognize those alterations which are produced by morbid 
processes. 
This membrane is nearly circular in form, concave on its external surface, 
fixed obliquely into the temporal bone at an acute angle with the floor of the 
cartilaginous canal, translucent, and of a grayish-white, a yellowish-white, 
or a pearl color. The inclination of the drum-head is such that its posterior 
superior portion is nearer to the external orifice of the canal than its ante- 
rior and lower part, an arrangement which exerts no small influence in 
communicating a refluent direction to liquids thrown into the ear. The 
membrane is seen to be divided into two unequal parts—the anterior larger 
than the posterior—by the long process, or manubrium, of the malleus, which 
is placed between the layers of the membrane. Corresponding to the ex- 
tremity of the long process of the malleus, and at the bottom of the con- 
cavity, will be seen a light spot. This spot is an optical result, and is 
produced partly by the oblique position of the membrane, partly by its 
lustre, and partly by the action of the malleus. 
This spot, apparently so insignificant a feature of the drum-head, possesses, 
nevertheless, great diagnostic importance. For example, when the con- 
cavity of the membrane is well pronounced by the traction of the malleus, 
the spot is most conspicuous: any diminution in its distinctness, therefore, 
provided there has been no inflammatory thickening of the drum-head, will 
indicate some disorder in the'ossicula. As the short process of the malleus 
separates the inner surface of the membrane into two portions or pockets, 
the accumulation of mucus in these explains the bulging seen on the external 
surface of the drum-head. 
Inflating the membrana tympani.—The ability to inflate the drum-head will 
depend on the pervious condition of the Eustachian tube and the tympanum. 
The manner of applying the test for diagnostic purposes is by means of the 
otoscope, a flexible rubber 
tube, with a bone ear-piece 
attached to each extremity. 
(Fig. 1920.) One end of it is 
placed in the patient’s ear, and 
the other end in that of the 
surgeon. After closing both 
nares and the mouth, the per- 
son examined is requested to 
make a forcible effort to blow 
the nose. In this act, the air, 
finding no external outlet, 
will, if the Eustachian tube 
is unobstructed, rush into the 
tympanum with a slight rustle or snap, and distend the membrana tympani, 
the movements of which may be observed by the surgeon through the oto- 
scope. If, on the other hand, there exists some mechanical impediment to 
the entrance of air, the sensation communicated to the ear of the observer 
will be a crackling, interrupted, or flapping sound, according as the tube is 
occupied by mucus, its walls thickened by inflammatory deposits, or the 
muscles regulating its orifice enfeebled. 
The permeability of the Eustachian tube may be determined by introducing 
Appearance of the Membrana Tympani. 
Fig. 1920. 
Politzer’s otoscope for the ear. 296 
DISEASES AND INJURIES OF THE EAR. 
into its orifice the catheter having a flexible tube, with mouth-piece attached 
(Fig. 1921), into which the surgeon blows. The air, if it meets with no ob- 
struction, passes up against the drum with 
the peculiar feeling or crack well understood 
by the patient. 
By inserting the ends of an otoscope into 
the ear of the patient and that of the sur- 
geon at the same time that the air is being 
forced through the Eustachian catheter, the 
operator will be able also to detect the char- 
acteristic sound. (Fig. 1922.) The figures 
1, 2, 3, and 4 point to the patient, catheter, 
operator, and otoscope. 
When the object of the examination is simply to ascertain the mobility of 
the drum-head, or its freedom from adhesions, the end may be attained by 
Fig. 1921. 
Otoscope. 
Fig. 1922. 
the use of Sigle’s speculum (Fig. 1923), consisting of a vulcanite speculum, 
which is fastened to a box of the same 
material, having a lens in its face. At- 
tached to the side of the box is a flexible 
tube, tipped with a hard-rubber or ivory 
mouth-piece. That the instrument may 
fit the canal of the ear sufficiently well to 
be air-tight, a washer of rubber tubing 
should be slipped over tbe nozzle. The 
latter being passed through the meatus, 
filling it with the neatness of a cork in a 
bottle, the surgeon places the end of the 
flexible tube in his mouth and by suction 
exhausts the air from the auditory canal. 
During this process he can watch the be- 
havior of the membrane through the eye- 
piece, the deep portion of the canal being 
properly illuminated by reflected light. If the drum-head is not tied by ad- 
Examination with the otoscope. 
Fig. 1923. 
Sigl6’s fenestrated speculum. APPEARANCE OF THE MEMBRANA TYMPANI. 
297 
hesions, it should, on the abstraction of the air, lose to some extent its concave 
form by moving in the direction of the observer. 
The instrument, however, which better than all others discloses the condi- 
tion of the Eustachian tube and the membrana tympani is that of Politzer,— 
a rubber bag having a valve at the bottom, and at the top a flexible tube with a 
vulcanite or bone tip fashioned so as to fit into the nose. (Fig. 1924.) The 
application of the Politzer method is based on two physiological facts,—first, 
that, in the act of swallowing, the soft palate moves backward and upward, 
applying itself so firmly and neatly to the wall of the pharynx that all com- 
munication between the post-nasal region of the latter and that below is for 
the time being cut off; and, secondly, that during the muscular movements 
involved in deglutition the pharyngeal orifices of the Eustachian tubes are 
opened. Proceeding on this knowledge, the surgeon introduces the tip of 
the flexible tube into the nose through one of the nostrils, and, compressing 
both nares closely between the thumb and fingers, directs the patient, at a 
given word or sign, to swallow some water previously taken into the mouth. 
Simultaneously with the swallowing the surgeon with the free hand forcibly 
compresses the gum bag. (Fig. 1925.) When the expelled air, driven through 
Fig. 1925. 
Fig. 1924. 
Politzer bag. 
Manner of using the Politzer bag. 
the nasal fossa, enters the pharynx, it is prevented from passing downward 
by the soft palate, which clings to the posterior pharyngeal wall and bars 
the way. The air is thus compelled to enter the gaping orifices of the Eus- 
tachian tubes, and, meeting with no obstruction, it enters the cavity of the 
tympanum. 
The same result can be attained with nearly equal success, without com- 
pelling the patient to swallow water, by adopting the plan suggested by 
Jones, in which the air is discharged from the gum bag at the moment when 
the last of four words—“heck, hick, hock, huck”—has been pronounced, the 
pronunciation causing the root of the tongue to push the palate back. The 
process is made still more certain if while the air is being forced into the 
pharynx the head is inclined well over towards the shouldor. 
A very common method of ascertaining the condition of the Eustachian 298 
DISEASES AND INJURIES OF THE EAR. 
tubes is that of Valsalva, which consists in making forcible efforts at expi- 
ration, after taking in a full breath, while the nostrils and the mouth are 
kept closed. 
Eustachian catheter.—This instrument constitutes another valuable means 
of diagnosis in aural disease. The cath- 
eteris made either from German silver or 
vulcanite. Each has its ad vantage,—the 
latter being best adapted for the passage 
of warm medicated vapors, which would 
in a short time render the metallic 
catheter uncomfortably hot. 
The Eustachian catheter requires to 
be about five or six inches long, slightly 
curved at its pharyngeal extremity, 
the other end being somewhat funnel- 
shaped. (Fig. 1926.) 
The introduction of the catheter is 
most conveniently accomplished with 
the patient in the sitting posture,—to 
avoid giddiness,—with the head thrown 
slightly back and supported either by 
the hands of an assistant or against the 
back of the chair, if the latter is suffi- 
ciently high for the purpose. The in- 
strument being moistened with a little 
vaseline or cold cream, and held in 
nearly a vertical position, its small ex- 
tremity is introduced into the antei’ior 
naris, its concavity downward, while 
at the same time the tip of the 
nose is slightly raised. As soon 
as the point has fairly passed the 
naris the catheter must be raised 
to a horizontal position, which 
will bring its beak in contact 
with the floor of the nasal cav- 
ity, in which position and with 
a light touch the instrument is 
to be carried backward until ar- 
rested by coming in contact with 
the posterior wall of the pharynx. 
(Fig. 1927.) To conduct it now 
into the orifice of the Eustachian 
tube, it only remains to draw the 
catheter a little forward and turn 
it on its axis, when the extremity 
of the instrument will probably 
enter the tube. 
The catheter, when rudely han- 
dled, is capable of doing great 
harm by lacerating the mem- 
brane lining the Eustachian ca- 
nal and giving rise to emphysema 
of the fauces and neck. An ac- 
cident of this kind, followed by 
difficult breathing, will require 
an incision or puncture to liberate the extravasation. 
Through the canal of the catheter air can be forced into the tube and 
tympanic cavity by fitting into its outer end the nozzle of a Politzer bag. 
Fig. 1926. 
Eustachian catheters. AFFECTIONS OF THE AURICLE. 
299 
Medicated vapors, or even fluids, at a proper temperature, may also he intro- 
duced through the catheter. 
Fig.1927. 
Cranial section showing the introduction of the Eustachian catheter. 
Bougies—one-sixteenth of an inch in diameter and made of catgut—are 
occasionally found useful in contracted states of the Eustachian tubes. When 
used, they should not be allowed to remain in the tube over twelve or fifteen 
minutes. 
Faucial and post-palatine regions.—No examination of an important case of 
deafness would be complete were these regions overlooked. Not a few of 
the diseases which come under the attention of the aurist begin in the 
fauces or in the pharynx. The enlarged tonsils of strumous children, the 
presence of a fibrous polypus, or a predisposition to inflammatory affections 
of the throat may lead to recurrent attacks, which cannot continue for any 
great length of time without the addition of new elements to the mucous, 
submucous, and glandular tissues of the pharynx, which, in turn, may cause 
similar changes in the Eustachian tubes. Hence the importance of exam- 
ining the region rhinoscopically and by the finger in a patient who com- 
plains of impaired hearing. 
Affections of the Auricle. 
The auricle serves to collect, reflect, and conduct the waves of sound, and 
concentrate them in the auditory canal. Its office is indicated by the in- 
stinctive movements which are frequently noticed in persons whose hearing 
is somewhat dull, such as placing the hand behind the ear in order to catch 
the sound and direct it into the organ. 
Malformations.—Malformations of the auricle are congenital, acquired, or 
pathological. 
Among the first may be noticed partial or complete absence of the auricle. 
There may be a semicircular rim of cartilage arising a short distance from 
the surface of the auditory process, and having one or two of the character- 
istic parts of the appendage, such as the tragus or the helix, imperfectly de- 
veloped ; or the rudimental auricle may consist of a small pointed appendage, 
resembling in some respects the ear of a dog when trimmed to suit the taste 
of the fancier. I was called to see a singular instance of this deformity in a 300 
DISEASES AND INJURIES OF THE EAR. 
little girl, which was attributed by the mother to an impression received 
when she was about one month advanced in pregnancy. She and her hus- 
band had gone to spend a day at a friend’s house in the country. While 
the lady was standing in the doorway, a terrier pup came running up the 
walk towards the house. She noticed its ears covered with blood, the 
appearance of which caused her considerable fright. The men at the barn 
had been engaged in clipping the ears of some puppies, and the one that 
occasioned the shock had broken loose and run to the house for protection. 
The resemblance between the auricles of the child and the trimmed ears of 
the terrier was certainly very striking. 
Absence of the external meatus, and sometimes of the entire auditory 
canal, may coexist with absence of the auricle. The auricle is sometimes 
found misplaced, occupying the shoulder, or, it may be, the side of the face. 
Supernumerary auricles are also witnessed among other singular freaks of 
disordered development, and should be removed by the knife. 
Acquired deformities of the auricle are generally the result of pressure by 
some form of head-dress, which crowds the appendages into an unnatural 
position, and causes distortion, atrophy, or malposition. 
Pathological malformations may be caused by burns or other injuries. 
Under this head we may place the cicatrices following lupus or old cases of 
eczema, and the inflammatory changes which not unfrequently result from 
the weai’ing of ear-rings. 
In those congenital malformations in which the meatus is absent, the 
condition of the internal organ can be determined by the tuning-fork, the 
sound of which, when placed on the top of the head or against the teeth 
(on account of the absence of the external auditory orifice), should be heard 
louder on the side of the deformity, provided the internal apparatus of the 
organ is intact. In one case I made an exploratory incision to ascertain if 
any portion of the auditory canal was open, but without success; and this 
will probably be the result whenever similar operations are done with the 
same object in view. 
Eczema of the auricle is a very common affection, met with chiefly in 
children, though adults are not exempt from it. The disease, which is of 
the vesicular form, often commences in the crease between the cartilage and 
the mastoid process of the temporal bone, and extends over the posterior 
surface of the auricle, involving frequently the anterior surface, and ex- 
tending into the external auditory canal. It is often seen associated with a 
similar condition of the scalp. 
Symptoms.—Eczema begins with redness of the surface, followed by the 
formation of vesicles, which are finally converted into pustules, and, later, are 
changed by the mingled accumulations of epithelium, sero-pus, and dust into 
yellow crusts, which adhere to the cartilage, and, when forcibly detached, 
leave exposed a raw, sensitive surface. In old chronic cases of the disease, 
which have either been badly treated or not treated at all, there not unfre- 
quently follow cicatricial contractions of portions of the auricle, which cause 
deformity of this cartilaginous appendage. 
Causes.—While in some cases the disease is undoubtedly the result of 
inattention to cleanliness on the part of parents or nurses, it is frequently 
due to reflex or to constitutional causes. The irritation resulting from den- 
tition will often cause an eruption of eczema. Children whose nutrition is 
imperfect are apt to be subjects of the disease. 
Treatment.—There is among mothers a popular notion that the eruption 
is salutary and ought not to be interfered with, a fallacy which I have 
known the physician to encourage, and hence the disease is too often al- 
lowed to run a chronic course. The sooner it is removed, the better for the 
patient. In the early and acute form of the affection, little is necessary ex- 
cept to keep the parts clean by washing them daily with carbolated soap and 
dusting them with a powder composed of one part of calomel and three TUMORS OF THE AURICLE. 
301 
parts of subnitrate of bismuth, or one part of sulphate of zinc and four parts 
of powdered starch. Any disorder of the digestive organs should be cor- 
rected by administering a few doses of hydrargyrum cum creta, followed 
by the compound syrup of rhubarb. In pale, anaemic children, benefit will 
follow the use of chalybeates. 
In chronic eczema, where the parts are encrusted with scales, the latter 
will require to be removed by an alkaline wash of bicarbonate of sodium, or 
a light flaxseed poultice applied over the parts for one or two nights, after 
which the surface should be treated with unguentum pieis, reduced some- 
what in strength by the addition of a little cosmoline, and in obstinate cases 
by mixing with the ointment a portion of calomel (3ss to £i). Should the 
eruption not yield after ten or twelve days of this treatment, the improve- 
ment will be facilitated by administering liquor potass® arsenitis (Fowler’s 
solution) along with tincture of sesquichloride of iron. 
Those cases of eczema in which the eruption extends into the external 
auditory canal require especially careful management, and should rarely be 
left to the care of a nurse or mother. The accumulations which block up 
the canal must be removed by injections of warm water containing a few 
grains of the bicarbonate of sodium, and the surface should be carefully 
dried with dossils of carbolated absorbent cotton, after which make an ap- 
plication of a solution of sulphate of zinc (zinci sulphatis, gr. v, aqu® ros®, 
or in its stead the following solution may be employed: hydrargyri 
bichloridi, gr. i, aqu® fontan®, fgij; or the bichloride may be added to tar- 
water. Any of these remedies addressed to the parts with a camel’s-hair 
brush will eradicate the disease. 
Calcareous Formations in the auricle occasionally appear, usually affecting 
the border of the helix. I saw a male patient, under the care of Hr. Hut- 
chinson, in the medical wards of the Pennsylvania Hospital, with this condition 
of the helix. These deposits consist, as has been shown by Garrod, of the 
urate of sodium, and are met with in rheumatic and gout}7 subjects. They 
give rise to a sensitive or painful condition of the auricle, and admit only of 
palliation, by the application of anodyne ointments and constitutional reme- 
dies adapted to the rheumatic and gouty diathesis. 
Tumors of the Auricle. 
Almost every form of morbid growth occurs on the auricle. 
Othaematoma.—This singular tumor consists of an extravasation of blood 
forming a swelling, which is often preceded by an oedematous state of the 
subcutaneous tissues. The surface of the swelling has either a leaden or livid 
color, mingled with a reddish tint, and is often shining or polished; or it 
may be colorless. With few exceptions the tumor is confined to the anterior 
surface of the ear, first appearing in the concha, and then growing in size 
until, in rare cases, the entire face of the auricle is covered, the tumor 
attaining not unfrequently the size of a hen’s egg. The diseaso may be 
bilateral or unilateral. In either case the left ear is the one generally first 
attacked. 
This blood tumor has attracted no small amount of attention from medical 
writers. The first systematic study of the disease was made in 1838, in 
France, by Ferrus, developing the relation between this tumor and mental 
disease. Since the observations made by Ferrus, this affection has been the 
subject of memoirs by Foville, Fischer, M. Maury, Ducros, Virchow, Lennox 
Browne, Hun, and others. 
While in the majority of cases this sanguineous tumor exists among the 
insane, without reference to any peculiar form of insanity, except, perhaps, 
monomania, with which it seems to be more frequently associated, yet it is 
met with in persons not insane, and may be either idiopathic or traumatic. 302 
DISEASES AND INJURIES OF THE EAR. 
The disease begins in the vessels of the perichondrium, and, while numerous 
theoretical explanations have been given touching the subject of causation, 
the view which perhaps most correctly represents the pathology of othajma- 
toma is that of Bonnet and Yirchow, in which there is recognized a vice 
of nutrition, induced by emotional causes acting through the vaso-motor 
system of nerves. The theory of the central origin of the disease among 
the insane appears to receive further confirmation from the researches of 
Brown-Sequard, who found that bloody tumors of the auricle of guinea- 
pigs followed section of the restiform bodies in the course of twelve or 
twenty hours. 
The traumatic form of the affection is to be regarded as an extravasation 
of blood in the subcutaneous connective tissue, rather than a sanguineous 
tumor having the source of its blood in the vessels of the perichondrium, 
the former being a local and the latter a constitutional affection. In other 
words, there is the same difference between the two swellings as between the 
blood tumor of the scalp, seen in new-born children,—the result of pressure 
(whether against the bones of the pelvis, or produced by the forceps),—and 
the cephalomata of the French writers, in wTiich the sanguineous collection is 
between the pericranium and the bones of the skull. The last-mentioned 
cases may be classed with extravasations of blood between the capsule of 
Glisson and the liver; and similar lesions may occur in other organs, the 
fibrous envelopes of which sustain the same relation to their bodies as the 
pericranium does to the bones which it covers. To the former variety, or 
subcutaneous extravasation, belong, no doubt, those auricular swellings 
which, as stated by Gudden, adorn the ears of some of the ancient statues 
representing Hercules, Hector, and other embodiments of prodigious human 
strength. 
Progress of othcematoma.—The tumor in time either ruptures or undergoes 
consolidation, and gradually disappears through the agency of absorption, 
and is followed by a new formation of cicatricial tissue, the contraction of 
which causes great deformity of the cartilage. 
Treatment.—As in other cases of blood tumors, these swTellings should be 
left to the kindly offices of nature. 
Fibroma.—Tumors seated on the auricle, the histological elements of which 
are composed of spindle-shaped cells and con- 
nective tissue, do not commence in the cartilage, 
but in the subcutaneous connective tissue, and 
have a traumatic or inflammatory origin, often 
following the use of ear-rings, and growing to a 
considerable size. (Fig. 1928.) These tumors 
are quite common among negroes, a fact attrib- 
utable, in part at least, to the very prevalent 
practice among this class of wearing ear-rings 
made of the baser metals. There is, however, 
among Africans a marked tendency to fibrous 
neoplasms, which must not be ignored in study- 
ing the fibrous growths of the auricle. 
Treatment.—Fibromata of the auricle can 
sometimes be aborted, when arising from local 
irritation, as from an ear-ring, by promptly re- 
moving the ornament and bathing the part fre- 
quently with a lotion of lead-water and laudanum. 
At this stage the enlargement is purely an inflam- 
matory one, which will disappear with the sub- 
sidence of the vascular disturbance. Rings which 
have once caused inflammatory infiltration should 
be laid aside; or, if they must be worn, they should be suspended from the 
ear by a clasp. 
Fig. 1928. 
Fibroma of the lobe of the ear. TUMORS OF THE AURICLE. 
303 
When, however, the new formation has assumed, by its size, the impor- 
tance of a tumor, the only remedy is to remove the growth by a V-shaped 
incision, and afterwards to bring the sides of the wound together by sutures, 
the latter either passing through the entire thickness of the auricle, or 
being inserted on both aspects of the appendage. 
Sebaceous Tumors occur chiefly on the tragus and the posterior face of the 
auricle. They do not differ either in appearance or in structure from similar 
growths on the scalp. 
Treatment.—Sebaceous tumors require to be extirpated by the knife. An 
incision is made over the cyst, through the skin and connective tissue, so as 
to expose the sac, which can then, with its contents, be enucleated by the 
curette extremity of a director. 
Papillomata, or Warts, may grow from any portion of the auricle. When 
small, a few applications of glacial acetic acid or of chromic acid will be suf- 
ficient for their destruction. When large, the knife will be the most expedi- 
tious mode of removal. 
Epithelioma occasionally develops on the auricle, sometimes at the brim 
of the concha and at other times on the helix, or showing itself along the 
auriculo-mastoid groove. The disease commences as a circumscribed papular 
elevation of the skin, which after a time begins to desquamate, and finally 
to ulcerate, the surface becoming encrusted with a scab, which on being 
detached exposes a raw, bleeding sore. The extension of the ulcer is slow, 
and its progress is always revealed by a surrounding induration. If not 
interfered with, the disease ultimately destroys the entire auricle and extends 
to the surrounding parts. 
Treatment.—If the disease is attacked early, before any extended surface 
of the auricle becomes implicated, it can be successfully eradicated by a caus- 
tic of zinc paste. When, however, any considerable portion of the auricle is 
involved, it will be better to excise the diseased part, cutting out the entire 
thickness of the cartilage and closing the sides of the wound with silver 
sutures. In cases requiring the removal of the entire auricle, attention 
should be directed during the subsequent treatment to the prevention of the 
closure of the external orifice of the auditory canal by cicatricial contrac- 
tion. The introduction of little rolls of oiled lint during the healing process 
will fulfill this purpose. 
Sarcoma.—Neoplasms of this nature have, in my own experience, generally 
developed either in the lobe or at its junction with the cartilage, and are of 
the spindle-celled variety. 
The prognosis is exceedingly unfavorable; but, though the disease has a 
strong tendency to return, this fact should not prevent an early resort to the 
knife. 
Angioma, or Naevus.—Congenital vascular growths of this character fre- 
quently appear on the auricle, the arterial elements prevailing in some and 
the venous in others. Angiomata of the former class, when superficial, dis- 
appear under one or two applications of nitric acid ; when too deep to be de- 
stroyed by this agent, they can be successfully removed either by excision 
or by passing two pins beneath the growth, at right angles to each other, 
and strangulating the transfixed tissue by a thread. In venous angioma, 
distinguished through the skin by a bluish tint and by its soft, doughy feel, 
the knife is to be preferred over other plans of treatment, the operator carry- 
ing the incision some distance beyond the disease into the sound tissues and 
closing the wound with sutures. 304 
DISEASES AND INJURIES OF THE EAR. 
Affections of the External Auditory Canal. 
Impacted Cerumen.—Accumulations of wax in the external auditory canal, 
mixed with detached epithelium, forming a firm plug, frequently cause deaf- 
ness by preventing the waves of sound from reaching the membrane of 
the tympanum. Singularly enough, these ceruminous plugs are often over- 
looked. I have known many patients subjected to various local and general 
remedies without any definite idea on the part of the physician as to the real 
cause of the deafness. 
The symptoms which point to obstruction of this kind are sudden dullness 
of hearing, tinnitus, a feeling of deep-seated fullness in the ear, with an occa- 
sional crackling sound in the canal, often accompanied by pain more or less 
severe. The diagnosis is rendered certain by raising the auricle upward and 
backward and looking into the meatus, with a good light, when the dark mass 
can be easily seen. These accumulations are frequently caused by pieces of 
cotton or wool, which have been worn in the canal of the auricle, working 
upward and forming a kind of nucleus for the collection of the wax. Some 
persons are peculiarly prone to these ceruminous accumulations, and need to 
have them removed once or twice every year. A careful examination of such 
patients will disclose either some alteration in the form of the canal or some 
tenderness when the cartilage is pressed upon, indicating the existence of a 
subacute inflammation modifying the character of the ceruminous secretion 
and lessening the capacity of the canal. The evil resulting from these 
plugs of inspissated cerumen is not limited to the canal, for the plug often 
causes hypersemia of the tympanic membrane. A reflex cough may even 
be provoked by such an accumulation of hardened wax, the auricular branch 
of the pneumogastric nerve forming the connecting link between the ear 
and the bronchial mucous membrane. 
Treatment.—The treatment for the removal of accumulations of cerumen 
is quite simple, and consists in syringing the ear with warm water. (See 
page 291.) All picks, curettes, or other instruments which have been devised 
for the extraction of wax are mischievous, and ought to have no place in aural 
therapeutics. If the mass is very solid and so firmly impacted that the 
water cannot get behind the obstruction, the difficulty can be overcome by 
pouring into the canal a solution of bicarbonate of sodium containing a little 
ether. This liquid will in a few minutes sufficiently soften the exterior crust 
of the plug to enable the water, after a few syringefuls have been injected, to 
pass onward in sufficient quantities to float out the mass. When the canal 
has been cleared of the obstruction, and of any water remaining, the hearing 
generally returns at once, and, if not with normal acuteness, an hour or two 
will in most cases suffice to make it so. When this is not the case, it will 
probably be due to some deviation of the drum-head from its proper shape, 
and the difficulty may be remedied by inflating the tympanum with the Po- 
litzer bag. Persons who frequently suffer from inspissated cerumen should 
have the auditory canal washed at intervals of six or eight weeks. 
Foreign Bodies in the Ear. 
The foreign bodies which are found in the ear belong to the three king- 
doms of nature,—the animal, the vegetable, and the mineral. 
Insects.—Though the odor of the cerumen is exceedingly obnoxious to in- 
sects, yet occasionally, despite this, flies, bugs, or beetles, carried onward by 
the impetus of flight, or driven to take refuge from the pursuit of an enemy, 
will enter the external auditory canal. There can be no mistaking the pres- 
ence of such a tenant. The noise, local pain, and distress which follow the 
entrance of the insect are of the most intense character, and often throw 
the patient into the greatest mental excitement. 
Treatment.—The removal of insects from the ear is quickly effected by FOREIGN BODIES IN THE EAR. 
305 
injecting warm water into the canal. Warm water not only destroys the 
animal by drowning, but at the same time washes it from the ear. When 
the accident occurs to a person so circumstanced as not to be able to com- 
mand the aid of a physician or a syringe, it will suffice to pour the water 
into the ear while the head is held to one side, which operation, should it 
not drive the insect out, will at least destroy its life and relieve the patient’s 
distress. Oil is often used in the same manner. It kills the insect by enter- 
ing the respiratory pores, but is less valuable than the warm water. 
Larvae of Insects.—Attracted by the odor emitted from the pus of suppu- 
rating ears, insects sometimes deposit their ova in the auditory canal. The 
larvae, when hatched, give rise to much local irritation, chiefly by their move- 
ments, and require to be washed from the canal with the syringe. As these 
grubs are supplied with hooklets which enable them to cling to the tissues 
on which they are found, their dislodgment is not always an easy task, unless 
the life of the animals has been previously destroyed. This can be done 
either by filling the ear with oil, which closes the respiratory openings of the 
larvae, or by introducing the vapor of chloroform into the canal. This latter 
can be satisfactorily done by soaking a dossil of absorbent cotton in the liquid 
and introducing it into the meatus. Subsequent and repeated syringing will 
be necessary in order to wash out the remains of the grubs. 
If the canal is kept free from purulent discharges, it is not probable that 
this region will be sought by flies as a place of deposit for their eggs. 
Foreign Bodies.—Children often mischievously introduce foreign substances 
into the ear. Among bodies of this kind we find buttons, beads, cherry-stones, 
beans, grains of corn or of coffee, pieces of slate-pencil, wads of paper, and a 
great variety of other materials. For the successful extraction of such bodies 
the greatest gentleness and care are needful. Much harm has been done, 
and even life sacrificed, by the rough and violent measures adopted for their 
removal, an injudicious procedure often wedging the offending body into the 
canal more tightly than it was found at first, or even forcing it into the 
tympanum through rupture or subsequent ulceration of the drum-head. 
Foreign bodies may remain a long time in the ear without causing any 
great inconvenience. In one instance I removed from the ear of a Scotch 
girl a nut which had been in the external auditory canal, I think she stated, 
for seventeen years. The body had produced denudation and caries of a 
portion of the bony walls of the canal. Cohen extracted from the ear a 
coffee-grain which had been there fifteen years. 
Treatment.—The syringe will in most cases be the only instrument re- 
quired for removing substances from the ear. If the water (warm) once 
passes beyond the obstruction, the outflow will generally carry the body to- 
wards the meatus, when it may be picked out by the forceps. If, after a 
proper trial, this plan fails, there are other means which may be resorted to 
with a fair prospect of success. If the substance is a round glass bead or a 
button, its extraction may be effected by introducing, under proper illumina- 
tion, a small blunt hook through- the eye of the body and bringing it out by 
traction ; or, this failing, a stout floss-silk thread may be secured to its body 
by some liquid glass applied to its surface with a camel’s-hair brush and 
allowed to harden before traction is made. A substance which cannot be re- 
moved by syringing or other simple moans at the first attempt will often, 
if allowed to remain undisturbed for a few days, yield to the same means 
on a second trial, in consequence of becoming loosened from suppuration. 
In fine, whatever attempts are made or whatever instruments are employed 
to extract foreign bodies from the ear, it is imperative that the entire pro- 
cedure should be distinctly visible to the eye, and that no injury be done 
to the walls of the canal. Manipulations in this region which are guided by 
the sense of touch alone are both officious and dangerous, and likely to work 
evil. 306 
DISEASES AND INJURIES OF THE EAR. 
It would appear, from observations made by Mayer, that when foreign 
bodies are allowed to remain in the ear a little over one-half the cases are 
followed by some form of aural or cei-ebral disturbance. Among the result- 
ing evils may be mentioned perforation of the membrana tympani, polypus, 
suppuration in the canal and in the cavity of the tympanum, hemorrhage, 
convulsions, and facial paralysis. With such possibilities threatening patients, 
I cannot concur in the teachings of some aurists, who discourage persevering 
efforts to remove these sources of danger. 
Parasitic Growths.—It is only a comparatively short time since parasitic 
vegetable growths were first discovered in the ear,—the first case being 
reported by Professor Scliwartze, of Ilalle, in 1867. This was followed by 
six cases of a similar character, published by Dr. Wieden, one year later, 
since wTiich time numerous cases characterized by the presence of vegetable 
growths of low type have been reported in the current medical literature of 
this and other countries. Among the papers on the subject, that of Dr. 
Burnett and that of Dr. Turnbull, of Philadelphia, are worthy of perusal. 
The particular fungus alluded to is the aspergillus, several species of which 
are found in the external auditory canal, the most common being A. flavus 
and A. nigricans. Through the courtesy of Dr. Charles S. Turnbull, I had 
an opportunity of examining a case marked by the presence of the latter 
species of aspergillus. The growth was very luxuriant, presenting a dark or 
soot-like appearance as it lay in the auditory canal. On a microscopical 
examination it exhibited an intricate mycelial web, from which grew stalks 
surmounted by fruit and spores in various stages of germination. The as- 
pergillus is alwTays found associated with inflammation of the lining mem- 
brane of the canal and of the membrana tympani, and is, no doubt, influential 
in maintaining the otitis. 
Symptoms.—The symptoms which are present in cases of parasitic otitis 
are impairment of hearing, tinnitus, vertigo, and some degree of pain. These 
signs, belonging, as they do, to other affections of the canal, particularly to 
ceruminous accumulations, are not certain indications of the mould, nor are 
the dai’k, yellow, or whitish flakes of ceruminous-looking material which 
cling to the sides of the canal or fill up its cavity in this form of otitis. Im- 
pacted cerumen and aspergillus, however, do not usually exist together. The 
diagnosis can only bo placed beyond conjecture by the microscope, under 
which the mycelium, fibres, spores, and fruit will be seen. (Fig. 1929.) 
Fig. 1929. 
Aspergillus uigricans. 
Treatment.—The treatment of parasitic otitis is usually somewhat tedious. 
The canal is to be cleansed of the mould by daily washings, the surgeon at 
the same time extracting with the forceps any portions of the fungus which 
may be seen adhering to the sides of the canal. In order to destroy every 
spore of the growth, agents inimical to the reproduction of these low forms FURUNCULUS. 
307 
of vegetable life can be used with great advantage. Several remedies pos- 
sessing parasiticide properties are at the command of the surgeon, prominent 
among which are carbolic acid, alcohol, hypochlorate of calcium, hyposul- 
phite of soda, and Fowler’s solution of arsenic. Any one of these drugs, 
properly diluted, may be employed every day: the solution is poured into 
the ear after the thorough washing of the canal. Benefit will also be derived 
from the application of iodoform (grs. xx, water and glycerin, of each f5ij); 
also from the local use of nitrate of silver (grs. x, distilled water, fgi). 
Washes containing zinc, alum, or tannic acid, according to Lowenberg, 
favor the growth of aspergillus, and should be avoided. 
Inflammation of the External Ear, of a diffuse character, is by no means 
so common as that of the middle ear,—a fact which is rather remarkable, con- 
sidering the exposure of the auditory canal to many sources of irritation. 
Symptoms.—The signs of external otitis are a feeling of irritation, itching, 
and fullness, with pain and diminished hearing. The severity of the pain 
increases with the depth of the inflammation, being greatest when the disease 
reaches the osseous part of the tube. The canal, when exposed to view, will 
be found red and swollen, and, after a brief period, it will be moistened with 
a purulent discharge, marking the stage of suppuration. 
Causes.—The causes which are concerned in producing external otitis are 
idiopathic and traumatic, as exposure to cold, draughts of air, the use of ear- 
picks, irritation from hardened wax, etc. It may be observed, in this con- 
nection, that the use of any instrument for the purpose of removing cerumen 
from the ear is unnecessary and injurious, and should be discouraged. The 
healthy ear is constructed so that it is able to relieve itself of all unnecessary 
cerumen without any external aid, and needs assistance only when particles 
of inspissated secretion appear in the meatus. 
Treatment.—External otitis, if attended to early, may be promptly 
checked by rest and the local abstraction of blood. This may be effected 
by means of two or three leeches applied to the tragus of the ear, the vessels 
of this part being most directly related with those within the canal, followed 
by the gentle instillation of warm water or of a warm infusion of hops by 
the aural douche. Steaming the ear with the vapor of hot water also exerts 
a soothing influence upon the inflamed surface of the canal. The simplest 
manner of doing this is to turn the expanded part of a funnel over a tea-cup 
filled with hot water and allow the steam to enter the ear through the nozzle. 
When the pain continues severe, these remedies may be supplemented by ap- 
plying over the auricle pledgets of hot cotton, or, what is more efficacious, a 
hot flaxseed-meal poultice, covered in with oiled silk and secured to the part 
by a handkerchief cravat. The prejudice manifested against the use of poul- 
tices in painful diseases of the ear 1 cannot understand. I am in the habit of 
using them often, and have never seen any of the evils laid to their charge 
by aurists, but, on the contrary, have seen the greatest benefits accrue from 
their employment. When the pain is sufficiently severe to prevent sleep, and 
is not assuaged by dropping a solution of morphia into the ear, opiates may 
be given internally; and, after the acute stage is passed, a blister laid over 
the mastoid process will hasten the cure. When the otitis is followed by 
suppuration, the canal must be kept free from the discharges by washings 
with water containing a little sulphate of zinc (grs. ij, water, f£i); and in 
applying this solution the syringe may soon be substituted for the douche. 
Furunculus, or abscess of the auditory canal, is the result of a circum- 
scribed inflammation, the symptoms of which are pain, swelling, and redness, 
with diminished hearing, a feeling of fullness, and frequently, as the disease 
advances, tinnitus. These boils may be single or multiple, and not unfre- 
quently as one disappears another forms. The pain is often exceedingly 
severe, as might be anticipated in an inflammation located in a structure like 
that lining the canal of the ear, in which the skin, in consequence of there 308 
DISEASES AND INJURIES OF THE EAR. 
being so little underlying connective tissue, lies close upon the perichondrium 
and periosteum. 
The causes of furunculus are obscure; for, while it is possible in some in- 
stances to discover a sufficient cause, such as exposure to a cold draught of 
air, there are many cases of the disease which seem to admit of no explana- 
tion. Feeble and unhealthy children are thought to be more predisposed to 
these attacks of aural abscess, yet examples of furuncle in children and other 
persons having strong, vigorous constitutions are quite common. 
Treatment.—We are rarely able to abort a furunculus of the ear, and it 
is, therefore, best to favor the maturation of the abscess as quickly as possi- 
ble,—which may be done by steaming the canal and applying over the auricle 
a hot poultice. As soon as the swelling becomes somewhat acuminated, it 
should be freely laid open with a curved bistoury and the contents allowed 
to escape. It is not even necessary to wait until suppuration takes place. 
After incision the swelling of the lining membrane rapidly subsides, when 
the canal of the ear may be washed with warm water. 
For a long time it has been my practice, after the opening of aural furun- 
culi, to smear over the canal daily some compound resin ointment mixed 
with a little morphia, to each drachm of which mixture may be added half 
a grain of carbolic acid. 
Where there is reason to believe that the furunculi are in some way de- 
pendent upon general disorder of the system, such as gives rise to boils else- 
where, it will be necessary to correct the vice, whatever it may be, by consti- 
tutional remedies. This may require a mercurial purge, a carefully-regulated 
diet, the use of tonics, especially iron, and a change of air. 
The morbid growths which are met with in the external auditory canal are 
both benign and malignant. The benign neoplasms are polypi, fibromata, 
cystomata, myxomata, and angiomata. 
Tumors of the External Auditory Canal. 
Benign Tumors. 
Polypi.—Soft or gelatinoid polypi are rarely found growing from the walls 
of the auditory canal. They usually have their origin in the tympanum, 
cause ulceration of the drum-head, and, passing through the perforation, ap- 
pear in the canal. They are sometimes confounded with exuberant granula- 
tion-tissue, such as occasionally arises in old cases of purulent discharge from 
the ear, in which the cutaneous lining has suffered excoriation. Indeed, all 
forms of polypi, whether soft or firm, have the soil for their development 
prepared by previous suppuration. 
The histological elements of soft polypi consist of a delicate net-work of 
connective tissue and blood-vessels, in the meshes of which are seen spindle 
and stellate cells, the whole invested with ciliated epithelium. 
Fibromata, sometimes called fibrous polypi, differ from soft polypi in pos- 
sessing a much larger amount of connective tissue, with cell-forms of a lower 
type, and covered by a pavement epithelium. Sections of these neoplasms 
sometimes exhibit traces of granular tissue, but this is probably not a new 
formation, being merely an inclusion of one or more of the sebaceous folli- 
cles of the canal. The attachment of fibromata is usually pedunculated. 
When the vascular element preponderates in these formations, the neoplasm 
has been distinguished by the term vascular polypus, a distinction altogether 
unnecessary and without any practical value. 
Cystomata occur within the meatus, having a semispherical form, and con- 
sisting of a cyst-wall, containing an accumulation of ordinary sebaceous 
substances. TUMORS OF THE EXTERNAL AUDITORY CANAL. 
309 
Angiomata within the auditory canal are of exceedingly rare occurrence, 
and do not differ in their structure from similar growths in other parts of the 
body. They can be diagnosed by their color, which is either purple or bluish, 
and by the facility with which they can be emptied of their blood by com- 
pression. 
Myxomata of the auditory canal are also uncommon neoplasms. Having 
the appearance of an ordinary soft polypus, the two tumors are liable to be 
confounded with each other. Myxomata are made up of scattered and deli- 
cate threads of connective tissue, with branching or stellate cells; and the 
tumors contain a soft, stringy, gelatinous material. 
Symptoms.—The symptoms of benign tumors of the external auditory re- 
gion are very much the same in all cases. There is a sense of fullness with 
occasional pain in the ear, and more or less discharge, purulent and bloody, 
with defective hearing. On looking into the meatus, the growth can usually 
be discovered by the eye, or, if not, on account of epithelial and purulent 
accumulations, it only requires that the ear shall be syringed in order to 
make the growth visible. 
Treatment.—With the exception of cystomata and angiomata, all of the 
growths described are to be treated by extraction with the forceps, the scis- 
sors, or the snare. The operation should be performed at the earliest mo- 
ment, as these tumors are capable of causing very extensive and sometimes 
fatal destruction of the parts. The membrana tympani rarely escapes dam- 
age, the bony walls of the canal are liable to become denuded and die, and, 
what is still more serious, meningeal inflammation, with intracranial abscess, 
is among the accidents likely to 
befall the patient. Indeed, it is 
rarely the case that any growth 
is extracted from the external au- 
ditory canal without leaving some 
permanent defect in the hearing. 
In performing extraction, the ear 
should bo previously washed with 
warm water so as fairly to ex- 
pose the tumor, the attachment 
of which having been tested by 
passing a probe cautiously along 
its sides, a pair of angular forceps 
(Fig. 1930) is to be slid, with open 
blades, down along the growth 
until its attachment has been reached, when the handles are to be closed 
and the tumor twisted off from its connection with the interior of the canal. 
The lever forceps of Toynbee (Fig. 1931) can be used for the same pur- 
Fia. 1930. 
Forceps for removing growths from the ear. 
FlQ. 1931. 
King and lever forceps of Toynbee. 
pose. The scissors (Fig. 1932), when'selected for this purpose, are to be 
conducted along the tumor in the same manner as the forceps, and its at- 
tachment severed by closing the blades of the instrument. Sometimes the 
snare of Wilde or Blake will be found to answer better than either the for- 
ceps or the scissors, especially when the growth is soft. (Figs. 1933, 1934.) 
This instrument has an angular shank armed with a wire loop, which can 
be expanded or closed at pleasure. In adjusting the snare, the wire is pushed 
out, and, after bending the loop or noose at an angle with the end of the 310 
DISEASES AND INJURIES OF THE EAR. 
shank, it is slipped over the growth, carried down to its attachment, and 
then tightened by drawing on one end of the wire. One or two turns of 
the instrument, followed by sud- 
den traction, will generally detach 
the tumor. 
Polypoid growths are very lia- 
ble to recur after removal, and 
the surgeon should not neglect to 
treat the surface from which they 
have been taken by touching it 
with nitrate of silver immediately 
after the operation, or as soon as 
the bleeding incident to the oper- 
ation has subsided, this usually 
requiring only a few minutes. If 
the hemorrhage persists, a gentle 
stream of warm water containing a little powdered alum or a few drops 
of Monsel’s solution of iron will close the vessels, when, after carefully 
wiping out the canal wTith dossils of absorbent cotton, a point of nitrate of 
Fig. 1932. 
Ear scissors. 
Fig. 1933. 
Wilde’s snare. 
silver can be carried to the diseased surface by means of a curved porte- 
caustique, or by Livingstone’s flexible caustic probe (Fig. 1935), the end 
being first dipped in the melted salt. All these manipulations are to be 
Fig. 1934. 
Blake’s snare. 
conducted through the speculum. Nitric acid or acid nitrate of mercury 
may be used for the same purpose, and also to repress redundant granulations 
such as may arise from an abraded surface on the walls of the canal. The 
Fig. 1935. 
Livingstone’s flexible caustic probe. 
application of these potent acids can be best made through a glass speculum 
on the point of an angular glass rod. 
Sebaceous tumors require to be laid open with a bistoury, and the sac 
with its contents must be shelled out with a scoop. 
Angiomata, when small, are susceptible of destruction by repeated appli- MALIGNANT GROWTHS. 
311 
cations of nitric acid; when large, by the galvanic cautery, the operator 
passing his needle into the centre of the tumor. The same result will follow 
the introduction of fine needles heated to redness in the flame of a spirit- 
lamp. 
Malignant Growths. 
The malignant neoplasms which are encountered in the auditory canal are 
carcinoma and sarcoma. 
Carcinoma.—The form of carcinoma which occurs in the region under 
consideration is the epithelial, and exceptionally the medullary. Generally 
its appearance in the canal is a secondary event, the disease beginning previ- 
ously in some portion of the auricle, on the face, or over the mastoid region, 
and extending to the meatus by continuity of tissue. 
Sarcoma.—Tumors of this class in the auditory canal are not numerous; 
those described being examples of spindle-celled or fasciculated osteo-sarcoma. 
It is not always an easy task to differentiate malignant neoplastic growths 
of this region from those which are benign. The existence of severe darting 
pains, a rapid increase of the disease, or recurrence soon after removal, with 
free hemorrhage and the development of brain-symptoms, are all significant 
phenomena pointing to malignancy. Greater certainty of diagnosis will be 
attained by subjecting a fragment of the diseased tissue to a microscopic test. 
Treatment.—Extirpation, though promising little permanent benefit, is 
not to be declined. The disease will certainly return, and eventually destroy 
the patient by encroaching upon the brain or its membranes, but that event 
will be delayed by keeping the canal as free as possible from diseased granu- 
lations and thus securing space for the increase of the neoplasm in the least 
dangerous direction. Twice have I succeeded, by caustics, in radically curing 
epithelial carcinoma in this region, even after the auricle had been destroyed. 
When contending with this form of the disease, the use of the curette to 
scoop away the granulations, followed by a layer of chloride of zinc paste, 
will, in my judgment, be found to fulfill most satisfactorily whatever is to be 
expected from remedial agents. 
Two varieties of bony growth are met with in the auditory canal, one a 
true circumscribed outgrowth of bone, the other 
apparently a general enlargement or increase of 
the bone (hyperostosis). That the division is well 
founded would appear from the fact that the hy- 
perostoses are regarded by some writers as con- 
genital, and that at least they do not appear ante- 
cedent to the complete ossification of the bony canal. 
They have a sessile base, occupy the inner extremity 
of the osseous canal, are exceedingly hard in tex- 
ture, and appear to arise independently of any 
previous disease of the ear. Exostosis is generally 
seated at or near the external bony meatus, is 
somewhat pedunculated in its attachment, its in- 
ternal structure is rather soft or spongy, and it 
is generally the result of previous suppuration. 
Various causes have been described as explaining 
the origin of these tumors. Toynbee believed in a 
rheumatic or gouty causation. Local irritation is, 
perhaps, chiefly concerned in the production of ac- 
quired exostoses. Wyman has observed that such 
tumors are very common among the Hawaiians, and, 
as these people live much in the water, Mr. Field 
attaches much importance to sea-bathing as a cause of these growths. The 
Exostosis. 
Fig. 1936. 
Cretaceous tumor of gouty origin. 
—Turnbull. 312 
DISEASES AND INJURIES OF THE EAR. 
connection between chronic suppuration of the ear and aural exostoses seems 
to be well established. Several examples of this association have been ob- 
served by Dr. Agnew, of Now York. 
Gouty formations of a chalky character are occasionally met with in the 
external ear (Fig. 1936), near the membrane of the tympanum. 
Treatment.—Hyperostoses do not admit of surgical interference. 
In cases of exostosis, the ear should be kept free from purulent accumu- 
lations, inasmuch as these are believed to favor their increase; and not 
until the growth continues to advance and threatens to block up the canal 
will surgical interference be demanded. The removal, when determined 
upon, can be accomplished by perforating the tumor in different directions 
with a fine drill, and, after weakening its structure, breaking it away either 
by a chisel or by forceps. 
Affections of the Membrana Tympani. 
The membrana tympani, placed between the external auditory canal and 
the cavity of the tympanum, is in part constituted of tissues peculiar to each. 
It is seldom the seat of primary disease, but frequently suffers from an ex- 
tension of some inflammatory process, either from the auditory canal or from 
the cavity of the tympanum. The majority, therefore, of independent affec- 
tions of the drum-head have a traumatic origin, as when a foreign body comes 
in forcible contact with the head or with the surface of the membrane, 
or when the membrane is accidentally punctured by the maladroit use of 
instruments, or ruptured by explosions of artillery. During the firing from 
Fort Sumter, at the commencement of the late civil war, it is said that 
several of the gunners suffered from ruptured drum-heads. It has also been 
stated that constant impact of the compressed air, following the discharge 
of cannon, against the membranm tympani of the soldiers, caused them to 
stagger and reel like drunken men from the singular cerebral disturbance 
produced. Such accidents, however, are not likely to occur except in the 
tight casemates of a fort, for the observations which have been made by 
Gruber and others show that firing in the open air, howTever heavy, rarely 
produces rupture of the membrana tympani. 
A most valuable paper on the effects of unusual atmospheric pressure upon 
the ear has been published by Dr. Andrew H. Smith, of New York, based on 
observations made upon workmen who were obliged to go into the caissons 
employed in constructing the foundations of the Brooklyn bridge over the 
East River. The drum-head is sometimes ruptured in sea-bathing by a 
bi*eaker striking against the side of the head. 
Ruptures of the membrana tympani can be diagnosed by ocular inspection, 
the parts being illuminated by the speculum and mirror; and also by the 
tuning-fork, the sound being heard loudest in the injured ear,—this at least 
being true when the effects of traumatism are confined to the drum-head. 
The accident, unless the violence producing the injury has been so great 
as to damage the internal ear, is not an irreparable one: the rupture heals 
in the course of seven or eight days, and in three or four weeks at most the 
infiltration and cicatricial thickening will have been so far removed that the 
hearing will be little diminished. 
Treatment.—Bodily quiet, the exclusion of cold air from the canal, and, 
when pain and throbbing are present, the application of two or three leeches 
to the tragus, are all that is requisite for the management of a case of rupture 
of this membrane. 
DISEASES OF THE MIDDLE EAR. 
Catarrhal Inflammation of the middle ear has been divided by writers into 
several different varieties. As I am unable to discover the practical utility of 
this nomenclature, I shall content myself with presenting the disease under ACUTE INFLAMMATION OF THE MIDDLE EAR. 
313 
the heads of acute, chronic, suppurative, and non-suppurative catarrh. The 
general term for all inflammations of the middle ear is otitis media. 
Acute Non-suppurative Inflammation of the Middle Ear. 
The onset of this form of inflammation is usually quite sudden, the patient 
retiring apparently well in the evening and awaking in the night complain- 
ing of pain, tinnitus, and a deep-seated fullness in the ears, accompanied with 
sore throat. The hearing at the commencement of the attack may not be 
impaired; indeed, the ear is sometimes painfully sensitive to sounds. The 
disease is accompanied by rigors, an increased temperature, and other signs 
of constitutional disturbance. In children too young to make their feelings 
understood, acute catarrh frequently goes unchecked in consequence of the 
practitioner failing to discover the seat of the inflammation, and therefore 
placing a wrong construction on the symptoms. Even in older persons, able 
to detail their sensations and to locate the seat of distress, the severe, dart- 
ing character of the pains may lead to the supposition that the case is only- 
one of neuralgia. The inflammation reaches the tympanum from one of two 
directions,—either from the pharynx along the Eustachian tube, or in the 
course of the external auditory canal; oftener by the former than by the 
latter route. The auriscope, however, will reveal the seat of inflammation. 
On illuminating the ear and exposing the membrana tympani to view, the 
latter will be seen to present a red or pinkish color, well pronounced in the 
regions of the richest vascular supply, as at its periphery and in the course of 
the handle of the malleus; and if twenty-four or thirty-six hours have elapsed 
since the attack and before the examination is made, in addition to the in- 
creased vascularity of the membrana tympani it will be seen to have lost its 
characteristic form and to bulge externally. 
Causes.—Exposure to cold, draughts of air, wet feet, injudicious sea- or 
fresh-water bathing when the atmosphere is cool, and particularly the act of 
dipping the head under the water as in diving, constitute the most fruitful 
sources of acute catarrh of the tympanum. I have witnessed brief attacks 
from the use of the nasal douche, in consequence of the water passing through 
the Eustachian tube into the cavity of the tympanum. 
Treatment.—Acute inflammation of the tympanum requires early and de- 
cided treatment, otherwise the disease either terminates in suppuration or 
gradually lapses into a chronic inflammation. 
In no form of aural disease are antiphlogistic remedies more imperatively 
demanded or more successfully employed than ifi acute catarrh. The abstrac- 
tion of blood ranks first among remedial measures. Leeches should be applied 
to the tragus, and, in order that the animals shall not enter the ear, the orifice 
of the canal should be stopped with a dossil of absorbent cotton ; or, if these 
cannot be obtained and the artificial leech is not at hand, cups can be advan- 
tageously applied over the mastoid region. The abstraction of blood may 
be next followed by a hot foot-bath. Much relief will also be experienced 
from the use of warm water passed into the ear in a continuous stream, or by 
means of the douche, or the vapor of hot water can be allowed to enter the 
canal. A household remedy much employed in painful affections of the ear, 
and not without benefit, is the smoke of tobacco blown into the meatus. 
Poultices, which appear to be unpopular with specialists at the present time, 
I have from long experience found exceedingly useful. They should not 
only cover the auricle, but should extend a short distance beyond. It is only 
when these applications are continued too long that they prove harmful. As 
soon as the inflammatory symptoms culminate, poultices are to be dispensed 
with, and dry heat applied; in which application nothing answers a better 
purpose than small bats of cotton heated and wrapped in hot flannels and 
frequently renewed. 
The constitutional treatment at the outset of the attack consists of a 314 
DISEASES AND INJURIES OF THE EAR. 
purge, opiates to relieve pain, and a moderately restricted, chiefly liquid diet, 
since the motion of the jaws in chewing aggravates the pain. 
When the disease is disposed to be stubborn and the symptoms do not 
yield, paracentesis of the membrana tympani will often in a short time 
change the entire aspect of the case for the better. 
Bulging of the drum-head is accepted by some as the sign indicating the 
propriety of puncture; by others it is regarded as unimportant. Those who 
hold the latter opinion advocate the incision in obstinate cases of acute 
catarrh, even though no such change of form is present. It is highly proba- 
ble that, if no interference is practiced, perforation will ensue spontaneously: 
why, then, should not the surgeon anticipate this result? 
The operation of paracentesis of the membrana tympani is a simple one, 
and is not very painful. 
While combating, in the manner detailed, the inflammation in the tympa- 
num, there are other regions involved in the diseaso which require attention. 
When the catarrh begins at the faucial side of the tympanum, reaching 
the latter through the Eustachian tube, it is necessary to address remedies to 
the inflamed mucous membrane of the pharynx. By relieving this inflamma- 
tion that of the tympanic cavity will also be relieved. For this purpose the 
local application of a solution of nitrate of silver, followed by a gargle made 
from the berries of rhus glabrum, or one of chlorate of potash, will prove 
helpful. 
As soon as the disease begins to decline, the gentle inflation of the tym- 
panum with the Politzer hag should begin, in order to secure the patency of 
the Eustachian tube, by stimulating the muscles which regulate the faucial 
opening of the canal and clearing away adherent mucus. 
Chronic Non-suppurative Inflammation of the Middle Ear. 
Chronic non-suppurative inflammation of the middle ear constitutes one- 
half of all aural disease. Like most chronic inflammations, it is the result 
either of an acute attack which from neglect has slowty glided into this state, 
or of repeated acute attacks, each one less pronounced than the preceding 
one, but each causing a certain amount of structural damage, until at length 
the disease becomes firmly intrenched in the middle ear. 
There are some persons whose vital resistance to atmospheric changes is 
so weak that they take cold on the slightest exposure. They are scarcely 
ever free from a naso-pharyngeal catarrh. These are the persons who are 
likely to become subjects of this disease. The secretions accumulate behind 
the soft palate, trickle down the pharynx, and provoke frequent efforts at 
hawking or blowing the nose, in order to dislodge the mucus. Persons thus 
affected rarely have normal acuity of hearing when tested by the watch. It 
is only, however, when they begin to realize a stuffed condition of the ears, 
as though the auditory canal were stopped, or when, in speaking, the voice 
seems to be closeted, and the conversation of others appears distant, that 
any anxiety is felt, or that they resolve to apply to a surgeon for relief. In 
addition to these symptoms, more unpleasant or even disti’essing ones are 
experienced, such as tinnitus aurium, vertigo, etc. The depressing effect of 
the various noises in the ears is very great, causing in not a few instances 
melancholia, and sometimes even impelling to suicide. 
In other cases, the above nasal and pharyngeal affections passing away, the 
inflammation in the middle ear remains; or the former may never have ex- 
isted at all, and yet the symptoms of chronic disease of the middle ear, with 
more or less deafness, may appear. 
The pathological changes which are induced in well-marked cases of 
chronic non-suppurative inflammation are quite extensive,—as extensive, 
indeed, as the irregular boundaries of the cavity of the tympanum. The 
membrana tympani participates in the inflammation, the effects of which 
vary according to the condition of the submucous infiltrate. When the lat- CHRONIC INFLAMMATION OF THE MIDDLE EAR. 
315 
ter has been organized into connective tissue, abridging the movements of the 
chain of bones, the mobility of the membrane will be greatly lessened ; while 
in other cases, when there has been only a simple inflammatory swelling and 
the products have been removed by retrogressive changes, the membrane 
may be even more movable than in health. The degree of mobility of the 
drum-head can be tested in two ways,—namely, by the Sigle speculum, de- 
scribed on page 296, which enables the observer alternately to exhaust the 
air of the external auditory canal and to readmit it, and at the same time to 
watch the behavior of the membrane under the test; and by efforts at 
inflation made by the patient attempting to blow the nose while the nostrils 
are kept closed. If the membrane is free, it will be known by the feeling 
experienced in the ear. 
Eustachian tube.—The inflammation in one class of cases of chronic non- 
suppurative inflammation of the middle ear, having traveled along the Eus- 
tachian tube to the tympanic cavity, leaves the traces of its march in the 
walls of this canal. The orifice of the tube may be collapsed in consequence 
of paresis of its dilator muscle,—the tensor palati,—not only causing reten- 
tion of mucus, but also, by preventing an interchange of air, and conse- 
quently causing a rarefaction of that within the tympanic cavity, favoring 
(as has been shown by Weber Liel) hyperaemia of the walls of the cavity 
of the tympanum, the closure of the tube thus becoming an active agent in 
the development of catarrh. In that form of non-suppurative catarrh of the 
middle ear which comes on without any inflammatory trouble either in the 
external auditory canal or in the dome of the pharynx, and in cases in which 
the structural alterations consist in thickening or a new formation of con- 
nective-tissue elements in the mucous membrane of the tympanum, it does 
seem probable that in this paralytic collapse of the walls of the Eustachian 
tube and the evils resulting therefrom we have a sufficient cause to account 
for the disease; and this explanation seems especially suited to those catarrhs 
which follow attacks of diphtheria, a disease in which the muscles of the soft 
palate are so often paralyzed. Inherited or acquired syphilis also plays a 
prominent part in the production of this type of the disease. 
The faucial orifice of the Eustachian tube may also be in a measure con- 
cealed by cedematous swelling, and finally the canal of the tube, in its whole 
length, may be greatly narrowed by cicatricial contraction. 
The patency of the Eustachian tube can be ascertained either by the 
Yalsalvan or the Politzer method of inflation. 
Cavity of the tympanum.—In addition to the changes noted, accumulations 
of mucus will be found in the cavity of the tympanum, with more or less 
thickening of the mucous membrane lining ils walls. Nor do the ossicula 
escape; their articulations become anchylosed, preventing mobility of the 
tympanum; in addition to which, false bands of organized lymph are some- 
times seen to intersect the cells in the mastoid portion of the temporal bone. 
Such are the leading changes which have been witnessed, particularly in 
chronic non-suppurative inflammation of the middle ear, and especially in 
cases where the new elements of the transudation assume an organized 
form. 
Naso-pharyngeal region.—It is impossible, in many cases of the disease under 
consideration, to ignore, in a study of pathological mutations, the naso- 
pharyngeal or post-palatine region. While it is true that chronic non-sup- 
purative inflammation of the cavity of the tympanum may exist without this 
region being implicated, yet the reverse is more generally the case; and in 
this condition must be recognized a most important factor in the chain of 
causation bearing on the production of Eustachian and middle-ear troubles. 
The condition alluded to is one of chronic pharyngitis and rhinitis, in which 
the elements of the mucous membrane of the pharynx, including its glands, 
all become hypertrophied, and that of the posterior nares is thickened and 
perhaps studded with polypi and granulations. 
Treatment.—The treatment of chronic non-suppurative catarrh embraces 316 
DISEASES AND INJURIES OF THE EAR. 
the use of both local and constitutional remedies, and demands patience and 
perseverance on the pai’t of both patient and physician. Associated as the 
inflammation commonly is with chronic hypertrophic pharyngitis, little 
progress will be made in relieving the disease of the tympanum until that of 
the pharynx has been removed. Accordingly, a vigorous treatment must be 
first addressed to the naso-pharyngeal region, comprising the use of post-nasal 
injections, such as warm solutions of bicarbonate of soda, chlorate of potash, 
or chloride of sodium, in order to dislodge from the surface of the mucous 
membrane the adhesive secretions. Similar washes may be passed thi’ough 
the nose, either by means of the nasal douche or by forcibly snuffing up the 
liquid through the nostrils into the throat and expelling it through the mouth. 
When the douche is used, the fountain ought never to be raised above the 
level of the root of the nose, a precaution which, if observed, exerts some 
influence in preventing a reflux of the solutions into the cavity of the tym- 
panum. Twice have I seen such unpleasant effects to the ear follow the 
use of the douche, so that 1 am disposed not to urge its employment in aural 
surgery. All the advantages of the douche can be secured by injecting the 
medicated fluid through one nostril of the patient while the other is held 
closed. The mucous surface of the pharynx, after being thus cleansed from 
all accumulations, is prepared for the alterative action of either nitrate of 
silver or a solution of iodine. After no small experience in the use of both 
of those remedies, I give the preference to the former, which can be applied 
directly to the part by the post-palatine swab or probang (see Fig. 1709, page 
51) every third day. The strength of the nitrate of silver solution should 
not be less than thirty grains of the salt to one fluidounce of distilled water. 
When there exists an external suppurative otitis, it is also important that 
this should have a place in the preliminary treatment. 
Along with the local management of the pharynx and the external audi- 
tory canal comes that of the Eustachian canal and the tympanic cavity. 
The former must be kept patulous and free from accumulations of mucus, 
in order to allow a ready interchange of air in the tympanum; and where 
thickening of the mucous membrane exists, resolving agents are to be intro- 
duced with a view to restore the normal anatomical character and physio- 
logical function of the membrane. These ends are to be sought through the 
agency of atmospheric air, medicated liquids and vapors, conducted to their 
destination by means of the Politzer air-bag, the Eustachian catheter, and 
the vaporizing-bottle. In utilizing atmospheric air, it is to be forced into the 
Eustachian tube and tympanum by the Politzer bag; and when it is found 
that the air does not penetrate the canal in the ordinary way,—that is, by 
inserting the nozzle of the tubo into one nostril while the other is closed 
by the fingers of the operator,—the inflation must be effected through the 
Eustachian catheter, which, after two or three applications, can often bo laid 
aside and the gum bag resumed alone with entire success. 
The fluids which possess the greatest value as local alteratives are solu- 
tions of nitrate of silver (gr. } to £, distilled water, fgi), of sulphate of copper 
(gr. ? to i, water, of liquor potassse (gtt. iij, water, f30, and of sulphate 
of zinc (gr. i, water, f$i). 
The best apparatus for conveying these solutions to their destination con- 
sists of a hard-rubber Eustachian or tympanic catheter, a Politzer bag, and 
a syringe (hypodermic). (Fig. 1937.) The syringe, charged Avith the medi- 
cated fluid, is fitted to the end of the Eustachian catheter. Simultaneously 
with the discharge of the liquid the rubber ball is compressed, and the effect 
of this is to drive the contents of the syringe into the Eustachian tube and 
the cavity of the tympanum. These injections should be made twice a week. 
The particular injection to be employed must be determined by the nature 
of the catarrh; the zinc and copper are suited to cases in which the inflam- 
mation is not accompanied by thickening of the mucous membrane of the 
middle ear; the others to cases where such a complication exists. 
It is in this last form of catarrh that steam or vapors do good. A copper CHRONIC INFLAMMATION OF THE MIDDLE EAR. 
317 
flask having two tubes fitted into the stopper, each connected with a rubber 
tube, one of which is attached to an air-bag and the other has a nozzle 
Fig. 1937. 
Apparatus for injecting liquids into the tympanum. 
adapted to the Eustachian catheter, constitutes the apparatus (Fig. 1938) 
for Using the steam. The liquid is vaporized by the flame of an alcohol-lamp 
Fig. 1938. 
Apparatus for steaming the tympanum. 
placed beneath the flask, and is blown into the tympanum by short, sudden 
compressions of the hag. After each compression of the bulb, it is well to 
detach the gum tube from the catheter, so as not to irritate the parts by too 
high a degree of heat. 
Bougies constitute another addition to the aural armamentarium. Their 
application is limited to cases of close stricture of the Eustachian tube (by 
no means a common condition), and requires the greatest degree of care in 
order that laceration of the mucous membrane be not produced, an accident 
of which there are numerous examples on record, and one which is often fol- 
lowed by emphysema of the fauces, neck, or face. The catgut bougies, with 
smooth conical ends, recommended by Dr. Weir, are to be preferred. They are 
passed through the Eustachian catheter, and, in order that their exact position 
can be determined when in the canal, they have four marks, one answering 
to the length of the catheter through w’hich they are passed, a second indi- 
cating the distance to the constricted portion of the tube, a third showing 318 
DISEASES AND INJURIES OF THE EAR. 
the distanco to the end of the tube, and a fourth the distance across the 
cavity of the tympanum. 
Incision of the drum-head, in obstinate cases of chronic non-suppurative 
catarrh which exhibit no disposition to yield to the ordinary remedies de- 
tailed, is growing into favor. The chief advantage resulting from the pro- 
cedure is the increased facility with which the tympanum can be ventilated 
and the mucus expelled from its cavity by inflation with the Politzer bag, 
or by washing it, as done by Hinton, by injections passed through the external 
auditory canal. 
The operation of paracentesis of the drum-head is said to have been first 
performed by Riolanus, of Paris, in 1650. Since the time of Sir Astley 
Cooper, who originated the operation in England for the relief of deafness 
arising from Eustachian obstruction, and who finally abandoned the practice, 
the results being negative, paracentesis has had a varying history. By some 
surgeons it has been extravagantly lauded, and by others dogmatically con- 
demned. The statistics furnished by some of its ardent advocates have been 
shown to be altogether unreliable; and even at the present time there is a 
singular absence of accord among aurists as to the particular class of cases 
requiring the membrane to be incised. The almost entire harmlessness of 
the operation, however, justifies its repetition in all cases where other ap- 
proaches to the tympanum for medication have been tried in vain. Gruber’s 
knife (Fig. 1939) answers well for the incision. 
Weber, in order to diminish the tension of the drum-head and of the chain 
of bones (which tension he believed to be instrumental in keeping up catarrhal 
conditions of the middle ear), executed an operation, suggested by Hyrtl, 
of dividing the tensor tympani muscle, a procedure which he accomplished 
with a curved tenotome, after piercing tho membrane at the front of the 
tympanum, the ear being perfectly illuminated at the 
time of the operation. The exceptional skill required for 
this particular tenotomy, of course, can be acquired only 
by repeating the process many times on the dead body. 
The operation has received the sanction of Gruber and 
others, but a larger accumulation of observations will bo 
required before this plan assumes an acknowledged place 
as a surgical resource. 
Other operations are performed with a view to over- 
Fig. 1939. 
Gruber’s tenotomy knife. 
come rigidity of the membrana tympani, such as dividing the posterior fold 
of the drum-head (Lucse) and incising the adhesions contracted by the 
membrane (Prout), the value of which operations time alone can establish. 
While it is evident that in treating these cases of chronic non-suppurating 
catarrh of the middle ear local remedies play the most conspicuous part, yet 
constitutional treatment must not be ignored. As the disease is often con- 
joined with a strumous or feeble organization, benefit will be realized from 
the use of iodide of iron, cod-liver oil, and bichloride of mercury,—the latter 
in small doses, given in the tincture of cinchona. When a syphilitic history 
can be discovered, local measures will be valueless without the general treat- 
ment. Iodide of potassium in such conditions constitutes a remedy of price- 
less value. 
Although the prognosis in cases of chronic non-suppurating catarrh is not 
very encouraging, especially when the subjects are somewhat advanced in 
life, yet the percentage of those cured and l’elieved is by no means insignifi- ACUTE SUPPURATIVE INFLAMMATION OF THE MIDDLE EAR. 
319 
cant. Of 514 cases given by Roosa, 41 per cent, were cured, and 31 per cent 
improved. 
Acute Suppurative Inflammation of the Middle Ear. 
Acute suppurative inflammation of the middle ear is usually sudden in its 
invasion, following sometimes a pharyngeal or naso-pharyngeal catarrh or 
an acute tonsillitis, or developing during the progress of certain exanthe- 
mata, such as scarlatina or rubeola. An acute non-suppurative catarrh may, 
in consequence of an accession of cold, or from irritating applications, be 
suddenly converted into a suppurative inflammation. Injuries to the drum 
of the ear are liable to cause the disease, the inflammation extending from 
the membrana tympani into the cavity of the tympanum. 
Symptoms.—The which characterize acute suppurative inflam- 
mation are pain, a deep-seated sense of fullness or stuffing in the ear, tinnitus, 
and obtuseness of hearing, accompanied with rigors, heat, and other signs of 
constitutional disturbance. The pain varies greatly in different cases. It is 
sometimes extremely severe and throbbing or lancinating, at other times 
quite insignificant. The drum-head generally discloses what is in progress 
within. The swelling of the membrane, with the loss of transparency, ob- 
literates its two characteristic features,—the handle of the malleus and the 
light-colored spot. Seldom does the drum-head escape participation in the 
disease, the inflammatory infiltrate spreading through its layers. There are 
cases in which the membrane, instead of being thickened, becomes attenu- 
ated and bulging, a condition indicative of a considerable accumulation of 
pus in the cavity of the tympanum. In addition to the above symptoms, 
there is often a tender, puffy, cedematous tumor or swelling over the mastoid 
portion of the temporal bone, the external evidence of an extension of the 
inflammation into the mastoid cells. 
If the disease is not early recognized and actively treated, the membrana 
tympani either ruptures or is perforated by ulceration, and the pus escapes 
into the external ear. 
Treatment.—If the surgeon expects to be successful in preventing sup- 
puration, he will have to bring his most energetic remedies to bear against 
the disease within a few hours after its appearance. Leeches are to be ap- 
plied to the tragus, and also over the mastoid region, if it is red or tender; a 
gentle purge must be given, and the warm douche should be used in the ex- 
ternal auditory canal. Should it appear on examination that suppuration 
has taken place,—a point which may be determined by the prominence of the 
membrane of the tympanum and by the increasing severity of the pain,—it 
is well to anticipate perforation or rupture of the drum-head by promptly 
incising the membrane and giving exit to the purulent accumulation. If 
the integuments over the mastoid continue swollen, sensitive, and red, they 
should bo incised down to the bone. After the drum-head has been opened 
and the pus discharged, the pain usually ceases, and along with it the gen- 
eral disturbance of the system. The ear must be kept cleansed by the warm- 
water douche, used three or four times in the twenty-four hours. The 
Politzer bag will also be required for inflating the tympanic cavity and 
keeping the Eustachian tube and middle ear free from all accumulations. 
Nor must the throat-symptoms be overlooked w'hen present. A decoction 
of the berries of rhus glabrum, with the addition of some chlorate of 
potash and tincture of guaiac, makes a very excellent gargle for the fauces 
and pharynx. To allay the soreness and swelling of the latter, much relief 
will be afforded by very hot poultices of corn-meal mush worn about the 
neck, repeating them as often as they become cool. Generally, after opening 
the drum-head the disease rapidly disappears, the pus becoming less each 
day, and the hole in the membrane closing by granulations, while the hearing 
is gradually restoi’ed. 
When, on the other hand, the suppuration is disposed to linger, it will be DISEASES AND INJURIES OF THE EAR. 
320 
well to add to the fluid used in the douche or the syringe some astringent, 
such as the sulphate of zinc, sulphate of copper, or alum. If these articles 
fail to lessen the discharge of pus, resort may be had to nitrate of silver, a 
strong solution of which (gr. xx, distilled water, f'3i) can be brought into 
contact with the mucous membrane of the tympanum by inclining the head 
to one side and pouring the liquid into the ear. 
This very common affection, which meets the physician almost every day 
in all our great eleemosynary institutions, and which is seen so often in houses 
of refuge and in orphan asylums, is very often misunderstood, the difficulty 
being regarded as having no deeper seat than the external auditory canal. 
In a very large proportion of all cases of chronic purulent discharge from 
the external ear the scat of the disease is the middle ear; and while such 
discharges may and often do go on for years without check, and with no ap- 
parent serious results, yet persons thus affected stand on dangerous ground, 
since there is no time when they are not in danger of some sudden calamity 
consequent on bone, meningeal, or brain lesion. 
Chronic suppuration is usually the result of an acute otitis media following 
naso-pharyngeal disease. In a large number of instances it is one of the 
entailments of scarlatina. 
Symptoms.—The symptom which individualizes chronic suppurative inflam- 
mation of the middle ear is a discharge of pus, abundant or scanty, from the 
external car, sometimes sero-purulent or ichorous or sanious in its character, 
and at other times thick and laudable. Occasionally it will bo noted that 
when there is a sudden increase in the amount of pus discharged, it will have 
been preceded by an exacerbation of pain; in other words, there has been a 
short-lived acute inflammation created by some unusual exposure or indis- 
cretion on the part of the patient. When the discharge is copious, it is fre- 
quently followed by excoriation of the external parts of the meatus and 
dependent portions of the auricle, and the affected ear emits an unpleasant 
odor. 
When the interior of the ear is subjected to examination, the membrana 
tympani will be found perforated, sometimes entirely destroyed. The chain 
of bones may also participate in the damage, its constituent parts being par- 
tially necrosed and displaced, or, as often happens, the ossicles may have 
totally disappeared. Nor do the ulcerative changes cease with the loss of 
the ossicula. The bony walls of the auditory canal, of the tympanum, and 
of the mastoid cells may also be the seat of caries. From the ulceration of 
the mucous membrane, bathed constantly in pus, springs a mass of fungous 
granulation-tissue or polypus; and should the devastation encroach upon 
the canal which transmits tho portio dura nerve, or should the mischief 
extend towards the surface of the petrous bone, facial paralysis or cerebral 
abscess may, in addition to the other evils, befall the patient. 
Prognosis.—As long as the walls which inclose the acoustic apparatus are 
not implicated, the disease is not beyond our therapeutic resources, considered 
from a catarrhal point of view. The discharge will gradually disappear under 
appropriate treatment, and the opening in the drum-head, if not too large, 
will heal up. There will probably be a retention of some degree of hearing; 
and even when the membrane of the tympanum has been destroyed, it is not 
impossible that the hearing may be retained in some degree. When, however, 
the ossicula have been destroyed and caries has begun in the surrounding 
bone, tho case assumes a new and serious importance, and becomes one, in- 
deed, in which little hope can be entertained, and the best-applied efforts of 
the surgeon can accomplish little more than to palliate the symptoms. 
Treatment.—In taking charge of a case of chronic suppuration of the 
middle ear, the first important step in the treatment is carefully to rid the 
cavity of the tympanum of all accumulations, purulent or otherwise. This 
Chronic Suppurative Inflammation of the Middle Ear. CHRONIC SUPPURATIVE INFLAMMATION OF THE MIDDLE EAR. 
321 
can be done only by the repeated use of the syringe or douche and by the 
Politzer bag, forcing the air through the Eustachian tube and expelling what- 
ever secretions may lie in the tympanum. This must be done daily, and 
should be followed by astringent washes of sulphate of zinc, boracic acid, 
acetate of lead, or nitrate of silver (grs. xx, distilled water, fgi). The effi- 
ciency of these agents will depend largely on the thoroughness with which 
the interior of the ear has been previously cleaned. If a point of granula- 
tion or a polypus is seen projecting from the cavity of the tympanum, it 
must be removed by the forceps. A small crop of granulations hidden away in 
the tympanum will often keep up the discharge in 
defiance of all remedies. It is important, therefore, 
to examine with great care the tympanic cavity 
under proper illumination, in search of such soux*ce 
of evil. A very small mirror (Blake’s) has been used 
with a view to explore portions of the drum-cavity 
not ordinarily accessible. The instrument 
can be introduced into the ear, and, its shaft 
being flexible, the mirror can be turned at 
any desired angle. (Fig. 1940.) 
Fig. 1940. 
The surface from which a growth or granulation has been removed, in 
order to prevent recuri-ence, should be touched with the solid nitrate of silver, 
applied on the end of a probe. The galvano-cautery has been recommended 
not only for this purpose, but also for the destruction of morbid growths. 
After the catarrh has been overcome, but the tympanum not restored, 
there may remain a deafness which can often be remedied to a considerable 
extent by the use of an artificial drum-head. 
Tympanic mirrors. 
Necrosis of that part of the petrous portion of the temporal bone which 
surrounds the middle and internal ear may 
follow old cases of chronic catarrh of the 
middle ear, destroying all connection be- 
tween the apparatus of hearing and the 
bone in which it is lodged. Where such 
extensive osseous devastation occurs, the 
organ of hearing may be discharged ex- 
ternally, or, what is more probable, the 
caries may be followed by meningitis, par- 
alysis, or abscess. Fig. 1941 was taken 
from a specimen of abscess over the petrous 
portion of the temporal bone in one of my 
hospital patients. The man had long been 
the subject of a chronic catarrh of the middle 
ear, and was admitted into the Pennsylvania 
Hospital suffering from persistent pain at 
the base of the brain, stupor, rigors, and a 
constant tendency to roll the head from 
side to side. There was delirium, and some 
purulent discharge from the ear, which, in 
connection with the above symptoms and 
with his previous history, led to the diag- 
nosis of meningitis and abscess,—a diagnosis verified by the autopsy. 
Treatment.—The treatment of a case of necrosis of the bony walls of the 
Fig. 1941. 
Abscess under the meninges of the brain. 322 
DISEASES AND INJURIES OF THE EAR. 
ear is not always absolutely fruitless. At least it often postpones the evil 
day, which in the end is likely to overtake the unfortunate patient, whose 
death finally occurs from abscess, pyaemia, or hemorrhage from the lateral 
sinus. The great indication is to make some way for the escape of the puru- 
lent discharge: hence the value of washing out the middle ear frequently 
with the douche or the syringe, and of the removal of accumulations from 
the tympanum by the Politzor method. Resort may be had, if need be, to 
trephining the mastoid. 
Mastoid Disease. 
The mastoid cells, communicating as they do with the middle ear, almost 
always participate in inflammations of the cavity of the tympanum, and 
these mastoid inflammations often disappear under treatment applied to the 
tympanic cavity. This termination, however, does not always occur. An 
inflammation may become so intrenched in the cavities of the mastoid bone 
as to involve the periosteum and give rise to abscess and to necrosis of the 
bone itself. 
The signs of mastoid periostitis are post-auricular swelling, and tenderness 
and redness of the integuments over the mastoid process, with deep-seated 
pain; but as these symptoms are frequently present in other inflammatory 
affections of the ear, they cannot in anj’- proper sense be regarded as differen- 
tial : indeed, I am not aware that there are any positive phenomena indicative 
either of periostitis or of purulent accumulations in the mastoid cavities. 
When, however, in the course of any inflammation of the middle or external 
ear accompanied or followed by deep-seated pain, there are tenderness and 
swelling over the mastoid region, and especially if the swelling is (ede- 
matous, and when, in addition, there is a history of rigors, with elevation of 
temperature and other signs of constitutional disturbance, then there is a 
reasonable presumption that periosteal trouble exists. When we consider 
the free vascular communication which exists between the vessels of the in- 
ternal and the external parts of the mastoid cavity, it is not difficult to 
understand the readiness with which an inflammation within may extend to 
the outer surface of the bone; and, again, the relation of this portion of the 
ear to the lateral sinus and to the meninges of the cerebellum is so close that 
intracranial complications are always to be guarded against. The dense 
resisting structures which overlie the mastoid process, particularly the tendi- 
nous attachment and expansion belonging to the sterno-cleido-mastoid muscle, 
necessarily oppose the progress of inflammatory formations towards the sur- 
face. Hence, when suppuration does take place, the pus will be more likely 
to travel towards the auricle and open into the cartilaginous canal than to 
open externally. 
Treatment.—In all cases where there are reasons to believe that periosti- 
tis of the mastoid portion of the temporal bone exists, and when the symp- 
toms do not subside after free leeching, a free incision should be made over 
the swelling and directly down to the bone, and the parts should be covered 
with a flaxseed-meal poultice. Even if the diagnosis is incorrect, no harm 
can come from the operation, while, if the supposed condition does exist, 
the relief will be almost instantaneous, and the risk to the other parts will 
bo materially lessened. Should the bone be discovered to be necrosed, the 
diseased portion or sequestrum must be taken away as soon as it has be- 
come loose. When the symptoms point strongly to abscess within the 
mastoid cavit}*-, and yet no fistulous orifice can be detected, an exploratory 
opening with a small bone-drill through the external wall of the process 
ought to precede any application of the trephine, as the outlet thus made, 
while comparatively unimportant in point of danger, will be sufficient to 
admit of the escape of pus, if any exists, and the preliminary operation will 
resolve all doubts as to the propriety of excising a portion of the bone with 
the trephine. When the operation has been performed, the interior of the 
cavities can be treated by removing granulations or fragments of dead bone, MASTOID DISEASE. 
323 
by the use of stimulating and astringent washes, as of zinc, copper, or 
iodine, and by keeping the parts open with a drainage-tube. 
Trephining the Mastoid. 
The operation of cutting away a portion of the external wall of the mas- 
toid was first executed by Petit, not with the trephine, but with the chisel. 
The first formal operation with the trephine, it is believed, was made by a 
military surgeon named Jasser, over a century ago. During the last fifteen 
years the operation has been so frequently repeated, and with so little danger 
to life, that it may be accepted as an established surgical resource ; though at 
the same time it is one not to be undertaken lightly or without sufficient 
reasons for its performance. 
Operation.—An incision one inch and a half in length should be made 
downward and backward over the most prominent part of the mastoid pro- 
cess, three-eighths of an inch posterior to the auricle, and terminating below 
about half an inch farther back. The incision should penetrato to the bone. 
A branch of the posterior auricular artery will be severed and may require a 
ligature. The sides of the wound being held asunder with retractors, the 
surface of the bone is uncovered to an extent which will admit of the appli- 
cation of the trephine (Fig. 1942), when by the usual rotatory movements, 
Fra. 1942. 
Trephines for the mastoid process. 
made with a light hand, the bone can be cut through and the cavity of the 
cells beneath exposed. 
Fio. 1943. 
If necrosis exists, the bone may be cut away with a strong knife (Fig. 
1943) in place of the trephine. 324 
DISEASES AND INJURIES OF THE EAR. 
AFFECTIONS OF THE INTERNAL EAR. 
The internal ear, or labyrinth, is the essential part of the organ of hearing, 
the part which accommodates the cochlear and vestibular divisions of the 
auditory nerve, the terminal portions of which exceed, both in their ana- 
tomical and their physiological complexity, even the retinal expansion of the 
optic nerve. It is rather singular that this part of the acoustic apparatus 
does not participate oftener in those obstinate chronic inflammations which 
linger so long in the middle ear. Probably this is due to the almost indepen- 
dent vascular supply of each, as there are hardl}' any anastomosing branches. 
Within the very narrow compass of the labyrinth, which includes the vesti- 
bule, the semicircular canals, and the cochlea, there still remains a considerable 
field for pathological research. 
Labyrinthic Deafness. 
The deafness which results from disease or accident in this portion of the 
ear is called nervous deafness, and the consequent phenomena are in many 
respects unlike those which belong to disease in other parts of the organ. 
The loss of hearing is often sudden and complete, and nothing is perceived 
by the patient, even though the examiner should scream into his ear at the 
top of the voice. In addition to the obliteration of hearing, there are often 
vertigo and an unsteady or staggering gait, the individual being unable either 
to direct his movements or to preserve an equilibrium. Accompanying these 
symptoms are vomiting, tinnitus, intolerance of sounds, and, in children, con- 
vulsions and delirium. 
The use of the tuning-fork will supply valuable information where symp- 
toms exist of the nature of those described. It has been stated already that 
when an obstruction of any kind is present in one of the ears, the sound of 
the tuning-fork is heard louder in the affected than in the well organ; but 
in deafness from causes affecting the labyrinth, if the ears are stopped, no in- 
crease of sound is experienced when the instrument is placed on the head or 
against the teeth, unless the nerves of the two ears are unequally affected, 
when the note will be louder on the side of the better ear. 
Another symptom of labyrinthic disease, though not absolutely peculiar 
to it, is double heai’ing; and still another is inability to hear certain sounds. 
The duplication of the same sound may be duo to the want of harmony 
between the corresponding receptive portions of the auditory nerves, the 
same note or tone not being heard in the two ears simultaneously. When 
the inability to hear certain sounds exists, it does not follow that only the 
indistinct ones escape recognition. On the contrary, it is often, if not gen- 
erally, the case that the decided tones are not perceived, while those of a 
much less degree of intensity are heard. If the opinion should be verified 
that the terminal rods of the auditory nerve, commonly called the fibres of 
Corti, which bear so remarkable a resemblance, in their arrangement, to the 
keys of a piano, are adapted to the perception of different sounds, such ec- 
centricities of hearing as we have described might be thought to be in some 
degree accounted for. 
The cochlea being regarded by physiologists as that part of the labyrinth 
which conduces to the perception of tones, it is reasonable in cases of deaf- 
ness, in which false tones and double tones constitute a part of the symp- 
tomatology, to locate the lesion in this division of the internal ear. 
The affection which is termed Meniere’s disease is one in which the domi- 
nant symptoms are deafness, vertigo, and an inability to maintain an equi- 
librium in the movements of the body: the disease is, consequently, to be 
located by the diagnostician in the labyrinth or (in view of the post-mortem 
discoveries made by Dr. Meniere) in the semicircular canals. 
With a view, therefore, to the diagnosis of a deafness located in the internal 
ear, the surgeon must carefully analyze symptoms, excluding as far as pos- LABYRINTHIC DEAFNESS. 
325 
sible those which are common to disease in other portions of the auditory 
apparatus. 
First, and most conclusive, is the sudden and total loss of hearing. In the 
absence of brain-symptoms, this symptom is decisive of a lesion implicating 
the auditory nerve. 
Secondly, the evidence furnished by the tuning-fork will aid in establishing 
a diagnosis. It has already been noticed that the sound of the tuning-fork 
placed upon the vertex will be heard louder in the ear in which there exists 
some mechanical obstruction, either in the middle or the external ear. If, 
therefore, on making the experiment with the auditory canals alternately 
closed by the fingers and opened, no difference in the intensity of the sound 
is observed, the sign points to labyrinthic disease; or, if the auditory nerves 
are unequally affected, and the sound is heard more distinctly in the ear less 
impaired, these signs, making allowance for a few exceptional personal idio- 
syncrasies, point to labyrinthic or nervous deafness. 
Thirdly, the same conclusion may be drawn when there is an inability to 
hear certain notes or tones, and particularly those remarkable for being high- 
pitched, or where, after rising in the normal scale above notes of a certain 
value, all sounds become inharmonious. 
There are other symptoms which, considered as isolated phenomena, are less 
important, but which, existing in common with those we have enumerated, 
lend additional corroboration to a diagnosis of nervous deafness. These are, 
first, tinnitus aurium, a sign common to various affections of the ear, and one 
which may not be present at all in the condition under consideration ; second, 
vertigo, staggering, and nausea or vomiting, all of which I have frequently 
seen when there was no evidence of labyrinthic disease, and w'hich may be 
artificially produced in some persons by the simple operation of syringing 
the ears, or by any cause which increases the pressure of the stapes against 
the round window. 
The cautious diagnostician, however, will not be content with committing 
himself to a positive opinion, even after weighing all the evidence wThich has 
been detailed, without a formal examination of the external auditory canal, 
and of the membrane of the tympanum, assuring himself of the patency of 
the latter, with that also of the Eustachian tube, under the test of the 
Politzer bag. 
Electro-galvanism has been applied, especially by Ilagen, of Leipsic, in the 
diagnosis of nervous deafness. The opinions on the subject, however, are so 
discordant that it would not be safe at present either to admit this potent 
agent into the list of aural resources or to exclude it. Leaving out of con- 
sideration the vexed question of diagnosis, I ftiay say that I have never seen 
any benefit result from the use of this agent in cases of nervous deafness. 
Causes.—The causes of labyrinthic deafness are traumatic and constitu- 
tional. 
Traumatic.—Among the traumatic causes may be enumerated fractures at 
the base of the skull. An injury of this nature passing through the petrous 
portion of the temporal bone will in all probability be followed by deafness, 
either complete or partial, on the injured side, as also by facial paralysis, 
both the auditory and the portio dura nerves being lodged in this bone. 
That this is not an invariable result of the injury seems to be probable 
from a case in point,—that of a physician whom, in connection with Professor 
Henry II. Smith, I attended for what was believed to be a fracture of the 
petrous portion of the temporal bone. The severity of the violence, which 
consisted in a heavy railroad gate falling upon the head of the patient and 
rendering him unconscious for several hours, was sufficient to produce the 
injury, and the symptoms (among which wyas a flow of blood from the ear, 
followed for many days by a discharge from the meatus of the cerebro- 
spinal fluid) appeared to render the diagnosis certain. This patient made 
a very slow recovery, but had not at any time a loss of hearing. The ques- 
tion has been raised in some quarters whether the cerebro-spinal fluid might 326 
DISEASES AND INJURIES OF THE EAR. 
not escape from the external ear without a fracture at the base of the cra- 
nium, on the supposition that there is an interval or passage between the 
subarachnoid space and the labyrinth. But, as no communication of the 
kind has as yet been positively demonstrated, we have no right to assume 
such an explanation. 
Concussions, both cranial and tympanic, often cause nervous deafness. 
Doubtless the effect of severe violence when applied to the skull is, in 
many instances, to lacerate some of the vessels of the internal ear, causing 
hemorrhage and pressure upon the expansion of the auditory nerve. Yet 
the suspension of hearing may follow a degree of concussion the vibrations 
of which cause no visible lesion in the nerve, just as we sometimes see a 
temporary loss of olfaction after similar violence applied to the head. 
There is a labyrinthic deafness which is said to be due to constantly-re- 
peated concussions of the drum-head. Of this nature is the impaired hearing 
of boiler-makers, ordnance-men, and, it is said, of telegraph-operators. I am 
not prepared to admit that the dullness of hearing met with in persons in 
these occupations is wholly labyrinthic. There is probably an anaesthesia of 
the perceptive portions of the auditory nerve, but it seems equally probable 
that the motor endowments of the muscles which move the ossicula have 
been enfeebled by the constant stimulus to which they are subjected, so that 
the ordinary waves of sound fail to elicit any responsive action. 
Inflammatory translations of serum or of sero-sanguinolent fluid may also 
cause serious injury to the auditory nerve. 
Basal meningitis, by traveling along the sheath of the auditory nerve, as 
it does in one form of optic neuritis, may cause loss of hearing. 
Catarrhal conditions of the naso-pharyngeal and tympanic surfaces conduce 
to internal-ear deafness, if not by continuity, at least by the contiguity of 
chronic inflammation. 
Quinia, when used to the extent of cinchonism causing tinnitus and ob- 
tuseness of hearing, effects which are so commonly experienced, constitutes 
another cause of nervous deafness; and in this case the drug probably acts 
by inducing congestion of the labyrinth. 
Among the causes of labyrinthic deafness which have a general or consti- 
tutional origin are: 
Syphilis.—In both acquired and inherited syphilis we have a fruitful source 
of nervous deafness, and it is presumable that the nature of the lesion is much 
the same as that which causes syphilitic paralysis or syphilitic blindness. 
The surgeon must rely on the personal or family history of the patient in 
tracing these symptoms to their true source. 
Diphtheria.—Some of the most sudden cases of loss of hearing which have 
come under my personal observation have occurred during an attack of diph- 
theria, the deafness being almost instantaneous, total, and hopeless. 
Exanthemata.—Deafness from the presence of morbid products in the in- 
ternal ear (probably inflammatory or hemorrhagic) is also among the accom- 
paniments and sequels of the different eruptive diseases, such as scarlatina, 
rubeola, variola, and typhus fever. 
Parturition.—Among the accidental incidents of difficult labors is the occur- 
rence of labyrinthic deafness. Of a number of cases of this kind I do not 
recall a single instance of recovery. The loss of hearing is generally sudden, 
but is not always complete, and arises, I presume, from hemorrhage into 
some portion of the labyrinth, the result of congestion of the intracranial 
vessels induced by the throes of labor. 
Cerebrospinal meningitis is frequently followed by incurable deafness. It is 
supposed that in a certain proportion of these cases the meningeal inflam- 
mation is propagated by structural continuity to the auditory nerve and its 
terminal expansion; though there are not wanting instances in which the 
autopsy revealed no lesion of any kind in the internal ear, and others, again, 
whore the morbid phenomena were limited to the middle ear. 
Central lesions affecting the roots of the auditory nerve must likewise be TINNITUS AURIUM AND AURAL VERTIGO. 
included among the causes of labyrinthic deafness. Hence in a considerable 
proportion of brain tumors, of aneurisms of the basilar artery, and frequently 
after hemorrhages at the base of the brain, deafness is one of the attendant 
symptoms. 
Hysterical deafness I have never witnessed, though it has been noticed by 
specialists. Hysterical blindness is a well-recognized affection, and there is 
no reason why, among the protean exhibitions of female eccentricities, there 
may not be a similar kind of deafness. 
Treatment.—Unpromising as labyrinthic deafness may be, no case should 
be dismissed without some effort being made to ameliorate the patient’s con- 
dition. As in a large number of these cases the immediate cause of the loss 
of hearing is either blood-extravasation or the presence of inflammatory 
products, no dogmatic opinion should be delivered until time and alterative 
remedies have been fairly tested. Every hospital surgeon of large expe- 
rience must have met with instances of deafness following head-injuries where 
the presumption was strongly in favor of the immediate cause of the loss of 
hearing being seated in the internal ear, and yet in many of these cases the 
function of the organ has been in a greater or less degree restored. Unless, 
therefore, the evidence is in favor of there being some necessarily incurable 
brain disease producing the local defect, the patient should have the benefit 
of an alterative course of treatment, either by mercury or by iodide of potas- 
sium. Particularly is such a plan to be pursued when the evidence is on the 
side of syphilitic deafness. 
When there is reason to believe that the deafness stands in a certain causal 
relation to contiguous catarrhal conditions, in addition to the local manage- 
ment proper for such, benefit may be anticipated from the administration 
of iodide of iron, cod-liver oil, or sulphide of calcium. The same treat- 
ment will be indicated in the labyrinthic deafness entailed by exanthematous 
diseases. 
Much good may be effected in the way of preventing deafness due to con- 
tinuous and powerful noises, or that occasioned by boiler-making, gunnery, 
etc., by plugging the ears with cotton during the hours of active employment. 
327 
Tinnitus Aurium and Aural Vertigo. 
Like otalgia, tinnitus and vertigo are for the most part symptomatic of 
some diseased condition of the auditory apparatus. 
The noises of which patients complain are of various kinds, and are often 
exceedingly distressing. With some persons the sounds are compared to the 
singing of a tea-kettle, to the ringing of bells, to the roaring of a cataract, 
and to musical notes, especially when their origin is nervous; with others 
they are said to resemble the chirping or buzzing of insects, the explosions 
of artillery, to have a rhythmic or pulse-like thud, or to seem like a mingling 
of various noises. Tinnitus has been regarded as so important a phenomenon 
that it has been made by Liel the basis of a classification of aural disease ; 
all the affections of the ear, according to this author, being arranged into 
two classes,—those with and those without tinnitus. 
Causes and Treatment.—The causes which originate ear noises and ear 
vertigo may be divided into cerebral, auditory, gastric, and toxic. 
The cerebral causes are congestive, inflammatory, hemorrhagic, and neo- 
plastic, and can be mitigated only (when susceptible of any relief at all) by 
treatment adapted to these varying conditions. 
The auditory causes admit of being divided into those which arise from 
disorders of the external auditory canal, of the drum-head, of the middle ear, 
of the Eustachian tube, and of the internal ear. 
External ear.—An accumulation of cerumen, the presence of a foreign 
body, or a morbid growth in the external ear will cause tinnitus. The remedy 
consists in removing the cause. 328 
DISEASES AND INJURIES OF THE EAR. 
Membrana tympani.—Pressure upon, or inflammatory swellings of, the 
membrana tympani, by increasing the pressure of the fluid in the labyrinth, 
will give rise to ear noises, which will disappear on the removal of the com- 
pressing cause, whether it be a foreign body, a neoplasm, or an inflammatory 
formation. 
Middle ear.—Of all the causes located in the middle ear, none is so prolific 
a source of aural tinnitus and vertigo as catarrh. Our ability to relieve the 
former will be proportionate to the success attending our efforts to cure the 
latter. 
The Politzer method of inflation will be a most important adjunct to other 
measures for treating the tinnitus, whether tympanic or Eustachian in its ori- 
gin. The naso-pharyngeal region must not be overlooked in tympanic tin- 
nitus, as there are few cases of catarrh of the middle ear disconnected with 
a similar state of the dome of the pharynx. The prevailing characteristic 
of the sounds referable to the middle ear is gurgling and crackling. 
Internal ear.—The most intractable of all cases of tinnitus are those which 
in many instances attend nervous deafness, or such as accompany or follow 
disease of the labyrinth. These are often rendered exceptionally distressing 
by the vertigo, staggering, and nausea which accompany the noises. The 
sounds which are quite common in labyrinthic tinnitus are pulsating or 
rushing, have an arterial or a venous origin, and may be referred to an im- 
properly-regulated circulation in the vertebral or the internal carotid artery. 
Anaunia, and also tumors of the auditory nerve, will cause similar noises. 
An interesting example of the effects of such tumors on the labyrinth is given 
by Dr. Burnett in his excellent work on diseases of the ear. 
Gastric tinnitus, being reflex and functional, and susceptible of recognition 
by the absence of any aural disease and the presence of those symptoms 
which indicate a disordei*ed stomach, will disappear on the correction of the 
gastro-intestinal and biliary secretions. 
Toxic tinnitus is present in cinchonism, and is believed to be due to tym- 
panic hjrpersemia. It usually disappears in a brief period after suspending 
the use of quinine, or it may be relieved by the administration of hydro- 
bromic acid. 
There are imaginary sounds, both aural and central,—hallucinations, as they 
are properly termed,—the latter depending on cerebral disease, and consti- 
tuting in many cases one of the accompaniments or foresigns of insanity: 
they should, therefore, where no evidence of ear disease exists, arouse the 
suspicions of the medical attendant. 
A considerable number of cases of tinnitus are wholly functional, and are 
due to nervous exhaustion or brain overwork, to the too free use of alcohol or 
tobacco, or to sexual excesses. Rest from work or study, and a temperate, 
abstemious life, constitute the remedies. 
There is a syphilitic tinnitus susceptible of relief, sometimes of cure, by 
large doses of the iodide of potassium. 
There are two internal remedies, though it must be confessed their use 
is somewhat empirical, which appear to exert control over tinnitus arising 
from congestive causes, cerebral or labj’rinthic. These are the bromide of 
potassium and hydrobromic ether. Twenty grains of the former and two or 
three drops of the latter may be given in some menstruum, two or three 
times a day. Tenotomy of the tensor tympani muscle has been practiced as a 
remedy in cases of tinnitus by Dr. Weber, of Berlin, who attributes this symp- 
tom in a certain proportion of cases to abnormal pressure on the labyrinth and 
consequent undue tension of the drum-head. A careful examination of the 
recorded cases of this operation shows that other and active treatment was 
instituted in addition to that of tenotomy, and therefore it is difficult to 
determine just how much of the good result obtained is to be placed to the 
credit of the tenotomy. There, are, however, reasons, both physiological 
and acoustic, which would justify the repetition of this operation by those 
who possess the necessary skill for its performance. INSTRUMENTAL AIDS FOR DEAFNESS. 
329 
Otalgia. 
Earache, except as a result of congestion, inflammation, or mechanical 
pressure, is a very uncommon affection. In children wTho roll the head 
during sleep, catch at the auricle with their hands, and start with a sudden 
scream, earache may be suspected. If the external auditory canal is ex- 
amined, there will generall}7 be discovered some redness and perhaps swelling. 
When the cause of the infant’s suffering has been overlooked at the time, it 
will frequently be disclosed afterwards by little brown stains or spots which 
appear upon the pillow, and which consist of matter spontaneously dis- 
charged from the ear. In older persons, such attacks of earache can usually 
be traced to congestion, to an external otitis, to hardened masses of cerumen 
pressing against the drum-head, to the presence of polypi, to foreign bodies 
in the auditory canal, or to acute inflammatory attacks of the membrana 
tympani or of the cavity of the tympanum. 
The congestive attacks affecting the external auditory canal, so common 
in infancy, may be quickly relieved by an ear-douche of very warm water, 
or by dropping one or two minims of laudanum into the canal. When the 
pain is an attendant of inflammatory conditions or of morbid growths, the 
same remedies will prove useful as temporary expedients; but permanent cure 
will depend upon the removal of the cause. 
That a primary otalgia or neuralgia may exist will not be denied. Ex- 
posure of the side of the face or head to strong currents of cold air, disorders 
of the digestive apparatus, malaria, diseased teeth, and in infants an inflamed 
gum, all are among the causes which produce the pain, and the remedy will 
have to be adapted to the particular condition. 
When originating from cold, warm applications, such as hot cotton batting, 
may be made over the auricle and the side of the head. When the trouble 
arises from gastro-intestinal disorders, mercury, followed by a gentle aperient, 
is an appropriate remedy; when miasmatic agencies are at work, quinine, 
arsenic, pipeline, and, if necessary, a temporary change of residence, will be 
required; and when the difficulty is from diseased teeth or inflamed gums, relief 
will be obtained by removing or plugging the former and incising the latter. 
Ear Cough and Ear Vomiting. 
Among the reflex phenomena which are occasionally witnessed in aural 
disease are an irritating cough and vomiting. They may be diagnosed as 
reflex phenomena by the absence of all the physical and rational signs of 
disease in the respiratory or the digestive organs. The medium through 
which local irritation from disease of the ear reacts upon the larynx or the 
stomach is the pneumogastrie nerve, its aural branch having communication 
with the superior laryngeal, and through the main branch with the oesopha- 
gus and the stomach. 
INSTRUMENTAL AIDS FOR DEAFNESS. 
Among the means for improving the hearing in cases where the drum-head 
has been partly or wholly destroyed are pledgets of cotton and disks of 
vulcanized rubber. The cotton was first employed for this purpose by Dr. 
Yearsley, an English physician (Fig. 1944), and the rubber was the device of 
Toynbee. The application of these artificial membranes does not improve 
the hearing by closing the aperture in the drum, as was once supposed to be 
the case, but by supplying pressure to the labyrinth through the connection 
with the stapes. Field and Turnbull have each modified the instrument of 
Toynbee,—the former by interposing between the rubber disks a little block 
of absorbent cotton (Fig. 1945), and the latter by placing the stem of the 
membrane on the side instead of the middle. (Fig. 1946.) The cotton, when 
used for this purpose, is fashioned into a little ovoid mass, secured to a cen- 330 
D IS EASES AND INJURIES OF THE EAR. 
tral thread, and moistened on the tympanic surface with a little glycerin, or 
with glycerin to which there has been added a little sulphate or sulpho- 
Fig. 1944. 
Fig. 1945. 
Fig 1946. 
Yearsley’s tympanum. 
Field’s tympanum. 
Turnbull’s tympanum. 
earbolate of zinc, three or four grains to the ounce. It is carried down with 
a pair of forceps to its destination, and is afterwards adjusted with a probe. 
Another plan of placing the cotton in position is by passing the thread, 
which is fastened to the dossil, through a delicate silver tube, which after- 
wards serves to adjust the appliance. It will, perhaps, require various little 
changes before a satisfactory position can be attained. One point is impor- 
tant in the adjustment,—that the cotton shall not fill up the opening. There 
must be a space between the latter and the artificial membrane for the 
admission of sound. 
The cotton drum may bo allowed to remain two or three days without 
being disturbed, unless there is pus in the canal, when its daily removal will 
be necessary. The artificial drums of Toynbee, of Field, and of Turnbull 
each have a metallic stem by which they can be conducted into position, and 
by which they can be removed at pleasure. In changing or removing the 
artificial membrane, the surgeon should not neglect to cleanse the opening 
and the canal from any morbid accumulations or secretions before replacing 
tbe drum. This is most conveniently effected by using for the purpose a 
little dossil of absorbent cotton twisted around the end of an aural probe. 
Ear-Trumpets. 
Taking advantage of known laws of acoustics, various instruments Lave 
been devised at different times to supplement aural defects, the object in all 
being to collect and focus the waves of 
sound upon the membrana tympani. In 
the absence of mechanical appliances, per- 
sons in listening to a speaker instinctively 
place the hand behind the auricle. In this 
case the hand serves to catch and reflect 
into the ear the sounds of the spoken 
words. 
The prevailing form of all instruments 
for aiding the hearing is the infundibular. 
The two trumpets which will be found 
most useful are those represented in Figs. 
1947 and 1948. The first consists of a 
flexible tube having a funnel-shaped piece 
of hard rubber at one end 
to collect the sound, and 
at the other a small nozzle 
of similar material to be 
placed in the external au- 
ditory meatus. This has 
an advantage over other 
instruments for conversa- 
tional purposes, in that it 
can be conveniently carried 
in the pocket. For the lecture-room or the church, the trumpet depicted in 
the other figure is to be preferred, as the expanded portion or mouth of the 
Fig. 1947. 
Fig. 1948. 
Ear-trumpets. DEAF-MUTISM. 
331 
instrument will collect better the scattered waves of sound as they come from 
a distant point. It is not a difficult matter for deaf persons who occupy a 
fixed place in a church to have a trumpet adjusted permanently to the seat, 
by which they can be saved the inconvenience and fatigue incident to holding 
an instrument for a long time to the ear. 
The small tubes which are sometimes worn in the ears, and which make 
no show externally, possess little acoustic value, and not unfrequently cause 
an abrasion of the lining membrane of the auditory canal. 
In view of the readiness with which vibrations are conducted by the 
bones of the cranium, an instrument called the audiphone has been con- 
structed in order to convey sounds to the auditory nerve. This appliance, 
as improved by Dr. C. II. Thomas, of Philadelphia, consists of a fan-shaped 
vulcanite diaphragm with a curved rod of wood attached, to be held between 
the teeth of the deaf person. The vibrations received by the diaphragm 
are focused upon the rod or stem, and in this way reach the jaws, to be con- 
ducted to the temporal bones and the auditory nerves. The experiments 
with this instrument have, however, not been sufficiently satisfactory to give 
promise of much benefit being derived from this mechanism. 
Among all the multiform sounds which fall upon the ear from earth, sea, 
and air, none possess such charms or thrill the spirit with such delight as 
the human voice. To be unable to speak is, therefore, a calamity of no ordi- 
nary nature. According to the census of 1880, there are in the United 
States, with a population of 50,156,000, 35,000 deaf-mutes, or about 1 deaf- 
mute to every 1430 of the population: by the same ratio, the number of 
deaf-mutes in the entire wrorld, assuming the population to be, as stated by 
Behm and Wagner, 1,396,483,000, would be not much less than a million. 
A large percentage of the acquired cases, depending as they do on catarrhal 
conditions of the throat and tympanum, might, had they received intelligent 
and timely attention, have been prevented. Of the 38,489 deaf-mutes in 
Germany, 15,000 suffered from acquired deafness; and of this latter number 
Yon Troeltsch asserts that it is not unreasonable to believe that one-fifth 
might, with early and proper treatment, have been saved from this calamity. 
Deaf-mutes are arranged under two classes,—those who suffer from congen- 
ital deafness, and those in whom the deafness has been acquired. The pro- 
portion of the two classes cannot be clearly made out, but it is probable 
that about one-third of all deaf-mutism is acquired, and the remaining two- 
thirds congenital. 
Causes.—The principal causes which appear to exert a determining influ- 
ence in the production of congenital deaf-mutism are either geographical or 
climatic, or else, as is often the case, the abnormal condition arises from 
the consanguinity of the parents of the deaf-mute. In those deep valleys 
of Switzerland in which cretinism abounds there is, in proportion to the 
number of inhabitants, the largest number of children born deaf. Still more 
striking is the influence of close marriage, or the marriage of parties who 
are related by blood, as first, second, or third cousins. According to Wilde, 
as quoted by Dr. Turnbull, the Irish census shows 100 cases of deaf-mutism 
among the issue of 154 such marriages. 
Post-mortem examinations of the auditory apparatus of congenital deaf- 
mutes often exhibit imperfect development of the organ of hearing, atrophy 
of the auditory nerve, or an abnormal collection of otoliths in the labyrinth. 
The causes of acquired deafness are in many cases naso-pharyngeal catarrhs, 
catarrhal inflammation of the middle ear, suppurating and proliferating in- 
flammation of the membranous labyrinth, and new formation of bone in the 
semicircular canals and the cochlea. 
Treatment.—One of the most signal triumphs of Christian benevolence 
DEAF-MUTISM. 332 
DISEASES AND INJURIES OF THE EAR. 
is the invention of systems of instruction by which deaf-mutes can be educated 
and thereby fitted to fill various useful positions in life. 
The two prevalent modes of instruction are the lip method and what is 
technically called dactylology,—the finger language. 
By the first, or lip method, advantage is taken of the faculty of imitation 
natural to children, and the pupil is taught the various vocal sounds, begin- 
ning with those consonants which are most easily formed, such as f,p, t, h, m, n, 
—the first letter,/, being formed by a movement similar to that made in blow- 
ing a piece of paper or a feather away, while the upper teeth are pressed 
against the lower lip; p, by first swelling out the lips with air and then 
opening them with a sudden expiration, etc. The vowels are next learned, 
after which vowels and consonants are joined. These few points* are noticed 
in order that medical men may be able to demonstrate to the parents of 
children affected with deaf-mutism the simplicity and feasibility of such a 
mode of instruction. The prospect of being able to interchange thoughts 
and to hold intercourse by the spoken word is much more inspiring to the 
deaf-mute than that of maintaining conversation through the sign or finger 
language, and the lip method is destined in time to supplant to some extent 
the latter. 
* Those desirous of studying the subject more in detail will find in Dr. Laurence Turnbull’s treatise 
on Diseases of the Ear a very excellent r&sume of the literature of deaf-mutism. CHAPTER XXXI. 
MALFORMATIONS AND DEFORMITIES —TENOTOMY IN THE 
TREATMENT OF ORTHOP^DIA. 
The idea of the beautiful, which occupied so largety the Greek and Roman 
mind, appears to have found its chief outward expression in never-wearying 
attempts to produce, either in painting or in sculpture, a faultless figure of 
the human body. Personal beauty, in which are included symmetry of form, 
grace of movement, and attractive expression, has commanded, and will to 
the end of the world command, the homage of mankind. The ancients be- 
lieved that physical defects were marks of the displeasure of the gods ; and 
there is little doubt that such imperfections, when patent to the eye and 
incapable of concealment, operate even at the present time to the great 
disadvantage of their possessor. The uppermost thoughts in the minds of 
mothers, even during the throes of labor, are often revealed to the accoucheur 
in the question so commonly asked after the birth of a child, “ Is all right, 
doctor?” Whatever, therefore, the art of surgery can do to correct deformi- 
ties, congenital or acquired, will contribute greatly to the sum of human 
happiness, and it is in this field that surgery has won some of her proudest 
conquests. 
Among the various methods of treatment which contribute largely to the 
removal or correction of malformations, by far the most important is the 
operation of tenotomy, through the application of which to the cases in 
question, aided by the use of proper apparatus, the important branch of 
surgery known as orthopsedics has been built up. 
The division of tendons for the purpose of correcting deformities is an old 
operation, having been done as early as 1784, by a surgeon named Lorenz, 
at the suggestion of Thilenius, a physician of Frankfort, Germany, on a 
female suffering from club-foot. The operation was repeated at the beginning 
of the present century (1806) by Sartorius, a'nd for a similar cause. In both 
instances the wound was an open one ; that is, an incision was made through 
the soft parts, and the tendon was exposed to view before being severed. The 
first performance of subcutaneous tenotomy is claimed by Mr. Hancock for 
Mark Anthony Petit, in 1799. It was done on the tendo A chillis, in order 
to bring down the heel of a patient whose foot had been in part removed by 
the Chopart method of amputation. The celebrated surgeon Delpech, in 
1816, not being guided by pathological considerations, but induced by the 
practical facility of the operation, divided the tendo Aehillis by a subtendi- 
nous incision,—a procedure which was some approach to the subcutaneous 
method, inasmuch as the overlying tissues were not cut, the knife, an ordi- 
nary bistoury, having been pushed completely through the leg beneath the 
tendon, which was divided from below upward. To Stromeyer, of Hanover, 
we are indebted for the first and almost perfect method of cutting tendons 
subcutaneously. The chief difference between the operation of Delpech and 
that of Stromeyer was in the size of the knife used. That employed by 
Stromeyer was much the smaller; a puncture and counter-puncture being 
made by both operators alike. Like almost every other great discovery in 
surgery, however, subcutaneous tenotomy was at first received with con- 334 
MALFORMATIONS AND DEFORMITIES. 
siderable distrust, and it was not until the master-hand of Dieffenbaeh had 
cleared the way for its general acceptance by practicing the operation on a 
large number of patients with club-feet, that it reached any general popu- 
larity among German and French surgeons. In America, l>r. David L. 
Rogers was the first to perform tenotomy. The tendon divided was the 
tendo Achillis, and the year of the operation, 1834. The first performance 
of subcutaneous myotomy on this side of the Atlantic was by Dr. Detmold, 
of New York, in 1837. The doctor, being a German, had witnessed the 
operation before leaving the Fatherland. In Philadelphia the operation of 
tenotomy was first practiced by Professor Thomas Mutter, in 1844, and about 
the same time in Lancaster, Pennsylvania, by Dr. John L. Atlee. 
It is evident from the history of the operation that none of the men 
whose names are prominently associated with early tenotomy had mastered 
the far-reaching pathological observations and deductions which had been 
made and formulated almost a quarter of a century before (1794) on the 
healing of subcutaneous wounds, by that unapproachable British surgeon, 
John Hunter, the Shakespeare of scientific medicine. 
The introduction of tenotomy into England from the Continent furnishes 
an illustration of how the misfortunes of individual persons may, in the un- 
folding of the future, result in great public blessings. A young physician 
living in London was the subject of club-foot. As might naturally be sup- 
posed, the deformity was to him a source of no small mental annoyance. 
When the operations of Delpech and Stromeyer became known, the hope of 
being relieved of his infirmity induced him, in 1835, to visit the Continent; 
and, after many discouragements from distinguished members of the profes- 
sion, he at length submitted to the subcutaneous division of the tendo Achillis, 
the operation being performed by Stromeyer himself. 
The operation proved to be a success, and Dr. Little, at present so widely 
known and distinguished in the ranks of our profession as an author, returned 
to England, and soon afterwards divided, for the first time in London, the 
tendo Achillis for the cure of club-foot. 
The principle announced by Hunter in regard to the healing of subcuta- 
neous wounds, or wounds in which no communication with the external air 
takes place, has had a practical extension in later times far beyond the ex- 
pectations of its early advocates. The fruit of this seed-thought is seen 
in subcutaneous tenotomy, myotomy, osteotomy, when practiced to correct 
deformities; in the various applications of the hypodermic syringe and of 
the aspirator; in the boldness with which false anchyloses of joints are 
broken up and vicious union of bones is refractured ; in the evacuating 
of abscesses, the reduction of old luxations by cutting opposing bands or 
ligaments, the obliteration of serous and bursal sacs, the ligation of veins, as 
in vai*icocele, the healing of ulcers which have long refused to cicatrize by 
dividing subcutaneously an underlying tendon or muscle the movements of 
which have defeated the work of repair, and, finally, in the introduction of 
antiseptic methods into the practice of surgery. 
Operation.—The operation of tenotomy is easy of execution, though one 
which requires thorough anatomical knowledge on the part of the operator, 
in order that no artery or important nerve shall be cut, for such an accident 
might occasion severe hemorrhage, or the paralysis of important groups of 
muscles. The only instruments required for the operation are two delicate 
knives, or tenotomes, the one sharp-pointed (Fig. 1949) and the other blunt- 
pointed (Fig. 1950). The cutting edge of the blades should not exceed in 
length three-fourths of an inch, nor at any point should it be more than one- 
eighth of an inch in breadth. I prefer also to have the edge of the blunt- 
pointed tenotome very slightly convex in its long diameter, since a blade 
fashioned after this manner will sever a tendon with greater ease than one in 
which the edge is straight, inasmuch as there is less structure encountered 
at any one time by the blade. 
If the sharp-pointed instrument is employed as a tenotome, there may be TENOTOMY IN ORTIIOPjEDIA. 
335 
some risk of puncturing a nerve or a blood-vessel, or, in some localities, of 
transfixing the part by counter-puncture. 
On this account, and in order to guard against the entrance of air,—the 
avoidance of which appears to be the great desideratum in subcutaneous 
surgery,—I employ the sharp-pointed bistoury merely to puncture the in- 
tegument and prepare the way for the blunt-pointed tenotome, which can 
then be readily thrust through the midst of the other tissues and made to 
do the work of tenotomy with entire safety. Both the bistoury and the 
tenotome are to be entered flatwise, and to be withdrawn in the same manner, 
precautions necessary to prevent the admission of air into the wound. That 
this object shall be most effectively attained, the external puncture through 
the skin should be planned so that it will not correspond with the deeper 
part of the wound. This can be done either by drawing the integument 
towards the tendon to be divided and retaining it in that position until the 
preliminary incision and the insertion of the tenotome have been made, or 
by making the puncture at some distance from the objective seat of opera- 
tion, and then carrying the tenotome onward between the integument and 
the subcutaneous structures until near the place where the tendon to be 
divided is situated, when a deeper direction can be given to the knife. 
In either case the external and internal wounds will be a considerable dis- 
Fig. 1949. 
D.W.KQUCS0N 
Sharp-pointed tenotome. 
Fig 1950 
liluut-puiuted tenotome. 
tanee apart, and the communication between the two will be rendered 
indirect. 
The division of tendons may be done in four different ways,—upward, 
downward, inward, or outward,—some tendons admitting of one and others 
of another plan. The tendo Achillis, for example, can be properly divided 
only in an upward or a downward direction, assuming the patient to be 
in a recumbent position, while the tendon of the flexor biceps cruris can be 
severed most conveniently by cutting laterally,—that is, inward or outward. 
When more than one tendon requires division in a given region, the work, 
if possible, should be done through the same'external opening, and without 
withdrawing the tenotome. To favor the adjustment of the knife to the sur- 
face of the tendon and promote the easy division of the latter, much can be 
done by the position given to the part on which the tendon is inserted. In 
the first place, the tendon or the muscle which is to be the subject of operation 
must be made tense for the purpose of localization, either by flexing, extending, 
abducting, or adducting, as the case may require. The tenotome, after being 
introduced, will glide most easily either under or over the tendon when the 
latter is somewhat relaxed, after which the division will be greatly favored 
by rendering the tendon tense. The division of tendons is effected by im- 
parting a sawing movement to the knife, and the completion of the oper- 
ation is announced by a distinct snap, which is both felt and heard. 
The operation of tenotomy is almost a bloodless one, only a few drops 
escaping from the wound. Simultaneously with the withdrawal of the knife 
the finger of the operator should cover the puncture, and it should not be 
removed until replaced by a strip of adhesive plaster, over which, as well as 
over some portion of the limb, a roller should be applied, and the part kept 
at rest four or five days. 
The subcutaneous division of tendons and muscles is considered so free 336 
MALFORMATIONS AND DEFORMITIES. 
from danger that vory little importance is attached by surgeons to enforced 
rest or other treatment preliminary to the operation, nor are subsequent inflam- 
matory accidents anticipated. Experience certainly goes a great way towards 
confirming the truth of this statement, but it cannot be said that tenotomy 
and myotomy are entirely free from dangerous complications. I have seen 
death from erysipelas follow the division of the tendon of the adductor longus 
muscle at its origin; I have known a child to perish from concealed hemor- 
rhage after an operation for club-foot; and I have seen a leg rendered useless 
in a great measure by the peroneal nerve having been severed while the outer 
hamstring tendon was being divided. Even' under the most skillful use of 
the knife, suppuration will sometimesTollow, especially in cases of contraction 
at the knee-joint requiring the extensivo division of tendons and bands of 
fascia. The possibility of such mishaps, therefore, will suggest the precau- 
tion of not allowing the insignificance of the operation to betray the surgeon 
into neglect of those measures which usually impart success to other surgical 
procedures. 
I shall now proceed to treat of various malformations and deformities, 
both acquired and congenital, of the upper and lower extremities. 
Etiology.—The causes which are concerned in the production of deformi- 
ties in general vary exceedingly, and may operate through either local or 
constitutional conditions, or by means of hereditary influence. The chief 
among them are as follows: 
1. Position.—The arm placed across the breast in the flexed position, or 
the leg flexed upon the thigh, and so retained for many consecutive weeks 
on account of injury or disease, will often, unless preventive measures are 
brought into requisition, remain in this deformed position permanently. 
Whether the deformity is due to fracture or anchylosis, rheumatism or 
gout, an important change takes place in the muscles of the limb,—one 
which will always follow whether disease exists or not, for it is the effect 
of position alone. Those muscles which are relaxed become shortened by 
contraction, and those which are placed on the stretch become lengthened 
by stretching. I do not mean, in speaking of this shortening and lengthening 
of muscles, that they shorten and lengthen in the same manner as when 
acting under the stimulus of volition. The shortening and lengthening in 
the latter instance are physiological, while in the former they are patho- 
logical, the sarcous cells undergoing atrophy and all the components of the 
muscle becoming rigid and inelastic. The resulting deformities, when no 
mechanical obstacle exists in the articulation about which the disabled mus- 
cles are placed, are susceptible of correction by treatment, which is designed 
at the same time to restore the muscles to their proper lengths and to im- 
prove their nutrition. These points are best attained by the use of extending 
force, by massage, and by passive movements,—all of which measures, by in- 
creasing functional activity, tend to increase the repair of the disabled mus- 
cles. To illustrate the origin of certain deformities, we may suppose that a 
lad has a sore on the inner border of the sole of his foot, and in order to re- 
lieve the part from pressure he walks on the outer side of the member. The 
effect of this posture is to lengthen the peroneal muscles on the outside of the 
leg, and at the same time to shorten the antagonizing muscles on the inside, 
thus creating a malposition which in time may become a permanent deform- 
ity. In the same manner, carelessness in regard to position will explain 
the habit of turning in the toes while walking (pigeon-toe), and several other 
vices of position. 
2. Fractures.—The fragments of a broken bone, when not properly adjusted, 
will often lead to very serious deformity, particularly when any angular 
displacement is present. A familiar illustration is seen in those cases of 
badly-treated fractures at the lower fifth of the fibula, where the patient, from 
the extreme abduction of the foot, is compelled to walk on its inside, the 
outward bending of the foot increasing with continued use in its mal- 
position. TALIPES. 
337 
3. Dislocations, when unreduced, are also sources of deformity and dis- 
ability, not only from the restricted movements of the luxated part, hut also 
from the unwonted directions in which the muscles are compelled tempo- 
rarily to act. 
4. Rickets constitutes another prolific cause of deformity, the bones bending 
both from muscular connection and from the superincumbent weight of the 
body. 
5. Articular disease.—Deformities of different portions of the extremities 
are frequently a result of anchylosis and of rheumatoid and gouty diseases 
affecting the joints. 
6. Burns.—Many of the most serious deformities follow the contraction of 
cicatrices from burns. 
7. Paralysis.—This constitutes a very common cause of deformity. When 
the paralysis is confined to a single muscle or to a group of muscles, the an- 
tagonizing muscles will draw the part towards the unaffected or sound side, 
and the degree of deformity will be in proportion to the completeness of the 
paralysis, after making allowance for the mechanical obstacles which may tend 
to prevent distortion. That form of pai’alysis which enters so largely into 
the causation of infantile deformities frequently has a spinal origin. It is 
an inflammation essentially of the anterior horns of the gray matter of the 
spinal marrow. The paralyzed muscles undergo fatty degeneration and become 
wasted, in time little else being left than their fibrous components. 
8. Spasmodic, tonic, or spastic conditions of the muscles are also concerned 
in giving rise to vicious positions of parts. The characteristic symptom in 
cases of this kind is the rigid contraction of the affected muscles. This 
spastic rigidity may be partly overcome, in some instances, by an energetic 
action of the will on the opposing muscles; but, on the other hand, it may 
be wholly independent of the volition of the patient. The primary seat of 
the excitation may be centi'al, either in the brain or the spinal marrow, 
or it may be peripheral, as when a nerve supplying a particular muscle or 
number of muscles has sustained some injury. Thus, a spiculum of bone, a 
pistol-ball, or any other foreign body remaining in contact with the median 
nerve is liable to cause spasm of the flexor muscles of the forearm and con- 
sequent distortion of the hand. Similar deformities of the foot may follow 
like causes acting on the nerves of the leg. The dentition of infants, pro- 
voking as it often does reflex convulsions and paralysis, is another example 
in point. 
9. Hereditary influences play an important part in the production of de- 
formities. This is particularly noticed in cases of web-finger, supernumerary 
toes, and, occasionally, club-foot. • 
10. Intra-uterine pressure has also been adduced to explain congenital de- 
formities, especially of one or both feet. It seems improbable, however, that 
the foetus, protected by the liquor amnii, should suffer in this way, or that 
the foot should be affected more than any other part of the child, or that 
one foot should suffer and the other escape from this injurious pressure. 
11. The idea that maternal impressions may act as a cause of congenital 
deformity has a strong hold on the popular mind; and that such impressions 
do occasionally react on the foetus does not seem improbable. 
Talipes—Club-Foot. 
Talipes is both a congenital and an acquired or non-congenital defect. It 
occurs more frequently in males than in females. Unilateral club-foot is 
more common than bilateral, the majority of cases being met with on 
the right side. There is, perhaps, a single exception to this rule, in the 
variety of talipes styled varus. In this deformity the largest number of 
cases in the writer’s experience has been seen on the left side. No satisfac- 
tory reason can be assigned why one foot should suffer more commonly than 
the other. 338 
MALFORMATIONS AND DEFORMITIES. 
The proportion which club-foot bears to all other varieties of deformity is 
quite large. Of 10,217 deformities treated at the Royal Orthopeedic Hos- 
pital, London, according to Mr. Tamplin, 1780 were cases of club-foot. Non- 
congenital club-foot is more common than congenital. Of the 1780 cases 
mentioned above, 764 were congenital and 1016 non-congenital. 
Causes.—The causes of congenital club-foot are seated in the brain and the 
spinal marrow, producing either paralysis or spasm of certain groups of mus- 
cles, and in consequence of this spasm or paralysis the equilibrium of mus- 
cular force is destroyed, either from loss of power or from increased power 
in certain muscles which act upon the distorted part. Cases of congenital 
talipes are for the most part due to muscular spasm, while the non-congenital 
are usually the result of infantile paralysis. 
Hereditary influences are to be included in the list of agencies determining 
the deformity. The physical peculiarities of individuals are transmitted to 
their offspring more certainly than their mental characteristics. Adams 
gives an instance of a club-footed man who was the father of thirteen chil- 
dren, five of whom were club-footed. A brother of this man, though himself 
free from the imperfection, had a club-footed child, and his daughter, a primi- 
para, also presented her husband with a club-footed child. 
Varieties.—There are four principal forms of club-foot, with other sub- 
ordinate varieties made by combinations among the four. The fundamental 
divisions are designated by adding to the generic term talipes a specific term 
expressive of some definite peculiarity of the deformity ; and when deformi- 
ties of two species coexist, the name of each is introduced. Hence there are 
recognized,— 
Equino-varus. 
Equino-valgus. 
1. Talipes equinus. 
Subdivisions. 
2. Talipes calcaneus. 
Calcaneo-varus. 
Calcaneo-valgus. 
3. Talipes varus. 
4. Talipes valgus. 
Record, of the Orthopaedic Hospital, Philadelphia, from January 1, 1870, to 
December 31, 1881. 
Males, 
Talipes equinus. 
right foot, 14 
left “ 5 
—19 
Males, 
Talipes calcaneus. 
right foot, 1 
left “ 3 
- 4 
' right foot, 15 
left “ 8 
[ —23 
right foot, 3 
left “ 3 
- 6 
Females, 
(males, 5 
< females, 4 
l - 9 
Females, 
Bilateral, 
Foot not stated, 
males, 3 
female, 1 
- 4 
Foot not stated, < 
males, 10 
females, 11 
—21 
Total, 14. Males, 7; females, 7 ; 
right foot, 4; left foot, 6. 
Total, 72. Males, 34; females, 
38; right foot, 29 ; left foot, 13. 
Talipes varus. 
Talipes valgus. 
Males,’ 
right foot, 13 
left “ 21 
—34 
Males, 
right foot, 8 
left “ 9 
-17 
Females, 
right foot, 7 
left “ 6 
-13 
Females, 
right foot, 12 
left “ 13 
—25 
males, 18 
females, 12 
—30 
males, 10 
females, 15 
—25 
Bilateral, 
Bilateral, 
Foot not stated, 
males, 9 
females, 6 
-15 
Foot not stated, 
males, 12 
females, 3 
—15 
Total, 92. Males, 61; females, 
31; right foot, 20; left foot, 27. 
Total, 82. Males, 39 ; females, 
43; right foot, 20; left foot, 22. TALIPES. 
339 
Talipes equino-varus. 
right foot, 30 
left “ 29 
—59 
Talipes equino-valgus. 
Males, 
Males, right foot, 5 
Females, 
right foot, 20 
left “ 10 
—30 
Females, 
right foot, 1 
left “ 2 
- 3 
Bilateral, 
' males, 50 
females, 24 
-74 
Bilateral, 
males, 2 
female, 1 
- 3 
males, 21 
females, 10 
—31 
Foot not stated, 
Foot not stated, males, 2 
Total, 13. Males, 9 ; females, 
4; right foot, 6; left foot, 2. 
Total, 194. Males, 130; fe- 
males, 64; right foot, 50; left foot, 
39. 
Talipes calcaneo-varus. 
I right foot, 1 
Females, -< left “ 2 
[ - 3 
(male, 1 
Bilateral, < female, 1 
1 - 2 
Total, 5. Male, 1; females, 4. 
Talipes ealcaneo-valyus. 
Males, right foot, 2 
Males, 9. 
Bilateral talipes, the variety different in the two feet. 
Females, 2. 
Equino-varus (R.). 
Valgus (L.). 
Equino-varus (R.). 
Calcaneus (L.). 
Equinus (R.). 
Equino-valgus (L.). 
Equino-varus (R.). 
Calcaneus (L.). 
Valgus (R.). 
Equinus (L.). 
Valgus (R.). 
Equino-varus (L.). 
Equino-valgus (R.). 
Valgus (L.). 
Equinus (R.). 
Equino-varus (L.). 
Equino-varus (R.). 
Varus (L.). 
Varus (R.). 
Calcaneus (L.). 
Calcaneo-valgus (R.). 
Equino-varus (L.). 
Also club-hands. 
Variety and foot not stated. 
Males 6 ; females, 5= 11. 
The preceding cases, taken from the records of the Orthopaedic Hospital 
of Philadelphia,—in which institution for several years I was one of the 
surgeons,—and tabulated by Dr. Baum, show that during a period of elevon 
years 495 cases of talipes have been treated in the wards of the hospital; 
298 of the number, or 60.2 per cent., being males, and 197, or 39.8 per cent., 
females. 
The relative frequency of double and single club-foot was 154, or 31.11 per 
cent., double, and 341, or 68.89 per cent., single. The three varieties of 
talipes in which the affection was most equally divided between the two 
sexes were talipes equinus, talipes calcaneus, and talipes valgus. In two 
forms of talipes, namely, equinus and valgus, though the numbers are too 
small to justify any generalization, the cases among females exceeded in 
number those among males. 
Of 243 unilateral cases in which the foot was recorded, the deformity oc- 
curred 132 times (54.3 per cent.) on the right side, and 111 times (45.7 per 
cent.) on the left side. 
The varieties of talipes furnishing the largest number of double club-feet 
are talipes varus, talipes equino-varus, and talipes valgus. 
From cases available for computation, of 77 of the first class, 30 were 
double; of the second form, including 163 cases, 74 were double; and of the 340 
MALFORMATIONS AND DEFORMITIES. 
third variety, 67 in number, 25 were double. There were no eases of double 
club-foot in talipes calcaneus. 
The association of club-foot with other malformations is not common, as 
in only one instance among the 495 cases is any other deformity noticed, and 
that was in a child atfected with calcaneo-valgus of the right foot and equino- 
varus of the left foot, who also suffered from club-hands. 
Pathological Changes in Club-Foot.—The structural alterations noticed 
in club-foot extend to the hones, ligaments, and muscles, but are by no means 
so radical as, a priori, might be supposed. The bones most involved in these 
deformities are the astragalus, the calcaneum, the cuboid, and the scaphoid. 
The cuneiform bones do not entirely escape. The changes which the first- 
named bones undergo consist chiefi}1- in an altered relation of their articu- 
lating surfaces, in consequence of the twisted state of the foot; and in this 
condition the pressure is unequally distributed, so that at one point the joint- 
surfaces of the bones are strongly pressed together, while at other places 
they scarcely touch. The effect of this is not only to alter, to some extent, 
the shape of the tarsal pieces, but to prevent their growth ; and in some in- 
stances there are produced irregular outgrowths or exostoses. The plantar 
extremities of the cuneiform bones become sharper, and the restricted move- 
ments which result from the malformation of the foot affect also the growth 
of the metatarsal and phalangeal bones. The ligaments are compelled to 
adjust themselves to the varying alterations in the shape of the articulations; 
and, unless the distortions receive timely attention, those ligaments which 
are subjected to tension gradually undergo elongation by growth (not by 
stretching), while those which are relaxed become shortened. The tendons 
are displaced from their normal directions, and their relations to important 
blood-vessels and nerves become somewhat altered. Occasionally the tendo 
Achillis, in congenital club-foot, instead of being oval, cord-like, and promi- 
nent, remains for a long time flat and somewhat indistinct. The muscles, at 
first retaining their normal appearance, very soon begin to exhibit the evi- 
dences of defective stimulus and faulty action, becoming paler in color, and at 
length undergoing fatty degeneration,—a process which makes the limb look 
thin and wasted. The blood-vessels are also smaller than natural, though 
not materially changed from their usual courses. In only one variety of 
talipes (calcaneus) can there be said to be no pathological alterations in the 
components of the foot. The integument covering that portion of the foot 
which, from its malposition, is compelled to endure the superincumbent 
weight of the body, becomes rough and thickened, forming not unfrequently 
a large, fleshy cushion or bursal swelling, which contains a fluid common to 
such enlargements. Indeed, in all cases of congenital club-foot where treat- 
ment has not been instituted, the entire limb in all its components will suffer 
in its development. The truth of this statement will be obvious after a com- 
parison of limbs where the affection is unilateral, the deformed member 
rarely, if ever, catching up in growth with its more fortunate companion. 
Independently of the disability entailed b}* talipes, the deformity is often 
followed by troublesome complications, some of which may present formi- 
dable obstacles to the correction of the deformity itself. The least important 
of these are abrasions of the skin, corns, and bunions; the most, important, 
ulcerations of the integument, cicatrices, thickening of the tarsal ligaments, 
necrosis, and anchyloses of the bones of the foot. 
Treatment.—The benefit to humanity which has resulted from the dis- 
covery of subcutaneous tenotomy is simply incalculable. Aided by the judi- 
cious application of mechanical force, tenotouy untwists the most horrid dis- 
tortions of different portions of the human body, and restores the victim of 
what would otherwise have been a hopeless infirmity to his place in human 
society and its ceaseless activities. If scientific medicine had done nothing 
more for the world than this, she would be entitled to the gratitude and 
homage of the race. 
It is of the utmost moment that the treatment which belongs to this class TALIPES. 
341 
of surgical affections should be instituted at an early period of life, at a time 
when, like plastic clay in the hands of the potter, the articulations and the 
muscles can be made obedient to surgical resources. 
The means to be employed.—The means at our command for rectifying these 
distortions of the feet are bathing, manipulation, faradization, mechanical 
apparatus, and operations. 
Bathing.—Soaking the deformed member for some time in a hot bath of 
bran-water, or of palm soap and water, not only renders the integument soft 
and pliable, but makes the muscles less rebellious to handling. Especially 
is this true when a spasmodic element is present. Bathing will be equally 
proper before and after operation. 
Manipulation.—Under this head are included frictions, kneadings, pinchings, 
flagellations, stretchings, and force exerted in directions the reverse of the 
deformity. (Fig. 1951.) The value of manipulations cannot be overestimated. 
In some deformities no other treatment will be required, and in club-foot it 
constitutes not only a valuable preliminary 
measure to operations, but also an important 
auxiliary to the success of the knife. These 
manipulations can be properly made only 
by the naked hand; and to secure the 
greatest benefit they ought to be practiced 
at least once a day, and in a certain class of 
cases twice daily. A procedure of this na- 
ture improves the nutrition of the part by 
imparting a new stimulus to the circulation 
and securing a more rapid interchange of 
blood. It is in this way that manipulation 
favors the removal of tho products of struc- 
tural waste and favors the absorption of in- 
flammatory formations. 
Faradization, when the paralytic element 
exists, is a valuable stimulus for the en- 
feebled muscles, both before and after operations. It tends to prevent fur- 
ther degeneration of the muscle-cells, and helps to increase their nutrition 
and power. 
Apparatus.—The true object of all mechanical appliances introduced into 
orthoptedy for the euro of club-foot is to retain the deformed part either in 
the normal position or in that which tends to remove the deformity. 
The principle observed in the construction of all the various mechanical 
appliances used in the treatment of club-foot* is the same as that embodied in 
the shoe of Scarpa. 
The apparatus in general use consists of a shoe with a metal sole, in two 
parts, with a side-clip answering to the metatarso-phalangeal joint of the 
great toe, and two side-pieces of steel extending a short distance above the 
knee. These side-pieces have an articulation at the knee-joint and another 
at the shoe, the latter admitting of movements in two directions,—viz., that 
of flexion and extension, and that of abduction and adduction, the first two 
being made by means of a screw placed on the outside of the ankle-joint 
articulation, the last two by a screw concealed in the heel of the shoe, both 
being moved by a key-wrench. The shoe is made of soft leather, lined with 
chamois or kid, and supplied with lacers, the foot and leg portions being 
laced separately. In addition, a strap buttons across the front of the ankle, 
designed to keep the heel and the sole of the foot in contact with the sole of 
the shoe. (Fig. 1952.) In adjusting the shoe to the foot, the side-screw should 
be run down until the foot and leg portions can be placed at an obtuse 
angle. The heel of the child being then placed accurately upon the heel of 
the sole of the shoe, it is to be secured in place by lacing the leather in front 
of the ankle and fastening across the latter the strap. This point consti- 
tutes the most important part of the adjustment,—namely, to seo that the 
Fig. 1951. 
Manner of stretching the foot. 342 
MALFORMATIONS AND DEFORMITIES. 
heel is securely fixed on the bottom of tho shoe. That portion of the leather 
which lies over the dorsum of the foot is next laced, a little cotton being 
first interposed between the side-clip and the tarsal joint of the great toe, as 
well as between the toes, and between the leather tongue and the toes, after 
which tho sides of the apparatus are made fast to the leg and the thigh by the 
proper straps and buckles. The appliance being now secured to the limb, 
the next step is to restore the foot to its normal position by turning the 
screws at the ankle and in the heel of the apparatus with the screw-wrench. 
(Fig. 1953.) The most assiduous attention must be given to the shoe, when 
Fig. 1953. 
Fig. 1952. 
Kolbe’s modification of the club-foot shoe. 
once'fitted to the limb, in order to prevent excoriation or ulceration, acci- 
dents which are often sufficient to defeat the cure by rendering it impossible 
to continue wearing tho shoe; and during the interval when the shoe is not 
worn the foot gradually resumes its original vicious position. To avoid so 
undesirable an embarrassment, the surgeon must for a time give his personal 
attention to the dressings, interposing cotton between the instrument and 
the portions of the foot which are required to endure the 
brunt of the pressure. Pads of this kind will be often needed 
at the root of the great toe, on the outer side of the dorsum, 
and in front of the instep. Small pieces of lint spread with 
benzoated oxide of zinc ointment and laid over the vulner- 
able spots I find to answer a very excellent purpose. But 
the most important of all prophylactic measures will be the 
daily removal of the apparatus, and before its replacement 
bathing the part with alcohol, followed by active frictions. 
When the skin is tender, or when the child is very restless 
under the shoe, the latter may be removed at night, and, 
after bathing the parts with alcohol and rubbing well with 
the hands, the limb may be encased in a felt or a tin splint, 
properly adjusted to the position of the corrected foot, and 
fastened with a bandage. (Pig. 1954.) 
When the malposition of the foot can be corrected with 
little force, a very satisfactory dressing can be made with a felt splint, slit 
to fit tho foot, leg, and thigh. After the splint has been softened in hot water 
Shoe adjusted and foot about to be screwed into place,—two views. 
Fig. 1954. 
Night splint. TALIPES. 
343 
and the foot carried into the normal position, the felt is to be moulded to the 
side of the limb opposite to the deformity, including half the breadth of the 
upper and under surfaces of the foot, and secured in place by a bandage or 
by adhesive straps. 
In unyielding cases of neglected club-foot, where more than ordinary force 
is required to overcome the distortion, the resistance being located chiefly 
in the ligaments and the bones, the apparatus of Mr. Kolbe applied for 
a short time every day will be found of the greatest value. (Fig. 1955.) 
Fig. 1955. 
Fig. 1956. 
Stretching the foot in an old varus. 
Kolbe foot-stretcher for ordinary use. 
In this mechanism the heel is placed in a U-shaped piece of metal fastened 
to a block of wood and well padded. Two straps running in opposite direc- 
tions, one in front and the other behind the instep, with powerful screws 
attached, draw the foot in opposite directions. (Fig. 1956.) Another appli- 
ance, made by the same cutler, is represented in Fig. 1957. A screw running 
through a metal arch, and having a pad beneath, when turned presses the 
tarsal bones down, flattening the foot and at the same time holding it in place. 
In cases of talipes equinus with paralysis of the anterior tibial muscles, 
allowing the foot to drop, a 
shoe with an elastic band at- 
tached to the anterior part of 
the sole and buttoned to one or 
both pieces of the steel side- 
splints will supply the muscu- 
lar defect and keep the foot 
raised to the proper angle with 
the leg. (Fig. 1958.) 
Operation. — The operative 
measures which may be re- 
quired are either tenotomy or 
excision. 
By the former, the tendons 
of those muscles or the bands 
of fascia which are concerned 
in drawing or holding the foot 
in an abnormal position are 
cut subcutaneously. By the lat- 
ter, or excision, a wedge-shaped 
piece is taken out of the tarsus when anchylosis has occurred, or when the 
Fig. 1957. 
Fig.1958. 
Club-foot stretcher for adult feet. 
Shoe with elastic strap 
to prevent foot-drop. 344 
MALFORMATIONS AND DEFORMITIES. 
contraction and distortion are so great that correction of the deformity by 
tenotom5r and by force is impossible. 
Time necessary to restore the limb to its proper position.—The opinions of 
operators upon this subject are not harmonious. In my own practice, after 
making the necessary division of structures, I endeavor (with an occasional 
exception, to be noticed hereafter), by force and counter-force applied 
at the proper points, to place the foot at once as nearly as possible in 
its normal position and to retain it there by the proper apparatus. The 
amount of power which is often necessary to do this might, to one not famil- 
iar with this kind of surgery, appear injurious, if not rude; but I can recall 
no case where threatening symptoms have followed the plan. I am certain 
that this course of procedure has advantages over the plan of gradually 
bringing the foot from the abnormal to the normal position. 
Period to operate.—I do not think that in infantile talipes anything is gained 
by operative measures at an earlier period than the fourth or fifth month, 
particularly in cases where the heel is very imperfectly developed, and the foot 
little else than a round, dumpling-shaped, or shapeless mass of flesh. Under 
these circumstances it is extremely difficult to keep the foot properly in any 
shoe, and the skin is often so tender that very little pressure can be tolerated. 
In cases of this kind, twTo or three months’ manipulation will do much to 
stimulate the growth and shapeliness of the foot. Advantage will be gained 
also by having the club-foot shoo prepared and worn by the little patient 
a portion of the day, with moderate correction of the deformity, accustoming 
the skin in this way to pressure. A little time spent in an introductory treat- 
ment of this kind will not only lessen the opposition to be encountered when 
the operation is performed, but will often shorten the period of cure. 
Cases for operation.—There are those who think that all cases of club-foot 
can be cui’ed without the use of the knife, and others, again, who use the 
tenotome as a last resort, not to be tried without having first, for a consid- 
erable time, employed manual and instrumental force. Barwell, who may 
be said to represent the advocates of the non-cutting cure of talipes, has 
probably few followers at the present day, and the “ forlorn hope” party, or 
those who cut only when every other resource fails, while to be commended 
for their conservatism and patience, waste, in my judgment, a great amount 
of time. If there were any great danger attending the operation of tenotomy, 
or any evils following the procedure likely to weaken the action of the mus- 
cles operated on, I should not challenge the wisdom of their course; but in 
the absence of such evils, not one of which have I ever witnessed, I would 
ask, Why take months to correct a rebellious deformity of the foot which, 
with the knife, can be overcome in as many days? 
Still, I do not wish to be understood as advocating the indiscriminate use of 
the knife. The simple fact of a part being distorted or turned into an abnor- 
mal position is not a sufficient reason for the performance of tenotomy. The 
rule laid down by Professor SajTre in determining the question of tenotomy is 
based on the reflex irritability of the contracting muscles. To make the test 
practical, the foot is to be grasped by the surgeon and carried as nearly as 
possible into the normal position. If, while the parts are thus retained in a 
state of tension, pressure made with the point of the finger over the muscles 
put upon the stretch is followed by spasmodic contraction, the case is one 
requiring the knife. If, on the contrary, no such spasm of the tense muscle 
can be developed under pressure, the deformity may be corrected by appa- 
ratus alone. Notwithstanding the fact that absence of reflex irritability 
of the muscles in club-foot may often contra-indicate tenotomy, there are 
many exceptions to the rule. If there is contraction of the plantar fascia, as 
is often the case, there can be no proper restoration of the foot to its normal 
position until the bands of contracted tissue have been severed. 
In non-congenital cases of club-foot of paralytic origin, tenotomy is not 
necessary, unless there exists at the same time spasm of the muscles opposing 
those which are paralyzed. TALIPES EQUINUS. 
345 
Paralyzed muscles, so long as they are kept stretched by the contraction 
of other muscles, are in an unfavorable condition for the recovery of their 
normal tonicity. 
With these observations on the subject of deformities in general, and 
of talipes in particular, I proceed to the treatment of the different varieties 
of club-foot. 
Talipes Equinus—Pes Equinus—Horse-Foot. 
This variety of club-foot, rarely seen as a congenital deformity, is the 
most common kind of non-congenital talipes. The heel is drawn up by the 
action of the calf-muscles, while the sole of the foot is rendered deeply con- 
cave, and its dorsum correspondingly convex. The toes assume a hooked 
appearance, the proximal phalanges being extended by the weight of tho 
body, while the intermediary 
and ungual phalanges are 
strongly flexed by the contrac- 
tion of the flexor longus digi- 
torum muscle. (Fig. 1959.) 
While usually, as stated, the 
weight of the body rests pretty 
evenly upon the fleshy cushion 
over the metatarso-phalangeal 
articulation, there are numer- 
ous exceptions, in which tho 
pressure falls upon tho ex- 
ternal part, or that over tho 
fourth and fifth metatarsal 
bones, or even upon the outer 
and dorsal borders of the foot. 
The deformity is the result 
either of paralysis of the ante- 
rior tibial muscles, or of a spas- 
modic, rigid state of the gas- 
trocnemius and soleus muscles. 
In extreme cases of equinus the foot becomes reversed, being carried be- 
hind the leg by the conjoined action of the calf-muscles and by pressure from 
the weight of the body, the sole being directed upward, so that the distortion 
compels the patient to walk on the dorsum of the foot. (Fig. 1960.) 
In addition to the causes named as giving rise to talipes equinus, wounds, 
abscesses, and inflammations in the posterior part of the leg may produce 
the deformity. A mild variety of equinus often 
occurs in persons who have been long eonfined 
to the supine position, or who have been obliged 
to walk for a protracted period on one foot 
with crutches, the other foot being allowed 
to hang with the toes tipped downward. An 
ulcer or other sore seated on the heel, by com- 
pelling a person to walk on the anterior portion 
ef the foot, may cause a similar deformity. 
In talipes equinus with well-marked charac- 
teristics, the os calcis is raised, and the head of 
the astragalus is thrust forward in advance of 
the ankle; the ligaments, notably tho anterior 
tibio-tarsal and tho calcaneo-scaphoid and cuboid, 
also participate in the deformity, the first becoming lengthened, and the last 
two, with the plantar fascia and short flexor muscles of the toes, shortened. 
The proportion of non-congenital equinus to all other forms of talipes is 
about as one of the former to three of the latter. Females are more fre- 
Fig. 1959. 
Talipes equinus,—two degrees. 
Fro. 1960. 
Extreme pes equinus. 346 
MALFORMATIONS AND DEFORMITIES. 
quently tho subjects of the deformity than males, as will be seen by refer- 
ence to the table on club-foot. The right foot is much more commonly 
affected than tho left, being involved in 66 per cent, of all cases. 
Treatment.—Except in very slight cases of talipes equinus, mechanical 
treatment alone is not likely to accomplish much in correcting the de- 
formity. It will be necessary to divide not only the tendo Achillis, but also 
the plantar fascia, and probably the short flexor of the toes, or at least its 
tendinous origin. In dividing the first, the patient, after being etherized, is 
placed upon the breast. The tendon is then rendered moderately tense 
by flexing the foot, when a puncture is made through the integument with 
the sharp-pointed tenotome, flatwise, a short distance from the cord to be 
divided, and preferably on the outer or fibular side, so as to avoid injury 
to the posterior tibial artery, which lies behind the posterior surface of the 
tibia. The knife being withdrawn, the blunt-pointed tenotomo is inserted 
into tho puncture, flatwise, as in the first instance, and pushed through 
the connective tissue until it passes beneath the tendon, when its edge 
is to be turned upward ; then, while the foot is still more strongly flexed, 
the overlying cord is severed by a slight sawing motion. The division of 
tho tendon is usually accompanied by a sensible snap, followed by a sink- 
ing in of the soft parts which lie over the chasm or gap made by the retrac- 
tion of the proximal extremity of the tendon. The knife is next turned on 
the flat and withdrawn, followed by a finger to keep the sides of the puncture 
in close contact until the opening has been covered 
with a strip of adhesive plaster. 
The operator now turns his attention to the sole 
of the foot. Having opened the way on tho inner 
side of the sole through the skin with the sharp- 
pointed bistoury for the blunt-pointed tenotome, he 
thrusts the latter flatwise beneath the dense plantar 
fascia, and divides it from below upward, covering the 
second wound, like the first, with adhesive plaster. 
A roller bandage is then applied to the foot and leg, 
and the shoe represented in Fig. 1961 is put on, which, 
by means of the strap buttoned across the instep, 
and the elastic band attached to the sole and hooked 
to one of the side-pieces, will keep the foot flattened 
and at the same time raised to the proper angle with 
the leg. 
Tho various details which are to be observed in 
the subsequent dressings have been minutely de- 
scribed under the head of treatment after operation 
for club-foot. In three or four days the roller band- 
age should be laid aside and the stocking worn in- 
stead, taking care that it fits neatly and without 
rucks or creases, which are almost certain to fret the 
skin. 
In non-paralytic equinus without contraction of the 
plantar fascia or shortening of the foot, three or four weeks will be sufficient 
to effect a cure, after which time an ordinary plain shoe can be worn. Where 
tho plantar fascia has required division, several months will pass before the 
dorsal pressure across the foot can be safely suspended; and in paralytic 
cases the elastic band used to support the foot will have to be constantly 
worn should the affected muscles remain powerless in spite of rubbing, 
electric stimulus, and repeated movements. 
Fig. 1961. 
Shoe for equinus. 
Talipes Calcaneus. 
The chief peculiarity of talipes calcaneus is the extreme flexion of the foot, 
the metatarsal portion of which is elevated and the heel depressed, rendering TALIPES CALCANEUS. 
347 
it necessary for the patient to stand or walk on the latter. (Fig. 1962.) In 
this affection a groove or concavity runs across the sole of the foot, an- 
swering in position to the tarso-metatarsal articulation. The inclination of 
the dorsal plane is outward, the inner border being higher than the outer. 
The malposition of the foot is due to the contraction of the tibialis anticus 
and extensor proprius muscles, in which contraction the extensor longus 
digitorum and peroneus tertius sometimes participate. Loss of power in the 
calf-muscles leads to the same deformity, the antagonizing or anterior tibial 
muscles, if unaffected, causing the flexion of the feet. 
The deformity is both congenital and non-congenital; but this is the rarest 
of all forms of congenital talipes. It is occasionally associated with an ex- 
tended and stiff condition of the knee-joints from contraction and shortening 
of the quadriceps extensor femoris muscles, a condition sometimes attributed 
to abnormal or breech positions of the foetus in utero. Congenital talipes cal- 
caneus is generalljT due to spastic contraction of the muscles in front of the 
leg. 
The non-congenital variety of the deformity usually has a paralytic origin, 
the loss of power being in the muscles forming the calf of the leg. It has 
been known to follow division of the tendo Achillis, when from some un- 
usual cause the tendon failed to unite. In cases of this nature, the foot often 
Fio. 1962. 
Fig. 1963. 
Talipes calcaneus. 
assumes a very peculiar shape, the soft parts of the heel becoming round and 
elongated, and the anterior portion of the foot pointing downward, with 
contraction of the plantar fascia. (Fig- 1963, A.) 
Treatment.—In mild cases of congenital and non-paralytic talipes cal- 
caneus, frictions and stretchings, aided by the use of the anterior splint 
applied to the front of the leg and the foot and increasing the obtusoness of 
the angle from time to time, will serve to overcome the defect; but where 
such means are unavailing, as in the more aggravated forms of the deformity, 
the correction can only bo made after tenotomy. The tendons requiring 
division will be the tibialis anticus, extensor proprius pollicis, extensor 
longus digitorum, and peroneus tertius. All of these tendons can readily be 
divided through a single puncture in front of the ankle by introducing the 
tenotome on the inner side of the extensor longus digitorum and carrying 
it inward sufficiently far to allow of the division of the tendons of the tibialis 
anticus and extensor proprius muscles, then, after withdrawing the knife and 
Apparatus for paralytic calcaneus applied. 348 
MA L FORMA TIONS A ND DEFOR MI TIES. 
re-entering the same puncture, carrying it on in an outward direction, sever- 
ing the tendons of the extensor longus digitorum and peroneus tertius mus- 
cles. The division of all these tendons should he made from below upward; 
and in performing the operation tho surgeon will take care to avoid the 
anterior tibial arteiy, which lies between the tendons of tho tibialis anticus 
and extensor longus digitorum muscles. The wound is next covered with a 
strip of plaster, and a well-padded concave splint adjusted and secured to the 
anterior aspect of the leg and foot. It must be remembered that the retrac- 
tion of the proximal ends of these anterior tendons, after division, is consid- 
erable ; and, to render their subsequent union certain, the extension of the 
foot, with a view to restore it to the proper position, should be made very 
gradually, by altering from time to time the angle of the splint. Two weeks 
can advantageously be occupied in effecting this restoration. 
The non-congenital paralytic variety of talipes calcaneus cannot be bene- 
fited by operation. A shoe with a spiral spring or an elastic band passing 
from the heel upward towards the knee, and fastened to the steel side-pieces, 
will constitute the best device for supplying the power required to raise 
the heel. (Fig. 1963, B.) 
This form of club-foot is the one most frequently seen, as well in the infant 
as in the adult subject, the deformity being often neglected during those 
3*ears when it could be corrected without difficulty. The chief character- 
istics of varus are inversion and twisting of the foot, its sole being directed 
backward, its inner border looking upward, and its outer border downward 
and forward, with generally an elevated and imperfectly-developed heel. 
(Fig. 1964.) In very pronounced cases of varus, the inversion of the foot is 
often carried to such a degree that it forms an 
acute angle with the leg, or even rests against the 
latter. 
The projection of the astragalus and the os 
calcis gives an irregular appearance to the dorsum 
of the foot, and if the latter has been exposed for 
any considerable time to the pressure of walking, 
the integument on its outer side becomes callous, 
rugose, and not unfrequently is massed into a 
thick cushion or bursa, nature’s improvised substi- 
tute for a heel. The sole of the foot is also deeply 
grooved, both in a longitudinal and a transverse 
direction. The heel is often very imperfectly de- 
veloped, and is generally drawn up by the con- 
joined contraction of the gastrocnemius, soleus, 
and plantaris muscles. These complications pro- 
duce a subvariety of talipes termed equino-vams. Most cases of varus have 
this modification in a greater or less degree. The tendo Achillis, which is 
composed of the tendons of the calf-muscles, is readily felt as a tense cord 
on the posterior and inner aspect of the leg: the tension of this tendon, 
with that of the tibialis anticus muscle, is concerned in giving to the foot 
its inward and upward twist. The limb, especiall}” below the knee, is 
often atrophied. This atrophy may exist at birth, but is generally acquired 
as the individual grows older, becoming well pronounced even in early child- 
hood. The atrophy arises, partly at least, from the vicious position of the 
foot, for the deformity is incompatible with the proper movements of the 
muscles. The defective nutrition extends, indeed, to the entire limb, which 
in many instances never attains to the length of the sound one. (Fig. 1965.) 
It was from this form of club-foot that Lord Byron suffered, and, indeed, it 
has been the legacy of a number of more than ordinarily gifted persons. 
Talipes varus, when bilateral, forces the individual, when walking, to raise 
one foot over the other: hence the name “ reel-footed” given to persons thus 
Talipes Varus. 
Fig. 1964. 
Talipes varus. TALIPES VARUS. 
349 
affected. While the os calcis is very materially altered in this variety 
from its proper functional position in the system of tarsal bones, it is the 
astragalus which is most profoundly af- 
fected, both in its shape and in the posi- 
tion of its articulating surfaces. 
.Non-congenital varus is generally in- 
duced by paralysis, occurring in infancy 
and not unfrequently during the period 
of early dentition, when the child has 
suffered from a convulsion or has ex- 
hibited severe head-symptoms. The nu- 
trition of the muscles suffers more in 
non-congenital than in congenital varus, 
the muscular structure undergoing rapid 
fatty degeneration and consequent atro- 
phy, the latter often extending to the 
tendons as well as to the muscular 
fibrill®. 
Treatment.—Mild cases of congenital 
non-paralytic varus, unattended by mus- 
cular spasm, can in time be corrected 
by manual and instrumental stretching; 
but well-pronounced cases of the de- 
formity, whether congenital or non-congenital, yield only to tenotomy. 
The particular tendons requiring division are the tendo Achillis, those of 
the tibialis anticus and tibialis posticus muscles, and often that of the flexor 
longus digitorum. The plantar fascia, when contracted, will also demand the 
knife. 
The division of the tendon of the tibialis posticus muscle, owing to its re- 
lation to the posterior tibial artery, requires both anatomical knowledge and 
precision in the use of the tenotome. The formal subcutaneous section of 
this tendon was first done in 1842 by Dr. Little. In executing this delicate 
task, the sharp-pointed tenotome should be introduced flatwise immediately 
above the internal malleolus and carried inward, keeping the blade in close 
contact with the posterior face of the tibia until the dense fascia which covers 
in the posterior tibial tendon has been opened. .The bistoury is then to be with- 
drawn, and the blunt-pointed tenotome introduced in the same track and 
pushed onward until lodged between the tendon and the bone. If necessary, 
the tendon of the long flexor muscle of the toes may also be reached by 
burying the knife a little deeper in the same direction. It only remains to 
turn the edge of the tenotome upward against the tendon. An assistant 
should now take hold of the foot and attempt to restore it to its normal posi- 
tion. The effect of such a movement is to force the tendon against the edge 
of the knife and to secure its division; or, should this result not follow, by 
giving a slight sawing motion to the blade the object in view will certainly 
be effected,—though even a movement so insignificant as this is to be avoided 
if possible. 
Whether all the tendons enumerated as concerned in keeping the foot in 
the false position need to be divided at one time is a question of some prac- 
tical importance. I very much doubt the propriety of so doing, and believe, 
with Mr. Adams, that it is better to divide the procedure into two stages,— 
the first consisting in cutting the tendons of the tibialis anticus, tibialis pos- 
ticus, and flexor longus digitorum. After the lapse of four or five weeks 
we may proceed with the second operation, which is commonly the division 
of the tendo Achillis. This division is made in order to relieve the equinus 
element of deformity, which is always present to some degree. At this time 
the plantar fascia can be cut, should such a step be necessary. 
The shoe should be adjusted to the foot after the first operation, in order to 
maintain the advantage gained. The same appai’atus must be worn after the 
Fig. 1965. 
Yarus in the adult. 350 
MALFORMATIONS AND DEFORMITIES. 
second tenotomy until the cure is complete. Rarely is this effected in a shorter 
period than from ten months to a year. 
Should the posterior tibial artery be wounded in the act of dividing the 
tendon of the tibialis posticus muscle, the occurrence of the accident may 
generally be ascertained at the time of the operation by the red jet of blood 
which issues through the external wound, and by the blanched appearance of 
the foot. In such event a compress of lint must be accurately adjusted over 
the line of the vessel and fastened in place to the limb by a roller. In a case 
where I was unfortunate enough to wound this vessel the compress controlled 
the bleeding perfectly, and the patient recovered without any untoward com- 
plication. The artery has been cut in several instances by the hands of the 
best operators. Once Mr. Tamplin saw the injury end in false aneurism ; 
and a similar case is noted by Mr. Adams. Both patients recovered,—the first 
after ligation of the vessel, and the second from injection into the aneurism 
of a solution of perchloride of iron, the latter consolidating the blood into a 
hard mass. Should any operation be required, the proper surgical procedure 
would be to cut down, search for the vessel, and ligate each end. If the 
wound in the artery is of the nature of a puncture, the vessel, after being tied 
above and below the seat of injury, should be severed between the threads. 
Cases of talipes equino-varus will occasionally be encountered in which, 
from distortion of the tarsal bones and the resistance of the ligaments, correc- 
tion by tenotomy and instrumental measures is impossible. The alternatives 
are then presented of leaving the patient a permanent cripple or of resorting 
to some radical operative measure for relief. To accomplish the desired 
result two plans are open to the surgeon,—namely, the excision of the cuboid 
bone (first executed by Mr. Solly, in 1857, but previously suggested by Dr. 
Little, in 1854), and the removal of a wedge-shaped piece from the tarsus. 
The latter operation, devised by Mr. Colby, of London, is beyond controversy 
the one to be preferred, and is executed as follows. 
An incision is made along the outer border of the foot, extending from the 
middle of the os calcis to a point one inch in ad- 
vance of the tuberosity of the metatarsal bone 
of the little toe, and from the middle of the first 
cut to the outer border of the common extensor 
of the toes. (Fig. 1966.) The flaps are next 
reflected, exposing the tarsus. A wedge- or 
V-shaped piece is to be excised, without refer- 
ence to individual articulations, by means of a 
metacarpal saw passed beneath the tendons, 
great care being taken not to harm the tissues 
in the sole of the foot. This end may be gained 
by interposing a thin, flat spatula. The removal 
of the wedge, the base of which corresponds to 
the outer border of the foot, admits at once of 
the foot being everted, in which position the 
raw surfaces of the bones are brought into con- 
tact, and, being there retained by a splint, the bones unite with almost the 
same facility as wounds in the soft parts. The operation has been done 
18 times on 15 patients, with 1 death. 
Fio. 1966. 
Linee of iucision, and V-shaped piece 
of tarsus excised. 
Talipes Valgus. 
Talipes valgus, comparatively rare as a congenital deformity, is common 
as a non-congenital variety of club-foot. 
It consists in an eversion of the foot, the patient standing commonly on its 
inner border and ankle. In aggravated degrees of valgus the sole of the 
foot is turned outward and backward. (Fig. 1967.) The elongation of the 
internal lateral or deltoid and calcaneo-scaphoid ligaments admits of so great 
an abduction of the foot that the internal malleolus becomes unnaturally 
prominent. The transverse and longitudinal plantar arches are both oblit- TALIPES VALGUS. 
351 
erated, and this causes so great a flattening of the foot that mild forms of 
valgus are known as cases of “splay-foot.” The peroneal muscles are some- 
Fig. 1967. 
Talipes valgus,—two views. 
times contracted and shortened, and those forming the calf of the leg will 
sometimes be found in a similar state. This shortening raises the heel some- 
what, and produces the deformity named equino-valgus. The muscles in- 
volved may be longer than natural, allowing the anterior tendons to flex the 
foot. In this way is produced another subvariety of talipes,—namely, 
calcaneo-valgus. 
The bones, except in tho change of relation of their articular facets, are 
very little altered. The disability in walking is greater than in valgus. In 
764 cases of different forms of club-foot, tabulated by Adams, talipes valgus 
occurred 42 times; in my own table it occurred 82 times in a collection of 
495 cases. Females appear to be more frequently tho subjects of the de- 
formity than males. The right foot is more commonly affected than the left, 
—15 times in 42 cases, according to Adams, and 25 times in 82 cases, accord- 
ing to my table. Double talipes valgus is seen in a little more than one- 
third of the cases of this variety of club-foot.' Tho influence of congenital 
valgus of non-paralytic origin on the nutrition of the leg becomes quite 
marked as the patient advances in years, the limb not keeping up in its 
growth with that of the unaffected side either in length or in circumference. 
Treatment.—When of moderate degree, valgus is correctible by manipu- 
lative and instrumental treatment. By the first the foot is forced inward, and 
at the same time is twisted upon its transverse axis, in order to bring the 
plantar surface into the proper plane. In case there exists also a degree of 
equinus or calcaneus, the foot must, in addition, be strongly flexed or ex- 
tended, according as one or other of these subvarieties is present. The 
stretchings should be practiced twice a day for ten minutes at a time, after 
which the foot may be bound to a splint placed along the inner aspect of the 
limb and having a wedge-shaped pad three or four inches from its lower end. 
The base of this splint is to rest against the internal malleolus, after the man- 
ner of the Dupuytren splint used in the treatment 
of Pott’s fracture. Or the correction may be main- 
tained by the club-foot apparatus similar to that 
used for varus, except in the position of the side- 
clips and the direction of the lateral movement 
of the shoe. (Fig. 1968.) 
Operation.—In rigid and severe forms of val- 
gus an operation will be necessary. The number 
of tendons requiring division must be determined by the degree of deformity. 
It may be sufficient to cut those of the peroneal muscles. If, after doing 
Fig. 1968. 
Steel sole, with the position of the side- 
clips used for valgus. 352 
MALFORMATIONS AND DEFORMITIES. 
80, much resistance is still encountered in correcting the eversion of the foot, 
the tendon of the extensor longus digitorum will require to be severed, 
together with the tendo Achillis, especially when tho valgus is associated 
with even a moderate degree of equinus. 
In dividing the tendons of the extensor longus digitorum and peroneus 
tertius, the tenotome should be introduced from the inner side, beneath the 
tendon of the first-named muscle, keeping close to the latter, in order that the 
anterior tibial artery may be avoided. Occasionally it will be found neces- 
sary also to cut the tendons of the tibialis anticus and extensor proprius 
pollicis muscles before the obstacles to the reduction of the deformity can be 
successfully surmounted. The wound in the integument requires to be pro- 
tected with a strip of adhesive plaster, and the foot and leg covered with a 
roller. 
A walking-shoe similar to that used after tho cure of varus will have to 
be worn for at least one year after the deformity has been 
overcome by the first apparatus, in order to prevent an}’ 
tendency to relapse. 
Valgus the result of defective organization of the osseous 
system, such as is seen in rachitis, requires no other than 
mechanical appliances for its correction; and the same 
may be said as to the management of paralytic valgus, 
except in those cases where the calf-muscles obstinately 
resist sufficient inversion, when it will be proper to cut the 
tendo Achillis. Unfortunately, 
paralytic cases of valgus, fol- 
lowing as they do central le- 
sions, require mechanical sup- 
port during the life of the pa- 
tient. 
The mixed varieties of talipes 
varus and valgus are associated 
with either equinus or calca- 
neus, and require no special 
notice, the treatment not differ- 
ing from that proper in varus 
or valgus. 
Valgus arising from a frac- 
ture at the lower fifth of the fibula requires only 
mechanical support. A shoe should be worn 
having steel side-pieces extending as high as the 
knee, with a leather stocking attached, accu- 
rately fitting the lower two-thirds of the leg. 
(Fig. 19G9.) By lacing the stocking the weight 
of the body is distributed over the leg, instead 
of being transmitted to the inner ankle, the ob- 
jective point of weakness. 
Fig. 1969. 
Fig. 1970. 
Shoe for valgus arising 
from Pott’s fracture. 
Adduction of the Thighs. — This deformity, 
generally an acquired one, is among the distor- 
tions which follow infantile paralysis. It also 
follows disease of the bones of the pelvis. 
The deformity is seen in all degrees of severity, 
from a simple inability to separate the thighs fully, 
to that in which the thighs and knees ai*e firmly 
held in contact with each other, or even crossed 
like the letter X. (Fig. 1970.) In some of the 
more aggravated cases occurring in married 
women, I have been consulted both in regard to the marital duties of the 
husband and the possible complications in parturition. 
Adducted thighs. GENU VALGUM. 
353 
The immediate cause of the adduction is contraction of the adductor and 
gracilis muscles. 
Treatment.—When the muscular resistance cannot be overcome by a 
screw splint (Fig. 1971) placed between the knees and gradually elongated, 
Fig.1971. 
Splint for abducting the thighs. 
it will be necessary to resort to tenotomy, dividing the adductors of the 
thigh as near as possible to their origins from the body and ramus of the 
pubic bone, and to an extent which will admit of the necessary separation of 
the limbs. The deep fascia will also require to be cut. The advantage thus 
gained is to be maintained by the screw splint until the fibrous intercalation 
of the divided tendons or muscles has been completed. 
Where the adduction of the thighs results from hip-joint disease, osteotomy 
may have to be added to tenotomy. 
Flexion of the Thigh.—There is another deformity of the lower extremity, 
in which the thigh is permanently flexed upon the abdomen, a position which 
renders the limb useless for purposes of locomotion. This postural deformity 
may arise from neglected coxalgia, acute iliac abscess, or psoitis. In one of 
my patients, a woman, it arose from urinary fistula following pelvic cellulitis. 
It may, indeed, arise from any cause which has induced a patient long bed- 
ridden to lie with the thigh flexed. 
The malposition in this deformity is due to different conditions. When it 
follows intra-pelvic inflammation, with or without bone disease, the flexion was 
originally an intuitive movement, made to relieve the psoas or the iliac mus- 
cles from pressure and tension; the fibres of these muscles at length shorten, 
and in some cases they become interpenetrated by plastic lymph, which, when 
consolidated, resists their subsequent elongation. It is not long, however, 
if the thigh remains flexed, before some of the muscles external to the pelvis, 
as well as the fasciai of the limb, participate in the shortening, which is 
especially liable to affect the rectus femoris and the tensor vagina} femoris. 
When coxalgia or rheumatism has been concerned in producing the postural 
deformity, the latter will probably be associated with anchylosis, true or 
false, at the coxo-femoral articulation. 
Treatment.—When no very marked degeneration has taken place in the 
muscles involved, and when the flexion occurs in hip-disease antecedent to 
anchylosis, the limb may readily be restored to its proper position by exten- 
sion applied as in fractures of the thigh (see Coxalgia, vol. ii. page 177), the 
weights being gradually added as the difficulty is overcome. When the op- 
position encountered can be traced to the tensor vaginae femoris and rectus 
muscles, and when the deformity is due in any degree to the contraction of 
the fascia lata, the tenotome must be freely used in dividing the structures. 
When anchylosis at the hip-joint exists, nothing short of subcutaneous 
osteotomy can avail for the relief of the patient, unless it is in instances of 
false anchylosis following rheumatism, in which case the adhesions may be 
broken up by manual force applied after the exhibition of an anaesthetic. 
Genu Valgum. 
There is a deformity in which one or both knees incline inward (Fig. 
1972), often to such a degree as to interfere with walking. This deformity 
has received various names, such as knock-kneo, cross-knee, calf-knee, in- 
knee, and genu valgum. 
The deformity arises from several and dissimilar causes. 354 
MALFORMATIONS AND DEFORMITIES. 
During the last few years the subject of knock-knee has received much 
attention, and our notions of the patholog}7 of the affection have become 
more exact and definite. It has been the com- 
mon practice of writers until a comparatively 
recent period to dismiss the subject of immediate 
causation by the general statement that the de- 
formity was to be ascribed to the relaxation of 
the internal lateral ligament and the unresisted 
contraction of the outer hamstring muscle, the 
flexor biceps cruris; but we must look deeper 
than this for the explanation of the distortion. 
The remoter predisposing cause of these in- 
knee deformities doubtless, in many instances, 
resides in a constitutional condition, original or 
acquired, which profoundly affects the general nu- 
trition and disturbs the orderly operation of the 
forces of development. The affection, therefore, 
is both congenital and non-congcnital. The de- 
formity is by no means so common here as in 
Great Britain. It is more frequently seen among 
negroes than among whites, and in great centres 
of population rather than in country districts. 
Among the causes of knock-knee or in-knee 
the following may bo mentioned. 
1. Heredity.—It is not very unusual to meet 
with examples of a moderate degree of the de- 
formity in several members of the same family 
the paternal or maternal head of which possesses 
this peculiarity of organization. In cases of this 
kind the inward inclination of the knees reaches a certain point and after- 
wards shows little or no tendency to increase. 
2. Rachitis is a prolific source of knock-knee. It is induced either by 
influences at work before birth, and affecting the offspring through the 
mother, who has during gestation been subject to the combined agency of 
famine and unwholesome hygienic surroundings, or else it arises after birth 
from the want of sufficient food, or from food deficient in the plastic elements 
of nutrition. The mothers of the land, who, without cause, and more cruel 
than the beasts of the field, refuse to supply to their offspring from the 
fountains of their own breasts the nutriment which God designed for the 
“ fruit of the body,” are entailing upon this country a weak, miserable 
progeny, which, even with all the ingenious machinery of the gymnasium 
and other hygienic resources which the physical degeneration of the race 
has originated, is very imperfectly fitted to take its place and to perform its 
duty in the ranks of the workers required for the coming century. Much 
of the artificial food prepared for infants is but a sorry substitute for the 
mother’s milk, and is far inferior to pure cow’s-milk, which, properly diluted, 
is, next to the milk of the mother, in most cases the best nourishment that 
can be provided for the infant. The deformity of in-knee arising from rickets 
does not begin primarily in the knee, but arises in the femur and the bones 
of the leg. The bones bend under superincumbent pressure and the action 
of the muscles. Bending of the bones, however, is not conclusive evidence 
of the presence of rickets, and unless other signs exist the trouble should 
not be considered as due to an osseous vice of this nature. Any doubt on the 
subject will be resolved if on examination there are found similar curves of 
other bones of the skeleton and unusual length of the processes, together 
with deformities of the chest, delayed dentition, etc. Such a group of symp- 
toms admits of no other explanation, and the deformity may with confidence 
be pronounced one of rachitic nature. Rickets, however, is strictly a disease 
of infancy, and is never seen, I believe, after the fifth year. By that time the 
Flo. 1972. 
Genu valgum, or knock-knee. GENU VALGUM. 
355 
consolidating changes in bone which constitute the cure of the disease are 
well advanced, and are not liable to retrograde. 
3. Yielding bones.—I have used the term yielding bones in enumerating the 
causes of in-knee. In cases coming under this head there is not necessarily 
any disease in the organization of the bony structure itself. I mean simply 
that the superincumbent weight which the bones of the legs are compelled 
to support is out of all proportion to the duty which should be legitimately 
put upon them at the period when the deformity begins. We see inward 
inclination of the knees occur in children who are either overfed or whose 
power of assimilating food is above the average, so that they become loaded 
with fat, and, consequently, when they commence standing or walking, the 
thigh- and leg-bones are unable to bear the burden imposed upon them, and 
gradually bend, either inward or outward. To the yielding of the bones in 
these cases of in-knee there must be added, in many instances at least, an 
imperfectly-developed muscular system, its growth probably retarded by the 
unusual activity of the cell-forces concerned in the formation of fat; and in 
consequence of this retardation there is a lack of power to neutralize or 
antagonize the action of different muscles in such a manner as to maintain 
the proper equilibrium of muscular action. 
4. Rheumatic disease, especially when assuming the form of rheumatoid 
arthritis, or arthritis deformans, is another cause of knock-knee. Here the 
deformity is referable directly to changes which take place in the components 
of the joint, and these changes, as the ligaments yield, allow the articulation 
to incline inward. 
5. Paralysis.—Another cause of knock-knee is the loss of power in the mus- 
cles of the limbs, such as is seen in infantile paralysis, followed, as it often is, 
by elongation of the internal lateral ligaments. 
6. Muscular rigidity.—Knock-knee is also one of the deformities following 
that curious condition of rigidity or spastic contraction of muscles,—a condi- 
tion which owes its existence to central lesion. This muscular disorder is 
sometimes associated with loss of the power of co-ordination, the patient 
moving in a kind of trot or in a jerky manner. 
7. Articular disease.—Inflammation of the knee-joint will also induce the 
deformity under consideration from elongation of the ligaments of the knee- 
joint (the result of articular distention due to serous effusion) and from subse- 
quent contraction of the flexor biceps cruris muscle. The distortion may be 
duo to another kind of muscular contraction,, which is of a reflex character, 
and this is more or less present in all cases of articular inflammation. 
8. Fractures of the femur, when allowed to unite with an uncorrected 
internal angular displacement, may ultimately bring about a serious internal 
projection of the knee, on account of the unfavorable line in which the weight 
of the body is received by the thigh-bone and transmitted to the foot. 
9. Condyloid development.—Under this head wo have to speak of a cause 
quite independent of those already enumerated,—one regarding which there 
has been considerable discussion and some conflict of opinion among surgical 
writers. 
The strict independency of genu valgum may be assumed to be established 
b}* the testimony of Mr. Baker, based on 800 cases of this distortion observed 
at the Royal Orthopsedic Hospital, London, in nearly all of which the earliest 
signs of the deformity began at the knee. Dr. Shaffer, of New York, had 
also challenged the current pathological views on the causation of knock- 
knee in an able paper on the subject. 
MacEwen, in discussing the etiology of the deformity in question, refers 
it to the existence of a supra-condyloid curve and an enlargement of the 
internal condyle of the femur. 
Mikulicz, while claiming for genu valgum a'predisposing constitutional 
factor, makes the local difficulty to consist essentially in an asymmetrical 
increase in the diaphyseal end of the bone. 
Verneuil and Gueniot restrict the change at the lower extremity of the 356 
MALFORMATIONS AND DEFORMITIES. 
femur to an abnormal growth of the internal condyle; while Little believes 
that the deformity is duo to an arrest in the development of the external con- 
dyle and to a corresponding enlargement of the internal condyle, in which 
opinion he is sustained by Mayor; and he believes also that this trouble arises 
from the "weight of the body resting too long on the articulation at a time 
when the extremities of the bones arc too soft to sustain it without injury. 
Before the etiology of this vexed question is settled, it will be necessary, in 
my judgment, to study carefully the transverse breadth of pelvis between the 
acetabula and the length of the necks of the femora in cases of in-knee, both 
of which must materially affect condyloid pressure. When a femur is placed 
perpendicularly to a plane, the bone rests chiefly on the internal condyle, on 
account of its superior length; and such would be the case in the living sub- 
ject if the hip- and knee-joints were in a perpendicular line. This, however, 
is not the case: the wide separation between the thigh-bones at the coxo- 
femoral articulations and their close approximation at the knees compensate 
for the inequality in the length of the condyles, so that the latter bear, when 
all the conditions of normal anatomy are observed, with about equal pressure 
upon the articulating surfaces of the tibia. It is not difficult, therefore, to 
understand how a little increase either in the transverse diameter of the 
pelvis or in the length of the neck of the femur would increase the pressure 
resulting from standing, or even that from muscular contraction, upon the 
external condyle, and thus cause, while the bones were still in a plastic con- 
dition, some absorption of that condyle and the corresponding portion of the 
tibia; while the growth of the internal condyle, in the absence of the nor- 
mal pressure, would be increased. This line of thought, I believe, will, if prac- 
tically followed out, reveal the true cause of uncomplicated genu valgum,—a 
cause which lies back of and determines those changes which exist at the 
lower end of the femur. 
Some of these varieties of knock-knee undergo periodical exacerbations of 
increase corresponding in the main to what may be called growth-periods of 
the body. Such periods may occur during the first eight or ten months of 
infantile life, and again between the eleventh and fourteenth years, at the 
period of puberty. 
Treatment.—A treatment designed to meet all the indications in knock- 
knee must be both constitutional and local. 
The constitutional treatment should be sucb as will correct disorders of the 
nutrition. Among the means adapted to this end are fresh, pure air, bathing, 
and wholesome nutritious food. If drugs are needed at all, cod-liver oil and 
the compound syrup of the phosphates may accomplish much good. 
The local treatment may be either manipulation, sudden forciblo straight- 
ening, gradual straightening, or osteotomy. 
Many of the milder cases of knock-knee in children do perfectly well 
under manual stretching and rubbing. The surgeon must instruct the nurse 
or patient how to apply the force. This is done either by interposing a firm 
pad or cushion between the knees (when both are affected), as practiced 
by Little, and then bringing the feet gradually towards each other, or by 
placing the palm of the hand against the inside of the knee as a fulcrum, 
and pressing it out, while with the other hand the leg is drawn towards its 
fellow. (Fig. 1973.) This should be repeated five or six times a day. At 
night the legs should be flexed on the thighs and thus retained by a bandage, 
as in this position the deformity spontaneously disappears. If under this 
treatment in-knee does not increase, but shows signs of improvement, the 
surgeon can assure the parents that nothing more will be required. Arti- 
ficial supports are resorted to prematurely and unwisely in a great many 
cases of this affection. 
Forcible straightening has been practiced, both with and without division 
of the external lateral ligament. Both methods have had their friends. 
The former was at one time advocated by Langcnbeck ; the latter has been 
commended by Delore, Duplay, and others. These violent measures, in which GENU VALGUM. 
357 
the epiphysis is separated from the diaphysis, are not to be countenanced. 
In fact, this operation has even been followed by the death of the patient. 
Straightening by apparatus.—When manual 
stretching fails to arrest the knee-inversion 
and the deformity is progressive, we can re- 
sort to orthopaedic apparatus with every pros- 
pect of success. The component parts of 
an appliance which meets the indications are 
a pair of shoes, a band to pass around the 
pelvis, two steel splints, one for the outer 
side of each limb, each, having three joints, one 
at the hip, one at the knee, and one at the 
ankle, and, finally, three strong leather straps, 
with buckles, the middle one being designed 
to draw the knee out, the others to hold the 
apparatus to the limb and prevent its dis- 
placement. (Fig- 1974.) This apparatus 
should be worn at first during the day, and 
after a short time both day and night. 
In cases of knock-knee of moderate degree 
the apparatus need not extend above the 
thigh. A pad on the inside to press the knee 
out, and a strap and buckle below to draw 
the leg in the opposite direction (Fig. 1975), 
will answer every purpose. 
Three or four months’ treatment, if faith- 
fully observed, will, in patients under six or 
eight years of age, so straighten the limbs 
that the apparatus may gradually be laid 
aside. A much longer time—eighteen or 
twenty months—will be required for patients who have passed the age of 
puberty. 
When an apparatus such as that represented in Fig. 1974 cannot be con- 
Fig. 1973. 
Straightening knock-knee by manual 
pressure. 
Fig. 1975. 
Fig. 1974. 
Fig. 1976. 
Apparatus for knock-knee applied. 
Apparatus for moderate degrees of knock-knee. 
In-knee splint applied. 
veniently obtained, on account either of expense or of distance from surgical 
cutlers, a good substitute can be extemporized by taking a piece of light 358 
MALFORMATIONS AND DEFORMITIES. 
board, long enough to extend from above the ankle to near the trochanter, 
and nailing to it at each end a semicircular piece of scrap-iron or hollowing 
out the extremities. This splint, after being well padded, is to he laid along 
the outer aspect of the thigh and secured in position by a roller at the 
middle and at each end. (Fig. 1976.) This arrangement will answer very 
well at any time before the little patient is able to walk. In most cases of 
commencing knock-knee a cure can be obtained by orthopedic apparatus 
without a resort to operation. 
Operations.—A certain number of cases of genu valgum of an aggravated 
type (always the result of neglect to use mechanical measures in early life) 
will require operative measures of some kind, and may even call for the 
operation of osteotomy. 
In France, M. Delore, of Lyons, introduced the “ redressement brusque,”— 
that is, the forcible separation of the epiphysis from the diaphysis. At times 
the process occupied half an hour. He claims to have performed it two hun- 
dred times with success. 
In cases of moderate deformity, Mr. Reeves divided the tendon of the biceps 
and the external lateral ligament, and at once forcibly straightened the limb. 
The several methods of osteotomy which have been employed are—first, 
the excision of a wedge-shaped piece of bone from the inner surface of the 
tibia, as at one time practiced by German surgeons ; second, detaching the 
internal condyle entirely from the femur by sawing obliquely through the 
process (Fig. 1977), the plan of Ogston ; third, cutting in the same line as 
Ogston, but with a chisel, and not 
entirely separating the condyle, 
and then straightening the limb 
by force, though not opening the 
joint: Mr. Reeves says he has per- 
formed the operation 71 times, and 
in case with success; fourth, 
the excision of a V- or wedge- 
shaped piece transversely from 
the condyle, the operation of Mac- 
ewen. (Fig. 1977.) Macewen 
has collected 820 cases, and has 
analyzed 580 other eases from 
the practice of British surgeons. 
Of this number, making in the 
aggregate 1400, there was hem- 
orrhage in 2, suppuration in 40, 
relapse in 5, anchylosis in 2, and 
death in 10. The mortality, except 
in two cases, could not be properly 
ascribed to the operation. Com- 
paring the above with the results 
in 525 cases by the Ogston opera- 
tion on the condyle, Macewen finds 
hemorrhage in 13 cases, suppura- 
tion in 8, and anchylosis in 4. It 
would appear, therefore, that the 
supra-condyloid method for the eure 
of genu valgum is the best. 
The operation should be performed antiseptically. After the patient is 
etherized, the limb, having been emptied of blood by means of the Esmarch 
elastic bandage, is laid on its outer side upon a bag tilled with damp sand. 
Two lines are then drawn across the internal condyle, one transversely, 
a finger’s breadth above the extreme end of the process, and the other 
vertically, cutting the first line half an inch in front of the insertion 
of the tendon of the adductor magnus muscle. A longitudinal incision is 
Fig. 1977. 
A, Ogston plan. 
B, Macewen plan. GENU EXTRORSUM CURVATUM. 
359 
made of sufficient extent through the point of intersection of the lines, 
through which the chisel is passed along the side of the knife. The osteo- 
tome (Fig. 1978), after being entered, is turned transversely, and then driven 
Fig. 1978. 
Osteotomes for dividing the femur in the operation for genu valgum. 
onward through the bone by successive strokes with a mallet, the instrument 
at the same time being directed slightly forward, with a view to avoid the 
popliteal vessels. The chisel, from its wedge-shape, in passing through the 
bone, displaces the osseous tissue in such a manner that when it is withdrawn 
a gap is left in the condyle with its base directed internally and its apex ex- 
ternally. The small bridge of bone which may remain undivided at the 
outer portion of the external condyle is readily bent or broken by using 
the limb as a lever, when the limb can without resistance be immediately 
brought into a straight position, after which 
the wound in the soft parts is to be closed 
by sutures covered with an antiseptic dress- 
ing, and the limb secured in a long fracture- 
box, and there maintained until the bone has 
become consolidated by callus, the work usu- 
ally of seven or eight weeks. The bony 
union in twelve weeks is sufficiently strong 
to allow the patient to walk. It is desirable 
to have several osteotomes of different sizes, 
so that in cases where the bone yields with 
difficulty smaller instruments may tako the 
place of the larger ones as the wound in the 
bone deepens. 
It is believed to be best, when the deformity 
is bilateral, that both limbs should be operated 
on at the same time. 
Knock-knee in which the flexor biceps cruris 
muscle is chiefly at fault—certainly not a 
common variety—will, mechanical treatment 
failing, require the division of the tendon 
above, and external to, the knee-joint. 
Knock-knee the result of paralysis will re- 
quire an apparatus which will include the feet, 
limbs, and pelvis, supplying to some extent 
the want of muscular power, so as to prevent 
the deformity from increasing. (Figs. 1979, 1980.) 
Fig. 1979. 
Fig 1980. 
Apparatus for pa- 
ralysis of both limbs, 
accompanied by 
knock-knee. 
Apparatus for 
paralysis of one 
limb. 
In this deformity the curve of the limbs is the reverse of that present 
in knock-knee, the legs being bowed in an outward direction. (Fig. 1981.) 
Out-knee is seen of all degrees, from the slightest external curve to one in 
which the two limbs form an ellipsoid figure. Even in moderate degrees 
of the curve the gait of the person is somewhat peculiar, a short, lateral, 
rocking movement in walking being noticeable. 
Bow-leg commences in infancy, and, unless some measures are early taken 
to correct the deformity, it will often continue to progress until adult life, 
when the distortion becomes a permanent one. Occasionally a case is met in 
which one leg is bent outward and the other inward. 
Genu Extrorsum Curvatum—Bow-Leg—Bandy-Leg—Out-Knee. 360 
MALFORMATIONS AND DEFORMITIES. 
The causes of the outward curve are similar to those which operate to 
produce knock-knee, though the former will be found to depend more often 
on a curve in the bones of the thigh and leg 
than on an alteration of the condyles of the 
femur. Thus, it is seen in rickets and in that 
form of slow osseous consolidation so often 
observed among negro and mulatto children. 
Young children whose growth has been rapid, 
especially in the accumulation of fat, when 
they begin to walk may develop an outward 
curve in the lower extremities. This does not, 
of necessity, imply any defect whatever in the 
skeleton of the leg. It shows only that the 
normal bones are compelled to bear an abnor- 
mal weight. 
Treatment.—In mild cases of bow-leg, the 
deformity will often disappear without any 
treatment. There is in the bones a reserve force 
which tends, under ordinary circumstances, to 
move in the direction of a normal type, that 
type being in the strictest accord with those 
physical forms which combine strength and 
lightness with grace of movement. The muscles 
are concerned in this work, and they assert 
their power, as they develop, in giving emphasis to the curves which naturally 
belong to the long bones. A little attention, therefore, at the commencement 
of bow-leg, in the way of bending the limb in a proper direction, by grasping 
the outside of the knee with one hand and the leg with the other and pressing 
in opposite directions, will be demanded. This manipulation, which can be 
done by the nurse or the parents, may be repeated four times a dajT, and pre- 
ceded once a day by massage of the limb. 
When the deformity is marked and progressive, it will have to be com- 
bated with orthopaedic apparatus, that of 
Kolbe (Fig. 1982) answering the object 
in view with entire satisfaction. This 
appliance consists of a shoe with side- 
splints extending to the upper part of the 
thigh, to which are affixed two pads, one 
on the outside, furnished with a strap and 
buckle, by which the knee can be drawn 
inward, and one on the inside, to receive 
the counter-pressure. These splints are 
frequently resorted to when no necessity 
exists for their employment, and I insist 
that their use is justifiable only when it is 
found that the deformity is not corrected 
by manipulation. Some writers direct 
that a child with a tendency to bow-legs 
should not be allowed to walk, under the 
impression that tho deformity is increased 
by the erect position ; but in this opinion 
I do not concur. I believe that a moderate 
amount of walking, by imparting vigor to 
the muscles of the limbs, conduces to the 
correction of the curves. 
When tho curvature is the result of ra- 
chitis, and has been neglected until the bone 
has reached the stage of eburnation,—nature’s method of cure,—oi’thopsedic 
appliances possess no power to restore the limb to its normal shape. It is 
Fig. 1981. 
Bow-legs. 
Fig. 1982. 
Kolbe’s bow-leg shoe. CURVATURE OF THE LEG. 
361 
very doubtful if the resulting inconvenience, unless very great, will justify 
the patient in assuming the risks which must attend a surgical operation 
undertaken for the correction of the evil,—an operation which necessitates 
the excision of a wedge-shaped piece of bone from the tibia and the fibula. 
Genu extrorsum may follow a badly-united fracture of the femur, in which 
the fragments join at an angle the apex of which is external. The remedy 
in such a case, where the usefulness of the limb is seriously impaired, consists 
in refracture of the bone by subcutaneous drilling, or sawing with an Adams 
saw, and bringing the femur into line. 
Anterior and Posterior Curvature of the Leg. 
The bones of the leg are frequently deformed by an anterior curvature of 
the tibia and fibula, particularly the former bone. This deformity begins in 
infancy or in early childhood (rarely later than the second year), and is of 
rachitic origin. When not amenable to manipulation or bending with the 
hand, the apparatus represented in Fig. 1983 will be required, and, if worn 
with regularity night and day, will eventually overcome the curvature. 
The disease undergoes, in time, a spontaneous cure by hardening of the 
bones, so that no increase of the curvature is likely to occur after the fifth 
or sixth year, nor is it likely that any surgical operation will be required 
in a case of this nature. In traumatic cases of anterior curvature, such, for 
example, as sometimes follows maladjustment of fractures of the tibia and 
fibula, refracture may be required. It is to be performed in the same 
manner as in treating the femur for angular deformity. 
Posterior curvature of the limb, or back-knee, may arise from inflammatory 
Fio. 1984. 
Tig. 1985. 
Fig. 1983. 
Apparatus for anterior cur- 
vature of the leg. 
Posterior curvature of the knee. 
Apparatus for back-knee 
applied, and result of 
treatment. 
transudation into the knee-joint, or from an atonic state of the general 
system, in which the ligaments of the knee-articulation become elongated, 
or from paralysis of the ham-string muscles. The knee in posterior curva- 
ture is carried back to so great an extent that the lozenge-shaped form of 
the popliteal space is exchanged for a marked prominence, the limb being 
concave anteriorly and convex posteriorly. (Fig. 1984.) The deformity is 
occasionally accompanied by subluxation of the tibia. 
This curvature is correctible by the apparatus shown in Fig. 1985, the 
constant wearing of which, particularly where the affection has a paralytic 
causation, will be a necessity. 362 
MALFORMATIONS AND DEFORMITIES. 
Weak Ankle. 
By weak ankle is understood an abnormal relaxation of the ligaments ot 
the ankle-joint, with such weakness of the leg-muscles as may allow the foot 
to bend involuntarily, either inward or outward, in the act of standing or 
walking. This affection is frequently observed in feeble children or those 
recovering from severe attacks of illness, or in children whose weight has 
increased so rapidly that the ankles are overtasked by the 
superincumbent pressure. 
The treatment must be directed chiefly to improving the 
nutrition of the muscles, to the weakness of which the defect 
is mainly due. Bathing, frictions, flagellations, faradization, 
and movements constitute the regimen, supplemented, when 
the general system exhibits signs of weakness, by iron, strych- 
nia, and food rich in those materials which administer to the 
wants of the tissues. Weakness of the ankles is often induced 
by putting high shoes on the feet of infants and lacing them 
tightly about the ankles, a practice which must necessarily in- 
terfere with the development of the muscular and tendinous 
apparatus which encompasses the articulation. 
When the treatment detailed fails to overcome the weak- 
ness, a piece of stiff leather may be placed in the sides of the 
boots worn by the child; and not until it is found that no 
improvement results from these methods should the limbs of 
the child be incarcerated in irons, in which case the best walking-shoe will be 
that shown in Fig. 1986. 
Pig. 1986. 
Shoe for weak 
ankles. 
The best type of a well-constructed foot, embodying both strength and 
symmetric beauty, is a foot which when planted upon a plane surface capable 
of receiving and retaining an impression, as wet sand, leaves four distinct 
impresses,—a posterior oval one, the heel cushion, two anterior oblique 
ones, the metatarso-phalangeal cushions and the digital 
cushions, and an external longitudinal one, the calcaneo- 
metatarsal cushion, extending along the outer border of 
the foot from the digital to the heel cushion. (Fig. 1987.) 
The deviations from this type of the normal foot are, first, 
those in which, in consequence of the height of the plantar 
arch, the outer or calcaneo-metatarsal cushion does not 
touch the ground ; second, those in which, from the ab- 
sence of this arch, the entire sole of the foot rests upon 
the surface of support, leaving the plantar impression most 
strongly marked at points corresponding to the heel and 
the inner extremity of the metatarso-phalangeal cushions. 
An extreme degree of the last variety of foot constitutes 
the plantigrade, flat-, or splay-foot, a form which brings 
the member often within the province of pathology. 
The conditions which are influential in producing alter- 
ations in the size and form of the feet are numerous. 
Among these, some are mechanical and others patho- 
logical. 
The habit of walking for a long time either on the heel 
or on the metatarso-phalangeal portions of the foot, in 
order to take the pressure from an ulcer on some portion 
of the sole, will at length exaggerate the plantar arch. 
Lads who work at machines moved by treadles have the 
foot used for the purpose larger than its fellow. Laborers who employ 
chiefly the shovel in their work have the left foot rather larger and flatter 
than the right one, as the left limb is made the fulcrum in using the lifting 
Deformities of the Foot. 
Fig. 1987. 
Best type of a normal 
foot. DEFORMITIES OF THE FOOT. 
363 
power necessarily expended in their work. It is not chimerical to believe 
that it would be possible by multiplying observations to determine many 
of the occupations of the laboring classes from peculiarities in the form of 
the foot. 
The graphic method, as it is termed, or the method of studying the physi- 
ological and pathological action of the muscles by taking impressions of the 
feet, which has been pursued at different times by Marey, Ludwig, Duhousset, 
Onimus,* Rohmer, and others, is by no means barren of results. Nor has the 
practice of sole-printing been confined to the study of disease: it has been 
applied to the solution of questions arising in criminal law, depending upon 
the identification of criminals. 
The influence of pathological causes in producing alterations in the size 
and form of this member has been well brought out by Hiltonf in connec- 
tion with rest enforced by joint-disease. Of all the causes concerned in cre- 
ating pedal deformity, none are so influential as badly-fitting shoes. It is sad 
to see a piece of mechanism anatomically and physiologically so wonderfully 
perfect as the foot deprived of its beauty and usefulness through motives 
of human pride and folly. 
Flat-foot, or splay-foot, is both a congenital and an acquired deformity. It 
is met with in both sexes. When congenital, it is due to some imperfection 
in the tarsal articulation. In the acquired form, which commences early in 
life, it is frequently associated with a strumous or a rheumatic diathesis, and 
may not very materially interfere with the usefulness of the member. Many 
persons who are subjects of the deformity are able to stand, walk, and labor 
without experiencing fatigue. The distortion often reaches a certain degree 
bejmnd which it does not advance. In other instances it is progressive, and 
may result in complete valgus. There are also a paralytic, a spastic, and a 
traumatic flat-foot. 
The deformity consists in a breaking down of the longitudinal and trans- 
verse arches of the foot. The latter becomes elongated, flattened, and 
everted, so that in standing the entire sole rests upon the ground. (Fig. 
1988.) The inner ankle, the head of the scaphoid, and the corresponding 
border of the foot become unnaturally 
prominent, rendering walking labori- 
ous and awkward. The anatomical 
parts concerned in the deformity are 
the long and short calcaneo-euboid 
and astragalo - scaphoid liganrfents, 
which being weakened and elongated 
allow the keystone of the arch, the 
astragalus, with its articulations, to 
sink down. This is followed by elon- 
gation of the deltoid ligament, causing 
the unnatural prominence of the in- 
ternal malleolus, and often such ever- 
sion that in standing or in walking the 
weight of the body is received chiefly 
on the inner border of the foot. In non- 
congenital valgus, sometimes called 
splay-foot, the plantar arch is destroyed, the foot becomes flat, and the in- 
ternal ankle prominent, from the same elongation of the deltoid. 
The causes of non-congenital valgus vary in different individuals. The 
deformity is sometimes hereditary. I have seen families in which parents 
and children alike possessed this peculiar conformation of the feet. In some 
Flat-Foot—Splay-Foot. 
Fig. 1988. 
Flat- or splay-foot. 
* Revue de Medeeine. 1881 ; Revue de Chirursie, June, 1882 ; Medical News, August 12, 1882. 
f Hilton, Rest and Pain, pp. 857, 372, 427, 430. 364 
MALFORMATIONS AND DEFORMITIES. 
of these cases the individuals are also the subjects of rheumatic and gouty 
diseases. Paralysis occurring in infancy is the most fruitful source of the de- 
formity. Sclerosis of the spinal cord and muscular spasm must also be recog- 
nized among the causes concerned in the production of valgus. Young per- 
sons who attain their growth too rapidly for the proper development of the 
muscular and ligamentous systems are liable to suffer from valgus, especially 
if there exists in the bones any vice of a rachitic nature. Fractures at the 
lower end of the fibula, in which the fragments have not been properly adjusted, 
the foot being allowed to remain everted, constitute another cause of valgus. 
Treatment.—No treatment will restore the normal arches of the foot when 
these are once lost, but much may be done by mechanical measures to pre- 
vent the continued progress of the deformity. The boot worn by the patient 
should have a convex pad of rubber or porous cork, or, best of all, a steel plate 
with a wing, fitted to the inner surface of the sole in the defective arch. The 
plate or pad should slope off externally, terminating in the latter direction about 
the middle of the sole. The heel of the shoe should extend farther forward, 
and be also raised on the inner side. A shoe constructed after this model, and 
faithfully worn until the ligaments have acquired their proper strength and the 
muscles their due tonicity, will do a great deal of good. Its use tends to give 
a compact solidity to the elements of the foot. This shoe may commonly at 
the end of a few years be laid aside for one of the usual form. In the severer 
varieties of non-congenital valgus it will be necessary to employ the shoe 
used in the treatment of the congenital defect, with the addition of a toggle- 
joint on the outer side of the ankle articulation,—an ingenious device of Mr. 
Kolbe’s by which the weight of the body in walking is thrown upon the outer 
border of the foot; or a steel plate may be fitted to the arch and worn inside 
of the shoe. Much exercise on the feet must be avoided in the early period 
of flat-foot, or until the ligaments and bones constituting the tarsal articula- 
tions have become consolidated and the muscles well developed. Horseback- 
and carriage-riding must to some extent take the place of walking. Where 
there is an absence of general good health, benefit will be experienced from 
the administration of cod-liver oil and iron. 
The foot is the subject of a peculiar multiple form of ulceration which 
has been described by writers under the term podelcoma. The affection 
is characterized by the appearance of numerous oval, thick-edged ulcers, 
commencing at the anterior part of the foot, or on the toes, which become 
confluent, and which give out an exceedingly offensive, acrid discharge, at- 
tended with pain and followed by diffuse, deep inflammation, involving soft 
parts and bones, and resulting in sinuses which ultimately burrow in all 
directions through the foot. The toes in time become distorted, and the 
foot shapeless. The disease has probably a constitutional origin, being very 
likely one of the protean manifestations of struma or of syphilis, and is 
rarely seen in this country. Twice only have I seen an affection of the feet 
which answers to the disease in question. One subject was a woman, a 
hospital patient, about thirty years of age, in whom such structural devas- 
tation was produced as to necessitate the removal of the principal part of 
the foot; the other was a private patient, a male, who had before visiting me 
lost one of the toes, the disease still progressing through the anterior portion 
of the foot. In both cases the disease, I thought, could be traced to a sub- 
acute periostitis. 
In hot or tropical climates the natives are subject to a disease of the foot of 
a similar character (in India called the “ mad ura foot”), which is believed by 
those who have investigated the subject to be caused by a peculiar fungus, 
capable of penetrating into the bones and causing their death. 
Treatment.—The remedies are both constitutional and local. Among the 
former, iodide of potassium, bichloride of mercury, cod-liver oil, and iodide 
Podelcoma. DEFORMITIES OF THE TOES. 
365 
of iron will be found most useful. The local remedies capable of effecting 
most good are solution of permanganate of potash to cleanse the sores and 
to destroy the offensive odor, and stimulating applications to the ulcers, as 
a two per cent, solution of bromine; the parts should be enveloped in a piece 
of old linen or lint wet with warm water and laudanum to alleviate pain. 
The strength must be sustained by proper food and by wine. When the 
bones perish, amputation will become necessary. 
Perforating Ulcer. 
A peculiar form of ulceration occurs in the sole of the foot, usually in the 
fleshy mass which overlies the metatarsal bones. This ulcer is remarkable 
for the regularity of its outline,—looking as though a piece had been cut 
out with a punch,—and also for its intractable character, not only destroy- 
ing the soft parts, but implicating the bones and articulations of the foot. 
The dissections of Duplay, Morat, Fischei’, and others leave little doubt 
that this singular ulcer originates in a degeneration of the nerves of the 
affected region, not unlike that which occurs at the distal end of a divided 
nerve. The papillae of the derm become enlarged, with great thickening 
of the epidermis, and inflammatory changes in the coats of the neigh- 
boring arteries. There is a circumferential anaesthesia of the walls of the 
ulcer. 
The treatment of perforating ulcer is largely expectant, consisting of 
removal of diseased bone, and, when the disorganization is extensive, am- 
putation of the damaged part of the foot. Electro-galvanism has been 
recommended in order to correct the trophic derangements of the integu- 
ment through the nervous system. 
Deformities of the Toes. 
Deformities of the toes are both congenital and acquired. Kudimental, 
supernumerary, hypertrophied, and webbed toes are examples of congenital 
malformations, while deviations in the direction of the toes, corns, bunions, 
and inversion of the nails, are the acquired deformities. The last three of 
these affections will be treated of under Diseases of the skin and its append- 
ages. 
Entire Absence of Toes.—Rudimental toes are sometimes seen projecting 
as stubby, fleshy processes, but entire absence of the toes is an extremely 
rare phenomenon. 
Polydactylism.—Supernumerary toes are not uncommon irregularities. 
Though the unusual number of seven and of nine toes has been observed, 
the supernumerary digit is usually a single one, and associated generally 
with the great toe, projecting from the inner side of its metatarso-phalan- 
geal joint: in one case of a boy about ten years of ago whom I saw, it 
stood nearly vertical on the back of the joint, and was almost equal in 
magnitude to the regular digit from which it grew. These supernumerary 
parts of the foot, though sometimes possessing the usual elements of the 
regular toes in considerable perfection, are usually but imitations, having 
a very slender attachment to the digit with which they are connected. 
Treatment.—As such redundant appendages can only become incum- 
brances, interfering often with the proper adjustment of shoes, they should 
be removed early, by embracing the root of the abnormal too between two 
elliptical incisions ample enough to permit the surgeon to close the wound 
left by the extirpation of the part. 
Webbed Toes are less commonly met with than webbed fingers. As the 
abnormality does not interfere with the usefulness of the foot, and the parts 366 
MALFORMATIONS AND DEFORMITIES. 
are concealed from view, surgical operations for the remedy of the deformity 
are not necessary; but if insisted upon by the person who is the subject of 
the defect, the operation should be made after the manner directed for the 
relief of a similar condition of the fingers. 
Overlapping of the Toes.—There is a deformity in which one or more of the 
toes are so changed from the normal direction as to override the adjoining 
digit. The great and the little toe are those which 
are usually the subject of the distortion. (Fig. 1989.) 
This condition, which is among the deformities fol- 
lowing bunions and rheumatoid and gouty disease, 
is in most instances one of the ill effects incident to 
wearing too narrow shoes, in consequence of which 
the toes are compelled to assume the unnatural 
position. That this is the proper explanation will 
be evident from the direction taken by the deformed 
digits. This direction in cases of this description 
is always inward or outward, according as the 
affected toe is on the inner or the outer side of the 
foot. 
The primary effect of the pressure is to weaken 
the abductor muscles of the great toe or the little 
toe, or of both, as the case may be, and to give the 
digits over to the unopposed action of the adductor 
muscles, which draw the phalanges towards the 
median axis of the foot. The ligament on the outer 
aspect of the metatarso-phalangeal articulation be- 
comes lengthened, and the ligament on the opposite 
side of the joint is correspondingly shortened, until 
at length a change takes place in the form of the articular surfaces of the 
metatarsal and phalangeal bones, which renders the vicious position a per- 
manent one. 
Treatment.—An essential part of the treatment consists in wearing shoes 
wide enough to allow the spread of the foot. If this is neglected, all other 
measures will prove useless. When the deformity has made considerable 
progress, it may be corrected in one of the following ways: 
1. Take a strip of adhesive plaster one inch and a half wide at one end 
and long enough to extend from the tip of the toe to a point behind the 
heel. Notch the end and sides of the wide extremity of the plaster, that it 
may be better adapted to the surface on which it is to be placed. Attach 
the notched extremity of the plaster to the tip and sides of the toe. Next 
place a little roll of lint immediately 
behind the metatarso-phalangeal artic- 
ulation as a fulcrum; then, after draw- 
ing the toe outward into position, pass 
the free end of the plaster over the roll 
of lint and fasten it to the inner or 
outer border of the foot, according to 
the toe involved. (Fig. 1990.) This 
dressing is better adapted for the great 
toe than for the little toe. 
2. The apparatus of Briggs, employed 
in the treatment of bunions, may also 
be used for the treatment of overlap- 
ping toes. (Fig. 1991.) 
3. Another method which can be adopted with great advantage, particu- 
larly where several of the toes are involved, is to moisten a quantity of plaster 
of Paris until it reaches the proper consistency, place it upon a board, and, 
after oiling the foot and bringing the toes into their proper positions, press the 
Fig. 1989. 
Overlapping toes. 
Fig. 1990. 
Correcting inward deformity of the great toe by 
adhesive plaster. DEFORMITIES OF THE TOES. 
367 
metatarso-phalangeal portion of the foot into the plastic gypsum. The latter 
being forced up between the toes, an accurate cast of the parts will be 
obtained. From this a mould can be made, which will furnish the model for 
the construction of a light felt or tin case, readily connected with a shoe 
Fig. 1091. 
Fig. 1992. 
Briggs’s apparatus. 
Shoe with case for distorted toes. 
(Fig. 1992), which, when laced over an interposed compress of lint, will keep 
the toes in their proper places. 
Flexed, Hammer, or Talon Toes.—The toes are sometimes permanently 
flexed or recurved in a claw- or talon-like manner. (Fig. 1993.) This de- 
formity renders it difficult for the person to vveai 
a shoe with comfort, in consequence of the promi 
nence of the dorsal surface of the digits. Tht 
distortion is the result of paralysis of the extensoi 
muscles of the toes, of muscular spasm, or of in 
flammation in the sheaths of the flexor tendons 
or it may be produced by the habit of wearing 
shoes too short for the feet. 
Treatment.—Several plans of treatment, arc 
open to the choice of the surgeon. In cases where 
little or no resistance is ottered to extension, il 
will suffice to employ a shoe with a mechanisn 
attached similar to that used for overlapping toes 
In rigid cases it will be better to resort to tenot 
omy, dividing subcutaneously the flexor tendons 
as they pass through their sheaths on the plantai 
surface of the first phalanges, and afterwards keep 
ing the toes extended by securing them with a bandage to a splint. When 
the great toe is recurved and an operation becomes necessary, the tendon of 
the flexor longus pollicis muscle can be most conveniently reached by intro- 
ducing the tenotome one inch behind the metatarso-phalangeal articulation. 
By forcibly extending the toe at the time, the tendon can be felt. It should 
be divided from behind forward, or towards the surface of the sole,—a 
precaution which will enable the operator to avoid the plantar arch. 
Fig. 1993. 
Recurved toes. 
Hypertrophy of the Toes.—A congenital enlargement of the toes, which 
may also include the feet and legs, is occasionally met. The bulk of the hy- 
pertrophied part is made up of adipose and fibrous tissue, with an abundant 
serosity. Should the disease increase to such a degree as seriously to impair 
the usefulness of the part, the only remedy is amputation. 368 
MALFORMATIONS AND DEFORMITIES. 
Congenital Absence of the upper extremity is occasionally seen. In some 
of these cases, rudimental fingers crop out from a fleshy prominence answer- 
ing to the shoulder. Persons born without arms and who are able, by their 
toes, to perform most of the offices of the hand, are frequently exhibited by 
showmen. 
Deformities of the Upper Extremity. 
Rachitic Curvatures of the upper extremities are never so strongly marked 
as those of the lower limbs, though it will be equally proper in a constitu- 
tional affection of this kind to counteract, as much as possible, any deviation 
from the normal curves belonging to the osseous framework of the limbs. 
This can be measurably attained by frequently repeated force, without re- 
sorting to apparatus. 
Paralysis and Spasm.—The upper extremity, like the lower, is liable to 
suffer from various contractions, the result of paralyzed or of rigid muscles. 
These difficulties often arise from cerebro-spinal disease occurring during in- 
fancy or early childhood. The treatment must be based on the same general 
principles as those which govern the surgeon in the use of mechanical and op- 
erative means for similar deformities of the lower extremity. Unfortunately, 
in many cases treatment falls far short of that which one would desire. 
Frequently more good will be effected by persistent manipulation than by 
any other procedure. In rigid flexion of the forearm from spastic contrac- 
tion, which cannot be overcome by an anterior screw splint, the tendon of 
the flexor biceps muscle may be divided. In operating, the tenotome should 
be introduced on the inside of the tendon, in order that the brachial artery, 
which lies on the same side, shall not be wounded. The division should be made 
from behind forward, the arm afterwards being placed on an anterior splint 
with a joint and screw, the angle of which can be changed from a right to 
an obtuse angle. The splint is to be worn until the gap between the divided 
ends of the tendon has been intercalated by a new formation of fibrous tissue. 
Deformities from anchylosis following frac- 
tures of the elbow-joint are treated of under 
fractures at the lower end of the humerus. 
(Yol. i. p. 895.) 
Fig. 1994. 
Club-Hand is frequently associated with 
club-feet. (Fig. 1994.) It is both con- 
genital and acquired, and may affect one 
or both hands. The hands are usually 
flexed on the forearm, the fingers strongly 
flexed by an attempt to extend the carpus. 
The deformity is due to paralysis of the 
extensors; to spastic contraction of the 
flexors; to nerve-irritation from pressure 
of a tumor, or of a foreign body, such as a 
bullet or a spicule of bone; to burns; and 
to sloughing brought about by the cai’eless 
use of splints in the treatment of fractures 
of the bones of the forearm. 
Treatment.—When following paralysis 
of the extensor muscles, a substitute for 
the latter can be supplied by the apparatus 
of Kolbe (Figs. 1995, 1996), applied either 
to the dorsal or the palmar aspect of the 
hand and forearm. 
When rigid muscles are concerned in producing the deformity, and the 
latter cannot be overcome by stretching, manipulation, and the anterior 
Club-hand. DEFORMITIES OF THE UPPER EXTREMITIES. 
369 
splint, tenotomy will be indicated. The tendons which require division in 
such cases are generally those of the palmaris longus, flexor carpi ulnaris, 
and flexor carpi radialis muscles. 
Cases of club-hand following nerve-irritation, whether from tumors, bullets, 
Fig. 1995. 
Fig. 1996. 
Kolbe’s modifications of Duclienne’s and Delacraux’s apparatus for paralysis of the 
extensor muscles of the hand. 
or bone, can be successfully remedied only by the removal of the offending 
body. 
When the deformity arises from burns or scalds, a cure can often be ac- 
complished by excising the cicatrix and replacing the diseased with sound 
tissue, taken from either an adjoining 
or a distant part. In the case of a 
negro whose hand, in consequence 
of a scald, had become strongly flexed 
and tied to the anterior surface of 
the arm, I succeeded in restoring 
Fig. 1998. 
Fig. 1997. 
Hand fastened to the arm from a scald, and 
strongly flexed. 
Appearance of the parts after recovery. 
the member to its normal position and usefulness, after removing an exten- 
sive surface of cicatricial tissue, by raising a large flap of integument from 
the front of the abdomen of the patient and stitching it to the wound in 
the arm, keeping the latter securely bound to his body by adhesive strips 
and roller bandages until the union was sufficiently advanced to justify the 
detachment of the pedicle of the flap and the connection of the latter to 
the freshened margin of the gap in the arm. (Figs. 1997, 1998.) 370 
MALFORMATIONS AND DEFORMITIES. 
The most hopeless deformities of the hand are those resulting trom slough- 
ing following the pressure of splints used in the treatment of fractures of the 
radius and ulna. Cases of this nature occasionally appear at our clinics. 
They are very unfortunate accidents, both for the patient and for the sur- 
geon ; for the former, inasmuch as they are seldom susceptible of correction, 
and for the latter, since they indicate carelessness or ignorance, either of 
which proves his unfitness for a responsible profession like that of surgery. 
The morbid changes which follow an accident of the above nature extend, 
according to my observation, deeper than the integument of the arm, in- 
volving the deep fascia, the intermuscular fasciae, and even the connective 
tissue of the muscles. Long-continued bathing or hot fomentations of the 
arm, followed by friction, kneading, and stretching of the muscles, will to 
some extent overcome the deformity, by favoring the absorption of inflam- 
matory deposits; yet the relief will lall far short of overcoming the disability. 
Manual and Digital Irregularities.—Examples of a supernumerary hand 
and of absence of the hand have been observed in a few instances. Mr. 
Murray and M. Giraldes each record a case of supernumerary hand. 
Polydactylism.—Supernumerary fingers are not common. Instances of 
seven, of nine, and in one case, that given by Yoight, of thirteen fingers 
on a single hand, have been recorded. The most common irregularity 
of the kind is an additional thumb (Fig. 1999) or little finger; sometimes 
Fig. 1999. 
Fig. 2000. 
Supernumerary thumb. 
Case of supernumerary and normal thumbs united. 
both occur on the same hand. Occasionally, similar irregularities of the 
fingers and toes are observed in the same person. The same difference in 
shape exists in supernumerary fingers as in toes; that is, they may rival in 
perfection of development the true digits, or they may be stumpy or fleshy, 
shapeless projections, having either a broad or pedunculated connection with 
the hand. Their attachment is usually over or near the metacarpo-phalan- 
geal joints of the thumb or the little finger. Rarely do we find eases in which 
the supernumerary digit, either of the hand or of the foot, is attached to a 
separate metacarpal or metatarsal bone. Among these irregularities a bifid 
metacarpal or metatarsal bone has been seen, each fork supporting a digit. 
When the normal and the supernumerary thumb have a common articula- 
tion with the metacarpal bone, or when they are close together, and neither 
is strong or well developed, it may be desirable, instead of sacrificing the 
weaker digit, to freshen their contiguous surfaces and unite the two in one, 
as was ingeniously done by Dr. W. B. Hopkins in a patient at the Episcopal 
Hospital of Philadelphia, with the result of giving the boy a strong, useful 
thumb. (Fig. 2000.) DEFORMITIES OF THE UPPER EXTREMITIES. 
371 
Absence of fingers is also among the curious freaks of nature. It is rare 
to meet with cases where all the digits are wanting, though many examples 
of the absence of one or two fingers are recorded by medical writers. 
As supernumerary fingers can only prove an incumbrance when the 
child grows older, they should be removed early. The only precautions 
necessary to be observed are to reserve sufficient flap to cover the wound 
and to be sure to leave no part of the member. The exceptions to this 
latter rule are those cases in which the joints of the two fingers commu- 
nicate: it will then be better to leave a small portion of the supernumerary 
phalanx, when the stump can be covered in by the flaps and be allowed to 
atrophy. 
The congenital absence of a finger will scarcely be noticed, and requires 
no prosthetic substitute. When a greater number are wanting, tho mecha- 
nician can supply the defect with artificial digits, which, if not practically 
useful, answer, with the addition of a glove, for purposes of appearance. A 
late very prominent physician of Philadelphia whose memory I cherish with 
great affection, and who in early life had lost a considerable portion of his 
hand, wore an artificial member, the presence of which many of his profes- 
sional brethren never suspected. 
Webbed Fingers are by no means uncommon. The deformity is often 
hereditary. In one of my own cases this peculiar condition had been trans- 
mitted through, I think, three generations, appearing always in the female 
children of female progenitors. The cutaneous w'eb occurs usually on both 
hands, affecting two or more fingers. (Fig. 2001.) 
In my own experience, the middle and ring fingers 
have most frequently been the ones united; the 
little and ring fingers come next in frequency. The 
same deformity will often be met with both in the 
fingers and the toes of the same person. 
Treatment.—Should the band extend only a little 
farther forward than the natural position of the 
interdigital cleft, nothing will be gained by an oper- 
ation ; but where the web unites the digits to a con- 
siderable extent, the usefulness of the fingers will 
be somewhat impaired, and the case will demand 
surgical interference. The last case of this kind 
which came under my care was an adult, who, 
though embarrassed in many of the manipulations 
of his hands, had endured the physical inconvenience until it could no longer 
be borne. 
Several operations have been devised for the cure of webbed fingers. One 
plan consists in pushing a sharp-pointed bistoury through the band at its 
base and dividing it forward to its free border. The edges of the wound are 
then stitched together along each side, and a pledget of lint placed in the 
interdigital cleft. An objection to this operation arises from the fact that 
unless the integuments can be united at the apex of the cleft the cicatrization 
will advance and the web be reformed. 
Another method is that in which an opening is made through the base of 
tbe web and maintained patulous until cicatrization is completed, after which 
the band is divided in its whole length and the edges on each side approx- 
imated by sutures. 
M. Giraldes describes a mode of treatment in which the web is divided by 
means of compression, an instrument being used for the purpose not unlike 
the enterotome of Dupuytren, the blades of which, after embracing the band, 
are gradually tightened until the latter is destroyed. 
The plan which I adopt, and which proves entirely satisfactory, is the 
following. A V-shaped flap is cut from the dorsal surface of tho base of the 
web, the apex anterior. (Fig. 2002.) The flap, which extends through one- 
Fig. 2001. 
Webbed fingers. 372 
MALFORMATIONS AND DEFORMITIES. 
half the thickness of the band, is next dissected back and the remaining 
portion of the web slit longitudinally. The reflected flap is then drawn 
through the cleft at the base of the fingers, its apex stitched to the palmar 
surface of the wound, and its sides to the adjoining sides of the fingers (Fig. 
2003), at the same time closing the edges of the wound on each side of the 
Fig. 2002. 
Fig. 2003. 
Form of incision for webbed fingers. 
Dorsal flap brought through between 
the Angers and stretched on the palmar 
side; also, wound closed on the op- 
posing side of the fingers. 
fingers with sutures, keeping a strip of oiled lint between the fingers, and 
supporting the hand on a palmar splint. 
Hypertrophy of the Fingers.—Hypertrophy of one or more fingers is an- 
other congenital deformity. It is one which, from the functions of the hand, 
is likely to cause, in the event of the growth becoming large, much incon- 
venience in executing various prehensile movements. As in hypertrophy of 
the toes and foot, this enlargement resides, like so many of the congenital 
tumors observed elsewhere, in the cellular and adipose tissues, both of which 
elements are increased. The deformity from congenital hypertrophy of the 
fingers and hand is sometimes greatly magnified by large and irregular 
localized depositions of fat and connective tissue seated on different portions 
of the growth. There is an acquired hypertrophy of these parts, involving, 
it may be, tbe limbs themselves. It depends on an altogether different 
cause, being due to a long-continued plastic transudation into the tissues, 
due to venous obstruction, or to disease of the blood-vessels. 
Treatment.—The course of the surgeon in dealing with the forms of hy- 
pertrophy under consideration must be guided by the circumstances of indi- 
vidual cases. Under gradually-increased pressure made by roller bandages, 
aided by water-irrigation, some improvement is possible, particularly in 
cases of acquired hypertrophy ; and in such cases the experiment may very 
properly be tried. If the malformation is bilateral, and includes all the 
digits, amputation should be declined as long as the functions of the hands 
can be performed, even imperfectly. When the hypertrophy is unilateral or 
asymmetrical and involves several of the digits, the question of operation 
must hinge on the utility or uselessness of the members involved. Where, 
however, a single finger is the subject of a conspicuous hypertrophy, which 
grows with the growth of the child, early amputation will be a proper 
surgical procedure. 
Contraction of the Fingers.—Contraction, or, more properly speaking, 
flexion, of the thumb and fingers of the hand, arises from various causes: 
contusions, punctured wounds, palmar abscesses, and burns are among those 
of a strictly local character, while those of a constitutional nature are rheuma- CONTRACTION OF THE FINGERS. 
tism and gout. The immediate cause is twofold : the flexion of the fingers 
is either due to contraction of the flexor muscles, or it arises from contraction 
of the palmar fascia. The two deformities are often confounded,—a mistake 
of some importance, inasmuch as the contraction resulting from the muscles 
and tendons is often not amenable to treatment, while that arising from the 
disorder of the fascia can generally be corrected. 
That form of finger-flexion which begins after middle life, affecting most 
frequently the little and ring digits, and progressing in a slow, painless man- 
ner, has attracted no small degree of professional interest. A case of this 
kind is characterized by certain phenomena which follow one another with 
considerable regularity. A little hard knot will be felt in the palm of the 
hand in the line of one of the fingers, probably, when first discovered, not 
larger than a small grain of shot. It is often situated over the most anterior 
of the three creases which cross the hand. In a short time it will be ob- 
served that the extension cannot be completely made. Up to this period 
the skin on the palm of the hand and over the seat of induration remains 
unchanged. A little later, as the flexion of the finger increases, a dense 
longitudinal band or cord can be discovered under the integuments, notably 
distinct when the affected digit is forcibly extended, and capable at this time 
of elevating somewhat the superincumbent tissues, to which the latter is now 
becoming attached. The subcutaneous cord or band is the palmar fascia, 
and as this structure sends off from each of its four primary divisions two 
processes which embrace and become attached to the sides of the proximal 
phalanges, the flexion of the finger is chiefly through traction made on the 
first phalanx by shortened fascia, altogether independent of the tendons. 
As the thickening and contraction of the palmar fascia progress, it becomes 
more extensively attached to the skin, which assumes a puckered appearance 
and is thrown up into longitudinal ridges. (Fig. 2004.) The morbid process 
continues until at length 
the palmar surface of 
the last phalanx of the 
flexed finger may come 
in contact with the palm 
of the hand. Dupuy- 
tren was the first to de- 
monstrate the true pa- 
thology of this affection 
by the dissection of a 
hand in which the de- 
formity existed, and 
which he was fortunate 
enough to obtain ; from 
which circumstance the 
deformity often passes 
under the name of “ Du- 
puytren’s contraction of 
the finger.” A similar 
dissection was made by 
Goyrand, with a like 
result, both going to 
show that the digital flexion was due to contraction and thickening of the 
palmar fascia, and that the flexor tendons were not at fault. (Fig. 2005.) 
Various causes have been adduced by writers in order to explain this 
finger-flexion, most of them of a local character, as pressure from the head 
of a walking-cane or the handling of bard, rough bodies. Mr. Paget, Mr. 
Adams, and others believe in the gouty origin of the contraction; and that 
this constitutional condition, in many instances, is the cause of the disease, 
there can be little doubt, though I am not disposed wholly to ignore the 
influence of local agencies. It is true that the affection is uncommon 
373 
Fig. 2004. 
Fig. 2005. 
Flexed ring and little fingers. 
Dissection showing the hands of 
contracted fascia. 374 
MALFORMATIONS AND DEFORMITIES. 
among mechanics and common laborers, whose hands are necessarily ex- 
posed, from the nature of their occupations, to rude and violent pressure. 
The persons who are most commonly subjects of the contraction are those 
in the higher walks of life. Twice I have seen the contraction follow a slight 
wound in the palm of the hand, and once in a gentleman who spent many 
hours every day in writing, and in whom the flexion involved the little and 
ring fingers, those which in using the pen are generally maintained in the 
flexed state. In these three cases there was not a suspicion of a gouty 
diathesis, based either on antecedent or on personal history. In others, the 
existence of a constitutional rheumatic condition seemed to have been the 
fountain and origin of the disease. Twice I have seen the deformity in 
women, who aro said by some writers never to be the subjects of this con- 
traction. Dr. Carter Lemmington reports 2 cases of the deformity in 
women, Mr. Reeves gives 5 cases, Mr. South ham 2 cases, and Mr. Berry, of 
Manchester, 1 case. 
In all cases, arising from whatever cause, the structural changes produced 
cannot be satisfactorily accounted for independently of a chronic inflamma- 
tion. 
Diagnosis.—As there are flexions of the fingers dependent on structural 
changes altogether independent of the palmar fascia, for example, contrac- 
tion of the flexor tendons, it is important to be able to distinguish between 
the two. 
The following considerations, I think, will sufficiently differentiate the two 
kinds of flexion: 
FINGER-FLEXION FROM CONTRACTED 
PALMAR FASCIA. 
FINGER-FLEXION FROM CONTRACTION 
OF THE FLEXOR MUSCLES. 
Rarely seen before fifty-five years of age. 
Rarely any history of injury or previous dis- 
ease. 
Local induration felt in the palm of the hand. 
No sign of inflammation, and painless. 
Integument of palm in ridges longitudinally. 
Flexion primarily limited to the first phalanx 
of the finger. 
May occur at any period of life. 
Frequently a history of injury or of previous 
disease. 
Nothing unusual felt or seen on the surface of 
the palm. 
Antecedent history of inflammation common, 
and pain often severe and throbbing. 
No ridging. 
Flexion of two or more of the phalanges. 
Treatment.—In all deep inflammations of the palm of the hand, that is, 
in all inflammations located under the deep fascia, whether primarily com- 
mencing there or extending from the theca of a finger, and followed by sup- 
puration, no time should be lost in opening a way for the escape of the pus 
by a free incision, made with the precautions directed under the surgical 
anatomy of the hand. (See vol. i. p. 384.) In punctured wounds of the palm 
of the hand followed by inflammatory tension, the more speedily the injury 
is converted into an incised wound the better. A practice based on the 
above principles would, if faithfully adhered to, prevent many of those dis- 
tortions of the fingers and hands wTiich are seen at clinics. 
When curved and rigid fingers are due to previous inflammation of the 
sheaths of the flexor tendons, an effort should be made to disrupt the adhe- 
sions and to straighten the digits by soaking the hand in hot water, or en- 
veloping it during the night in a hot flaxseed-meal poultice, followed in the 
morning by a thorough kneading and stretching of the parts. The surgeon 
should preserve the amount of extension gained at each successive manipula- 
tion, however small, by adjusting to the palmar surface of the hand a splint 
with a convex block at the end, over which the fingers may rest, the convexity 
of which should lessen as improvement progresses. When these measures 
fail and the digits can be released only by tenotomy, the propriety of the 
operation must be determined by the number of the fingers which are flexed. 
If two or three are contracted, nothing will be gained by an operation. The LOCK-FINGER. 
375 
retraction of the tendons after division will be so great that the intermediate 
chasm will never be filled, and the fingers will remain useless, perhaps more 
so than before the operation. When a single finger is flexed, accompanied 
with malposition, the result of contraction of its superficial flexor muscle, the 
insertion of which is upon the second phalanx, the tendon may be severed at 
the root of the finger, as the lumbricales and the tendon of the deep flexor 
muscle remain, by which the power to flex the finger will still be preserved. 
It may be asked, How can it be known that the superficial flexor tendon is 
the contracted one ? This may be ascertained by attempting to extend the 
finger, and while so doing, if the last phalanx of the finger can be flexed and 
extended while the other two remain rigid, the inference is in favor of the 
tendon of the superficial flexor being the one at fault. In a young man who 
labored under a deformity of this kind, I effected considerable improvement 
by pursuing the course above directed. In cases where the middle or ring 
finger is the contracted digit, the deformity being primarily seated in the 
tendons, it will be proper, on account of its position in the digital series, 
and the great resulting inconvenience, to amputate at the metacarpo-phalan- 
geal joint. 
When the contraction of the fingers can be traced to the presence of a 
foreign body in the muscles of the forearm, as a pin, a needle, shot, or ball, 
relief can be obtained only by the removal of the exciting cause,—a necessity 
so urgent as to justify a prolonged and extensive search, guided by the 
best light which can be obtained from anatomical and physiological knowd- 
edge. 
Contractions of the fingers following burns, when the cicatrix is superficial 
and not extensive, occasionally admit of improvement by dissecting out the 
diseased tissue and replacing it with healthy tissue. 
Flexion of the fingers due to thickening and contraction of the palmar 
fascia, at one time deemed hopeless, admits of correction by subcutaneous 
division of the shortened bands,— a method for which the profession is 
indebted to Mr. Adams. Division of the fascia by open wound was prac- 
ticed by Dupuytren in France, by Taniplin and other surgeons in Great 
Britain, and by Post in this country, before subcutaneous tenotomy had 
become known. 
The method of Mr. Adams consists in introducing a small tenotome between 
the skin and the contracted band of fascia, and dividing the latter cautiously 
from above downward. That portion of the cord which is farthest removed 
from the finger, that is to say, towards the wrist, is divided first; division 
is then made near the root of the finger; and, finally, the lateral slips of the 
fascia, which lie astride of tho carpal extremity of the proximal phalanx, 
are divided by a third and a fourth puncture, taking care in these last 
cuts not to injure the digital arteries and nerves, which divide at the inter- 
digital clefts. If more than one finger is affected, the second should be the 
subject of a subsequent operation after the first has healed. On completing 
the incisions, the finger should be immediately straightened and kept in the 
extended position by means of a palmar splint, well padded, and fastened in 
place with a bandage. 
Lock-Finger.—A peculiar and very uncommon affection of the fingers 
I have designated as lock-finger, in consequence of the sudden manner in 
which a finger from enjoying perfect freedom of motion may become fixed 
in a flexed position. The middle and ring fingers are those most frequently 
affected in the digital series. The explanation of the “lock” is an anatomical 
one, and will readily be understood by recalling the arrangement of struc- 
tures in the palm of the hand, opposite to the metacarpo-phalangeal articu- 
lations. At the point named, the palmar fascia sends off its digital processes, 
which divide, one band going to each side of the first phalanges. Between 
the bifurcations of these fascial prolongations and the commencement of the 
sheaths of the flexor tendons is an interval occupied only by the tendon and its 376 
MALFORMATIONS AND DEFORMITIES. 
delicate investing synovial membrano. If there should exist a small fibroma 
formed from the little processes or fringes 
which normally belong to the synovial 
membrane, it is liable, during extension 
of the finger, to be carried out, along with 
the tendon to which the new formation 
is attached, beyond the apex of the digi- 
tal processes of the palmar fascia, and, 
meeting with no resistance, it rises up 
between the latter and the sheath of 
the tendon, so that when an attempt is 
made to flex or to extend the finger the 
movement is arrested at semiflexion, and 
the finger is locked. (Fig. 2006.) 
Treatment.—The lock is removed 
and the digit released by pressing the 
little body, which generally can be felt, 
directly back, at the same time either 
flexing or extending the finger. In one 
case, that of a young woman, who was 
admitted into the University Hospital, 
the disability recurred so often that I 
removed the little growth through an incision,—the proper course to be 
adopted when the interruption to the use of the finger becomes frequent. 
Fig. 2000. 
A, digital divisions of the palmar fascia; B, sheath 
of the flexor tendon; C, the interspace marked black, 
and showing where the fibrous body escapes. 
Tortic ollis—W ry-N eck. 
Torticollis is a distortion of the neck, in which the back of the head is 
drawn to one side, the face being turned in an opposite and somewhat upward 
direction. The neck on the affected side is concave and shortened, and on 
the opposite sido correspondingly convex and elongated. In well-pronounced 
cases the head is so lateralized and rotated that the occiput approaches the 
shoulder, the face is turned upward and backward, so that the eyes of the 
patient look in the direction of the 
shoulder of the sound side, and the 
neck on the affected side is buried 
out of sight. (Fig. 2007.) The expres- 
sion of the face, owing to the droop- 
ing of the eyelids, a slight depression 
of the lower corner of the mouth, and 
the greater fullness of the face on the 
affected side, is quite peculiar, and, 
taken in connection with the constrained 
movements enforced by the immovable 
state of the head (requiring the patient, 
when looking at objects not directly 
before the eyes, to turn the whole body 
instead of the head), this peculiar facial 
expression renders it impossible not to 
recognize the nature of the affection. 
Wry-neck is both congenital and ac- 
quired, the latter variety being more 
common than the former. In my own 
experience the affection occurs with 
nearly equal frequency in the two 
sexes. The muscles involved in the dis- 
tortion are the sterno-cleido-mastoid, the scaleni, the splenius, the trapezius, 
and, rarely, the complexus. In some cases the first-named muscle is the only 
one involved; and in all cases, whatever the number of muscles associated 
Fig. 2007. 
Wry-neck. WRY-NECK. 
377 
with it in producing the distortion, the sterno-cleido-mastoid, particularly its 
sternal half, is most prominently concerned. The deep fascia of the neck in 
old cases of torticollis is also shortened, and sometimes thickened on the 
affected side. When the head is forcibly straightened and carried over to- 
wards the sound side, a rigid cord, the sterno-cleido-mastoid muscle, will be 
seen running diagonally across the neck from the sterno-clavicular region— 
where it commences in two distinct portions, one round, the other flat—to 
the mastoid part of the temporal bone. A second ridge, the trapezius muscle, 
can also be traced at the latero-posterior line of the neck, extending from the 
clavicle to the occiput. 
The constant traction to which the sternum and clavicle are subjected 
causes in time a change in the shape of these bones. At the seat of muscu- 
lar attachment they become inordinately developed in an upward direction. 
A change in the form of the cervical division of the spino ma}r also be de- 
tected,—the column being concave, with the transverse processes crowded 
together on the affected side, and with a compensating curve below in the op- 
posite direction. The affected sterno-cleido-mastoid muscle undergoes fibrous 
degeneration, becoming hard and unyielding; and to these changes may be 
added an as}rmmetrical development of the two halves of the face, that of 
the affected or uppermost half not keeping pace in growth with the other,— 
a result, I think, due in some measure to gravitation, a larger amount of blood 
being thereby supplied to the more dependent side. 
Causes.—The causes of torticollis are central, peripheral, or traumatic. 
Central torticollis, like spastic and paralytic club-foot, has its essential seat 
in the brain or the spinal cord. Peripheral Avry-neck arises from inflam- 
matory states of the bones, ligaments, or muscles of the neck, such as are 
known to accompany rheumatism and scrofula. The traumatic variety is 
caused by scalds, blows, or twists of the neck. 
All central causes act upon the sterno-cleido-mastoid muscle through the 
spinal accessory nerve, a nerve which is also distributed to the trapezius 
muscle. The deeper muscles, which play a subordinate part in some cases 
of wry-neck, though they receive their nerve-supply from the cervical 
branches of the spinal nerves, are nevertheless brought into sympathy with 
the sterno-cleido-mastoid through the four communicating branches which 
unite the spinal accessory with the cervical nerves. 
Some cases of wry-neck ascribed to congenital origin, because noticed im- 
mediately after birth, should with more propriety be classified as traumatic, 
the distortion being the result of violence experienced during delivery, from 
the use of the forceps or in “turning.” 
Acquired as well as congenital torticollis may originate from cerebro-spinal 
irritation. Like strabismus, it sometimes follows a convulsion caused by 
an inflamed gum; or it may come on in the child stealthily after recovery 
from an attack of illness in Avhich head-symptoms were prominent. The 
reprehensible habit of lifting children by tlio head and allowing them to 
struggle, may likewise cause the affection. Contraction of the sterno-cleido- 
mastoid causing torticollis is sometimes complicated by chorea of the same 
muscle; and in this event the case is peculiarly rebellious to treatment. 
Treatment.—The treatment of torticollis must be governed by the patho- 
logical conditions which are concerned in causing the distortion. When it 
arises from rheumatic disease, a condition which can generally be diagnosed 
by the local soreness, aggravated by every movement of the head, or by the 
coexistence of rheumatic symptoms elsewhere, and marked perhaps by some 
attendant constitutional disturbance, little more will be required than to 
administer a gentle purge, followed by some alkaline remedy, such as nitrate 
or acetate of potash, or, what in some instances acts with greater promptness, 
salicylate of soda. These general remedies may be accompanied with the 
local application of anodyne liniments, frictions, and warmth. When the 
soreness and pain are great, the hypodermic use of atropia will give im- 
mediate and, in some instances, permanent relief. When wry-neck remains 378 
MALFORMATIONS AND DEFORMITIES. 
after the acute symptoms which have given rise to the deformity disappear, 
as sometimes occurs in inflammation of the deep parts in the back of the 
neck following violence or after deep abscesses in the same region, the 
distortion depends on adhesions between the muscles. A case of this nature 
can be identified by the antecedent history and by the absence in a great 
measure of the ordinary hard contraction of the sterno-cleido-mastoid muscle. 
The rectification of the deformity can bo effected only by frictions, stretchings, 
and kneadings, followed, if necessary, by forcible straightening of the neck 
while the patient is under the influence of ether. In the case of a little girl, 
eight years old, brought to me from the South, in whom the distortion was 
very prominent, I succeeded, after administering an anaesthetic, in breaking 
up the adhesions and restoring the head to its place at a single sitting. 
In typical forms of torticollis, those, for example, arising from cerebro- 
spinal irritation, constitutional and local remedies can be of no possible value. 
The knife alone, followed by orthopaedic apparatus, can release the patient 
from the infirmity. The clavicular and sternal portions of the sterno-cleido- 
mastoid muscle should be severed near their origins, and the head, after 
being straightened, must be kept in the proper position by the apparatus 
represented in Figs. 2008, 2009, or, if such a mechanism is not attainable, 
Fig 2008. 
Fig. 2009. 
Apparatus for wry-neck. 
Apparatus applied. 
recourse may bo had to a tightly-fitting night-cap, with a piece of muslin, 
broad in the centre and tapering towards the ends, sewed to it. This cap 
is placed on the head of the child immediately after the operation, with the 
muslin strip securely sewed to the side answering to that of the contraction. 
The head being brought straight, the bands or loose ends of the muslin strip 
are crossed over the opposite shoulder and carried down along the sides 
of the chest, where they are made fast either by a circular roller or by 
adhesive straps, or by both. After six or seven dayk it will contribute to the 
perfection of the cure to begin a daily course of manipulation by rubbing and 
stretching the muscles. To do this properly, it is necessary that an assistant 
fix the shoulder, while the surgeon turns the chin to the sound side and drags TENOTOMY OF THE STERNO-MASTOID MUSCLE. 
the head well over in the same direction. It will not be well to dispense with 
the apparatus until after the lapse of six or seven weeks. 
Paralytic cases of wry-neck (those, for example, which, so far as can he 
ascertained, appear to depend on injury of the muscles of the neck, hut not of 
the sterno-cleido-mastoid alone) can be distinguished by the manner in which 
the head topples over to one side. These cases require time and care. It 
will prove advantageous to keep the head properly supported on a pillow be- 
tween two small sand-bags. Frictions with stimulating liniments and very 
gentle use of electro-galvanism will aid in recalling the lost muscular power. 
If these fail after the child is old enough to sit up, and restoration does not 
occur, our only resource will be a mechanical support. 
Wry-neck from muscular atony is frequently met with in young children 
who are deficient in constitutional vigor. It is particularly noticeable when 
the child is fatigued, the head dropping over to one side. The remedies are 
massage, good food, fresh air, and general bathing. 
Choreic torticollis is not benefited by tenotomy. In the case of a young 
man who was a great sufferer from spasmodic or choreic contractions of the 
sterno-cleido-mastoid muscle, I succeeded in almost completely curing his dis- 
ease, after failing with bromide of potassium, Fowler’s solution of arsenic, and 
sea-bathing, by repeated cauterizations on the back of the neck with the hot 
iron. Encouraging success in this form of wry-neck has followed excision 
of a portion of the spinal accessory nerve: cases of successful operation have 
been given by De Morgan, Eivington, and Annandale. Nerve-stretching has 
also been practiced for the cure of spasmodic torticollis: two successful cases 
have been reported by Hausen. 
Wry-neck due to caries of the cervical vertebrae will reveal its true nature 
by the great reluctance on the part of the patient to move the head or to 
have it moved ; by the feeling of deep-seated pain or uneasiness, and sometimes 
by dysphagia, with the coexistence of characteristic strumous indications 
in other parts of the body. The disease is often attended by deformity of 
the neck and by post-pharyngeal abscess. In cases of this kind forcible 
stretching or other manipulations are not to he thought of. The recumbent 
position must be enforced in the very young, and, when the patient is able 
to walk, the head must be supported by a suspension apparatus affixed to 
the ordinary leather spinal jacket. 
Posterior Torticollis, or Spasmodic Extension of the Head. 
Another deformity, due to spasmodic contraction of the muscles of the 
back of the neck, is that in which the head is drawn directly backward, the 
occiput touching the vertebra prominens, and the face directed upward. The 
head, in addition, is sometimes turned to one side or the other. The deform- 
ity may be temporary in its duration, or it may remain permanently. While 
it is the result of central irritation, it is not unfrequently a purely hysterical 
condition, attacking women whose nervous systems have been disturbed by 
fatigue, care, or bad health. 
The remedies are the hot iron applied to the nucha, antispasmodics, tonics, 
the shower-bath, and forcible flexion under anaesthetics, as practiced by M. 
Delore, and keeping the head forward by proper bandages. The most con- 
venient arrangement is a night-cap with a broad muslin strip sewed to that 
part of the head-gear which is over the occipital protuberance, the ends of 
the aforesaid strip being fastened to a circular bandage about the chest. 
Plaster-of-Paris rollers can bo substituted for the muslin ones directed to 
be used over the cap and around the thorax. 
In dividing subcutaneously the tendinous and muscular portions of the 
sterno-cleido-mastoid muscle near their origins, the tenotome, after the 
Tenotomy of the Sterno-Mastoid Muscle. 380 
MALFORMATIONS AND DEFORMITIES. 
patient has been etherized, should be introduced flatwise a little distance 
anterior to the inner edge of the muscle, and then passed onwards beneath 
its deep surface. The edge of the knife is next to be turned against the 
tendon in such a way that the sternal portion of the latter is divided 
from behind forward. The surgeon should impart to the tenotome a slight 
sawing movement, the head at the same time being extended. The com- 
pletion of the section will be announced by a distinct sound, followed by 
a marked retraction of the muscle, with some external bulging of the over- 
lying integument. Should the tension not bo entirely relieved, the clavic- 
ular portion of the muscle must be severed by re-entering the knife through 
the original puncture, passing it beneath the muscle, and cutting, as in 
the first instance, from behind forward. (Fig. 2010.) When the clavicular 
origin of the muscle is very broad, 
it will bo better, instead of ap- 
proaching it from so remote a 
point as the opening made in cut- 
ting the sternal portion, to make 
a second puncture at the posterior 
border. The proper place to divide 
the muscio is about half an inch 
above its origin. No vessels of any 
importance are likely to be injured 
in the operation if the knife is kept 
in close contact with the deep sur- 
face of the muscle. The surgeon 
should, before making the anterior 
puncture, ascertain if the anterior 
jugular vein is present; if it is, 
it will be found lying along the 
anterior border of the muscle, and 
may be avoided either by pass- 
ing the point of the tenotome be- 
tween the vessel and the edge of 
the muscle, or, if the contiguity is 
too close to allow of this being 
done, by entering tho knife anterior to the vein. After completing the section 
of the muscle and withdrawing the knife in the same position in which it 
was introduced, a finger should command the orifice of the little wound in 
the integuments until it is covered by a strip of adhesive plaster. 
Fio. 2010. 
Tenotomy of the sterno-nmstoid muscle. 
Dividing or Stretching the Spinal Accessory Nerve. 
In order to expose the spinal accessory nerve for the purpose of stretching, 
or for excision of a portion of its trunk in the neck, an incision must be 
made three inches in length along the posterior border of the sterno-cleido- 
mastoid muscle. The middle of the cut should be half an inch above the 
middle of the muscle. The skin, superficial fascia, and deep fascia being 
divided, the fibres of muscle will be brought into view. At this stage of the 
operation the head should be flexed and slightly turned to the side being 
operated on, when, by the use of the handle of the scalpel, the director, and 
the finger, the muscle can be separated from its deep attachment and turned 
towards the median line of the neck, exposing the nerve where it enters its 
substance. The nerve can then be raised upon a blunt hook, and dealt wuth 
according to the wish of the surgeon, partial excision being in every way 
the preferable operation. CHAPTER XXXII. 
AFFECTIONS OF THE MUSCLES, TENDONS, BURS.E, AND 
APONEUROSES. 
Muscles. 
The living muscle possesses in health more power than the tendons to 
resist a tensile strain, but after death the latter are the stronger. This 
difference is, no doubt, due to the fact that fibrous or tendinous tissue after 
death resists the destructive processes of decomposition longer than muscular 
tissue, and that during life the function of the muscles under the stimulus 
of the will is a vital one, while that of the tendons is only mechanical or 
passive. Thus we often find in the dissecting-room that some of the muscles 
have been torn during the process of straightening the rigid limbs of the 
cadaver, but never the tendons. 
During the reign of Louis XV. of France, a man by the name of Damiens, 
who had attempted to assassinate the king, was condemned to death by being 
drawn asunder. When the sentence was carried into effect, notwithstanding 
four horses were hitched to his limbs, so powerful was the resistance offered 
by the muscles that the executioner was compelled to cut large gashes in 
the arms and thighs before the horrible dismemberment was accomplished. 
The muscles are subject to various injuries, such as wounds, contusions, 
pareses, and luxations, to changes in their nutrition, such as hypertrophy 
and atrophy, and to degenerations of different kinds, such as the fatty, the 
granular, the waxy or vitreous, the pseudo-hypertrophic, and the ossific. 
Wounds.—Wounds of the muscles may be classed as incised, contused, 
lacerated, punctured, and gunshot wounds. They may also bo divided into 
open and closetl wounds, according as the skin is broken or unbroken,—a 
division not unlike that of fractures into simple and compound. 
Incised Wounds of muscles are those made with a sharp instrument, and are 
followed by retraction, hemorrhage, and pain. The degree of retraction or 
gaping will be determined by a number of circumstances: 1, by the direction 
of the incision, the gaping being always greater when the cut is transverse 
to the course of the muscular fibres; thus,#a wound across the front of the 
thigh will gape very much more than one made in the long axis of the limb; 
2, by the surrounding fascial attachment of the muscle, the gaping being 
less, for example, in wounds of the muscles of the forearm than in those of 
the upper arm; 3, by the length of the muscle, the flexor biceps eubiti and 
the hamstring muscles retracting (when incised transversely) far more than 
those on the front of the leg; 4, by the class to which the muscle belongs, 
retraction being greater in the voluntary muscles than in the involuntary,— 
a wound of the soft palate, for example, gaping less than one of the occipito- 
frontalis muscle; 5, by structural peculiarities, as when intermingled with 
the muscular there is much fibrous or tendinous material; thus, the retrac- 
tion following a Avound of the masseter muscle, in which both of these com- 
ponents exist to a considerable degree, will be less than that following a 
similar injury of the gracilis, or of one of the recti muscles of the eye ; and, 6, 
sometimes by the degree of division, which may be either partial or complete. 382 
AFFECTIONS OF THE MUSCLES, TENDONS, AND BURSAE. 
Treatment.—The indications in the treatment of incised wounds are to 
arrest hemorrhage, to remove any foreign matters which may have entered 
the wound, and to bring the divided parts together with sutures. As the bond 
of union will be fibrous, muscular tissue not being reproduced when once de- 
stroyed, it is necessary that the approximation be close and accurate, in order 
that the function of the muscle shall not be permanently impaired. The 
sutures, therefore, silver being the best, should include not only the integu- 
ment, but the entire thickness of the divided muscle, unless in cases where the 
division of the latter is incomplete or the retraction insignificant. To favor 
the adjustment, advantage must be taken of position, the surgeon placing 
the limb or other part in that posture which will most effectually relax the 
wounded muscle. Before closing the wound, it should be washed thoroughly 
with carbolized water, and after the introduction of the sutures it is to be 
covered with a piece of lint or old linen, moistened with carbolated oil. In 
order that the union may not be retarded or disturbed, a roller bandage 
should be smoothly applied so as to control muscular action. When the 
wound is situated in the leg or the arm, the twofold object of giving support to 
the sutures and controlling muscular action will be best attained by using 
two rollers and bandaging from the opposite extremities of the limb towards 
the wound. The dressing will be rendered complete by enforcing a position 
of muscular relaxation and maintaining the same by the addition of a prop- 
erly-fashioned splint. 
Contused Wounds are such as are inflicted by blunt missiles, like bludgeons 
and stones, or such as are received when one falls across pieces of timber. 
The skin necessarily participates in the injury. The fibres of the muscle 
are bruised, and there is rupture of the blood-vessels, chiefly veins, the blood 
from which imparts a dark discoloration to the injured portion of the muscle 
and often penetrates to some distance beyond the seat of violence. The 
superficial discoloration, or ecchymosis, or that which lies beneath the skin, 
is in a great measure due to the rupture of subcutaneous veins. These con- 
tusions are generally accompanied by numbness, which is followed by sore- 
ness in the affected part and pain on movement. They are also often followed 
by rheumatism within the damaged region, and by atrophic, fatty, and other 
degenerations of the injured muscle. 
Treatment.—In the treatment of muscular contusions the injured part 
should be put at complete rest, and the surface covered with a lotion of lead- 
water and laudanum, or of alcohol, with the addition of tincture of aconite 
or of arnica. When the soreness or pain is great, marked alleviation will be 
obtained by the use of hot applications, like hot-water cloths or flaxseed-meal 
poultices, covered with oiled silk. Rigidity and soreness often remain long 
after the injury is inflicted, and may sometimes require for their removal a 
judicious use of massage. These muscular contusions often constitute an 
important factor in the genesis of morbid growths, especially sarcoma. 
Rupture and Laceration.—Partial rupture, or rupture of a few fibres of a 
muscle, is not an uncommon occurrence. The muscles most exposed to such 
accidents are the gastrocnemius, the flexor biceps cubiti. and the adductor 
longus. In the case of the first-named muscle, I have seen the rupture follow 
the act of slipping from a curb-stone, when the toes alone reached the pave- 
ment and slipped off at the moment of raising the weight of the body on 
the limb. Complete rupture of a healthy muscle can occur only from ex- 
traordinary violence or force. It may happen in leaping or wrestling, or may 
occur in falls or in efforts made to prevent falls. Most commonly it happens 
under circumstances in which the muscle is taken by surprise oris off guard. 
Spontaneous rupture of muscles has been observed in several instances in 
the spasm of tetanus. The lesion generally takes place near the tendon. 
In typhoid fever a rupture of the recti muscles of the abdomen is occasion- 
ally met with,—the result of degenerative changes. Rupture of the mus- GUNSHOT WOUNDS OF MUSCLES. 
383 
cles of the perineum during parturition is by no means an uncommon ac- 
cident. I have seen the sphincter ani ruptured during difficult defecation ; 
the rectus femoris torn across above its tendon in a heavy man who fell upon 
the ice; and a similar injury of the three broad muscles of the abdomen, 
caused by a fall, the injury permitting a portion of the intestines to escape 
through the rent. In dislocations, the muscles in the neighborhood of the 
displaced joint are frequently torn. Very extensive laceration of muscles is 
often seen to follow the passage of the wheel of a heavily-loaded wagon over 
the abdomen, and examples are recorded of like injuries occurring in different 
parts of the body when struck by a spent cannon-ball. 
Symptoms.—Among the symptoms which indicate rupture of a muscle 
there are seen, in many cases, two noticeable bulgings answering to the 
retracted ends of the muscle, with a depression or falling in of the integu- 
ment over the chasm between, accompanied by loss of function and by pain, 
which for a time is often intense. When the broad muscles constituting the 
walls of the abdomen are torn, the injury is followed by symptoms of pro- 
found shock, such as palloi’, a small, feeble pulse, cold, damp skin, vomiting, 
and great prostration. Lacerations of muscles, with open wounds (such as 
are often produced in manufactories, when parts of the body are caught in 
the belting or wheels of machinery, or such as result from injuries inflicted 
by the bumpers or wheels of railway-cars), possess characteristics which 
do not belong to those in which the skin remains unbroken. Muscular con- 
tractility is frequently destroyed, and wThen the deep fascia is ruptured 
the muscular tissue may protrude through or hang out of the external 
wound; or it may be black, bruised into a pulp, and filled with extravasated 
blood; or it may have ground into its substance tar, dirt, and other foreign 
matters. 
Treatment.—In the simplest form of rupture, that in which a few muscu- 
lar fibres or fasciculi are torn, it will be sufficient to direct absolute rest in a 
position which shall insure the greatest degree of relaxation to the injured 
muscle, together with anodyne lotions and a roller bandage such as is applied 
after incised wounds. Even these partial ruptures may disable a patient for 
a long time after all visible evidences of the injury have disappeared, proba- 
bly on account of the restored fasciculi not contracting and relaxing to the 
same extent as the adjoining portions of the muscle. 
When the rupture is complete, it has been advised to convert the injury 
into an open wound and stitch together the retracted ends of the broken 
muscle. Only when the function of the muscle is one of superior importance, 
or when its ends cannot be included in deep stitches passed through the integu- 
ment by stout curved needles, do I deem this opening of the wound a neces- 
sary or advisable procedure. Except under these circumstances, it will be 
sufficient to make the approximation as complete as possible by position, and 
by the use of compresses, splints, and roller bandages. 
When the extremities of a broken muscle hang out of the external wound 
and are not hopelessly disorganized, instead of being retrenched with the 
knife or scissors they should be replaced, since their contractility will be re- 
gained when the patient recovers from the shock. Pulpified muscles will 
perish, and the process of mortification and detachment should be favored 
by poultices, the parts being thoroughly cleansed, at each renewal of the 
dressing, with chlorinated water or with solution of permanganate of potash. 
Gunshot Wounds of muscles heal only after a certain amount of devitalized 
tissue (its extent determined in part by the velocity of the missile) has sep- 
arated and been discharged. Neither the opening of entrance nor that of 
exit is as great in shot wounds of the muscle-tissue as in similar injuries of 
other structures, since muscles appear to be pushed aside by the missile to 
some extent, and after its passage they close again over the opening: hence 
the difficulty often experienced in following with a probe the track of a 
ball after it has passed beyond the integument. The loss of substance is 384 
AFFECTIONS OF TIIE MUSCLES, TENDONS, AND BURSJE. 
replaced by fibrous tissue in the process of repair, during which the muscle 
often becomes adherent to the adjoining parts, the effect of which is ever 
after to detract from its functional perfection. 
Treatment.—In shot wounds of muscles no attempt is to be made to close 
the opening. After the arrest of hemorrhage and the extraction of the ball, 
when the latter does not pass entirely through, the wound is to be dressed 
with carbolated water or oil. After the separation of the slough the opening 
will be closed by granulation-tissue. 
Paresis of muscles is that temporary loss of power during the continuance 
of which they are unable to contract, or can only respond feebly to the behests 
of the will. The condition is usually induced either by a sudden overstretching 
of the fibres of the muscle, or by its excessive use. I have seen the hand 
remain powerless for weeks after an unusually prolonged and forcible grasp 
made when the flexor muscles,' in consequence of the position of the arm, 
were compelled to act at a great disadvantage. A blow over the deltoid 
will frequently be followed by inability to raise the arm for some time. 
Not unfrequently the surgeon takes advantage of this kind of muscular 
paralysis to cure certain forms of ulcers; as when, for example, in fissures 
of the anus he overstretches the external sphincter. 
Muscular paresis is very often the underlying fact in deformities: an il- 
lustration is seen in certain varieties of club-foot, in which the sound and 
antagonizing muscles overbalance the affected ones and produce the distor- 
tion. 
Treatment.—To favor the recovery of a muscle which has temporarily lost 
more or less of its contractility, it must be placed for a short time in a state 
of relaxation ; and afterwards it must be stimulated by frictions, by occa- 
sional energetic concentration of the will, and by the judicious application 
of electricity. Unless some central lesion has caused the paresis, recovery 
may be confidently anticipated. 
Luxation of muscles will be considered in connection with the affections of 
the tendons. 
Inflammation of Muscles, or Myositis.—Muscles are not exempt from at- 
tacks both of acute and of chronic inflammation. Except as the result of 
wounds, the latter is much more common than the former. When of trau- 
matic origin, muscular inflammation can be best studied in connection with 
an account of the process of repair. The inflammatory infiltrate which 
interpenetrates the muscular fibres consists of cells and a plastic serosity. 
In muscles, as elsewhere, inflammation may result in suppuration, ulcera- 
tion, and mortification. The suppuration may be circumscribed, diffuse, or 
metastatic, the first two varieties being common among the sequels of 
compound fractures or severe lacerations of the soft tissues of a limb, or 
resulting from erysipelas; the metastatic variety is one of the phenomena 
of pyaemia. 
Syphilis constitutes another source of inflammation in muscles. Gum- 
mata (which are products of advanced constitutional syphilis, and are of 
inflammatory origin) may form in the muscles, and they are prone, particu- 
larly in broken-down systems, to terminate in suppuration. A gentleman 
somewhat advanced in life, whom I saw with Dr. Black, of Delaware, and 
who suffered very much from the ravages of syphilis,—contracted innocently, 
it is believed, from contact with the secondaries of a room-mate, while in the 
navy,—presented numerous gummy lesions in different parts of the body. 
The tumors, deeply situated in the muscles, after a time became adherent 
to the skin. Some of them became confluent, and then underwent softening, 
followed by ulceration, and the discharge was a fluid of mucilaginous char- 
acter, mingled with unhealthy pus. Ulcers of this nature are replaced by 
cicatricial tissue which leaves depressed indurations of the parts. The mus- INFLAMMATION OF MUSCLES, OR MYOSITIS. 
385 
cles which suffer most from syphilitic lesions of this kind are the gastroc- 
nemius and soleus, the flexor biceps cubiti, and the glutsei. 
Infants often suffer from inflammatory deposits in the sterno-cleido-mastoid 
muscle. These formations are painful on pressure, have a knotty feel, and 
are accompanied by shortening of the muscle, often sufficient to draw the 
head to one side, so as to produce an imitation of wry-neck. Though this 
trouble is sometimes of syphilitic origin, this is not always the case, for I 
have seen instances of the affection where there was every reason to believe 
that no antecedent history of syphilis existed. 
Among the syphilitic affections implicating the muscular system is one 
characterized by slowly-developed contraction, more or less permanent. The 
flexor biceps cubiti and the sterno-cleido-mastoid are the muscles peculiarly 
liable to suffer. As the muscular structure undergoes apparently no actual 
change in these contractions, I am disposed to regard the affection not as 
a local inflammation, but rather as one arising from central irritation not 
unlike that which exists in spastic talipes. These contractures are some- 
times associated with muscular tremors and with some loss in muscular co- 
ordination.* 
There is also a muscular contraction which is the result of a rheumatic or 
a gouty state of the system. 
When the syphilitic contraction is inflammatory, an exudation interpene- 
trates both the fasciculi and the fibres of the muscles, leaving the latter hard 
and unyielding; and this condition is often accompanied by nocturnal pains. 
It is usually associated with other manifestations of the constitutional dis- 
ease, whether acquired or inherited, such as the remains of lesions in the 
skin, mucous membranes, or bones, if the patient is an adult; and in the 
case of new-born children we may often observe snuffles, condylomata, and, 
at a later period, notched teeth. 
The infiltrate of myositis, instead of being absorbed, may undergo various 
metamorphoses, and may thus become fibrous, earthy, or bony. I have 
seen almost an entire muscle undergo calcareous degeneration. 
Treatment.—In the management of these different disorders of muscular 
tissue it will be necessary to trace them to the proper cause before any in- 
telligent plan of treatment can be instituted. If the origin proves to be 
syphilitic, we have no remedy which can take the place of the iodide of po- 
tassium. As these syphilides are seen only among the later entailments of 
the disease, when the deterioration of the tissues of the body is far advanced 
and the vital capacity to resist invasion is at a low point, the iodide should 
be administered in connection with vegetable and mineral tonics, such as 
gentian, cinchona, and iron. Mercury can rarely be given with advantage 
at this stage of the disease; if it is used, it should be combined with the 
iodide. 
For the treatment of the ulcers resulting from gummata, see Syphilis. 
Rheumatic and gouty myositis seem to affect mainly the fibrous compo- 
nents of muscles, and they require for their treatment alkaline remedies, 
such as iodide of potassium, or nitrate or acetate of potash, with guaiacum 
and colchicum. 
In the non-syphilitic contraction of the sterno-cleido-mastoid muscle of 
infants, cod-liver oil and syrup of iodide of iron constitute proper internal 
remedies; at the same time the nurse should rub the oil well into the affected 
muscle. As the subjects of this affection are generally feeble and emaciated 
children, especial attention should be given to the quality of the milk which 
they are using. Even the milk of the mother may not be suited to the neces- 
sities of the child. 
In suppuration occurring in a muscular structure, the connective tissue, 
I believe, plays an important part in the process; and, as these abscesses 
are more likely to be diffused than to be circumscribed in character, the 
importance of an early evacuation and free drainage is manifest. 
* M. F. Bousson, of Montpellier, has written at some length on syphilitic affections of muscles. 386 
AFFECTIONS OF THE MUSCLES, TENDONS, AND B URSJE. 
Myalgia, or Muscular Neuralgia, is a painful condition of certain muscles, 
coming on suddenly, and intensified by movements. It is frequently desig- 
nated, in popular language, a “crick.” It is often confounded with rheu- 
matism or neuralgia. The attack is in many instances referred to some 
sudden twist or sprain, and is not unfrequently attended by violent spasm 
of several muscles, especially when an attempt is made to change the posi- 
tion of the body. The muscles of the back are most commonly affected. 
The remedy which acts most promptly in curing myalgia is atropia used 
hypodermically,—one-seventieth to one-sixty-fiftli of a grain of the alkaloid 
being thus injected. The use of this remedy is in most instances quickly 
followed by relief. If necessary, it can be repeated the following day. When 
the means for administering this remedy are not at hand, the surgeon may 
try dry-cupping, frictions with stimulating and anodjme liniments, and iron- 
ing the parts with a hot flat-iron, such as is used for laundry purposes, 
a piece of flannel being interposed between the skin and the applied iron. 
When a rheumatic element is suspected, salicylate of soda or iodide of potas- 
sium should be administered. Massage is always a useful adjunct to other 
measures. 
Degeneration of Muscles.—The degenerations observed are— 
1. Simple atrophy, or wasting of bulk without any obvious material change 
of structure in the muscle affected. Except in the bloodless appearance of 
its fibres, the transverse and longitudinal striations remain as in health. This 
condition is often seen in the wasting of phthisis and of typhoid fever, and 
in other exhausting diseases. 
2. Granular and fatty atrophy.—The sarcous elements may entirely dis- 
appear, or may be converted into granular or fatty particles, leaving only the 
fibrous skeleton of the muscle, a mere band without color, and with a new 
formation of fibrous tissue occupying what was originally the inter-fascicular 
spaces. 
In fatty degeneration of muscles the transformation may be observable 
either in the sarcous cells or between the individual fibrillae. Muscles which 
lie contiguous to structures in a state of chronic inflammation sometimes un- 
dergo extensive fatty degeneration. The most striking example of this change 
is seen in certain cases of necrosis of the femur or of other bones of the 
skeleton, in which the overlying muscles can scarcely be distinguished from 
the adipose constituent of the limb. It is not to be inferred, however, that 
the transformation occurs simply from contiguity to the inflamed bone. 
There is, of course, a propagated secondary inflammatory condition in the 
muscles themselves. 
3. Waxy atrophy.—Another degeneration of muscular tissue is the waxy 
degeneration of Zenker, the “ vitreous degeneration” of the French patholo- 
gists, which the latter regard as a form of colloid metamorphosis. In 
muscles undergoing the above change, the fibres enlarge and become trans- 
parent from the presence of cells filled with a colorless hyaline or colloid 
substance. The transverse and longitudinal striations disappear, their 
original situation often being indicated by lines of fracture running in 
similar directions. The parts which in the early stage of the degeneration 
escape are the sarcolemma and the nuclei of the fibres. This singular meta- 
morphosis does not involve the whole muscle, but only isolated fasciculi. 
It is sometimes noticed after certain low fevers, such as typhoid, and is 
peculiar, it is believed, to the muscles of animal life. 
4. Progressive atrophy.—There is a variety of muscular atrophy termed 
“ progressive” from the gradual, steady manner in which the waste advances. 
This affection is preceded, as first described by Clarke, by circumscribed spots 
of granular alteration or disintegration in the gray and white matter of the 
spinal cord; and it begins generally in the muscles of the hand, preferably 
the right, I suppose on account of its more general use. The muscles of the 
ball of the thumb and of the little finger, with the interossei, begin to waste, PARASITIC CYSTS IN MUSCLES. 
imparting after a time a bony or skeleton-like appearance to tlie hand. This 
is the “ main en griffe" of the French. Males suffer in this way much more 
frequently than females. The atrophy is not limited to the muscles of the 
hand, but is prone to extend to those of the arm and other portions of the 
body. The disease is preceded by a gradual loss of power in the affected 
muscles, which loss, together with a certain inability to combine and direct 
the hand’s movements, gives to the latter a kind of mechanical stiffness. This 
atrophy as it advances is further characterized by cramps, tremblings, and 
spasmodic contractions of isolated portions of the affected muscles. When 
the disease extends to the muscles of the body, and thence to the lower ex- 
tremities, the gait becomes unsteady. 
Though in progressive atrophy the diseased muscles may exhibit no other 
evidence of change than a mere reduction in the size of their anatomical ele- 
ments, yet the affected muscular tissue may be the seat of granular, fatty, 
and waxy degenerations. 
Progressive muscular atrophy appears to run in certain families, and must 
therefore depend on causes of an hereditary character, and these are some- 
times of a syphilitic nature. Among the local or determining causes are 
Occupations carried on in cold, damp localities. 
Treatment.—Unfortunately, progressive muscular atrophy is an incurable 
malady. The march of the disease may be temporarily retarded, but it 
slowly extends from muscle to muscle until finally the patient dies in a state 
of extreme exhaustion. 
The remedies with which the degeneration is to be combated are arsenic 
(Donovan’s solution), electro-galvanism (constant current), cod-liver oil, iron, 
and, when there is reason to believe in a syphilitic causation, iodide of 
potassium. 
The muscular atrophy following infantile paralysis, so many examples of 
which are furnished by our clinics, has a central origin, and, though not often 
fatal, is a fruitful source of deformity, requiring the use of mechanical ap- 
pliances of different kinds with a view to compensate for the loss of power 
in the affected muscles. In many of these cases, while the sarcous elements 
are diminished, the fibrous constituent of the muscle is increased very much. 
The management of distortions arising from this cause has been considered 
under the head of club-foot and other deformities. 
387 
Hypertrophic Muscular Paralysis.—Another form of muscular degenera- 
tion peculiar to childhood is the pseudo-hypertrophic. The disease, first rec- 
ognized by Duchenne, begins in early childhood, about the period when the 
patient has just begun to walk. The distinguishing features of the affection 
are a somewhat anomalous condition of a growing inability to stand or walk, 
followed by an apparent increase in the development of the muscles. But, 
as the disease progresses, these appearances change, and with the deepening 
paralysis the muscles undergo rapid atrophy. The enlargement affects most 
frequently the muscles of the calves of the legs, the hips, and the loins. The 
muscular fibres, when examined, are found to have much finer striations 
than are normal, with a large increase of connective and adipose tissue. 
The disease, unless recognized in the initial stage, is incurable, and life ter- 
minates during the years of adolescence. 
The therapeutic measures for the arrest of hypertrophic muscular paralysis 
are massage and electro-galvanism. 
Parasitic Cysts in Muscles. 
There are three kinds of cyst which have a parasitic origin and are met 
with in muscles. The pai’asites producing these are the cysticercus, the 
echinococcus, and the trichina spiralis. 
Cysts arising from the first two parasites are rare. I removed from 
the serratus magnus muscle of a patient at the clinic of the University of 388 
AFFECTIONS OF THE MUSCLES, TENDONS, AND BURSAE. 
Pennsylvania three hydatid cysts, in which the bladders containing the 
animals extended into the cellular tissue. 
A more common parasitic cyst is that produced by the trichina spiralis, a 
parasite first discovered in pork by my colleague, Dr. Joseph Leidy, Profes- 
sor of Anatomy in the University of Pennsylvania. These parasites, as long 
as they remain in the flesh of the swine, do not procreate, being sexless ; 
but when the affected flesh is eaten without being first sufficiently cooked,— 
a high temperature being destructive to the animal,—sexual development fol- 
lows, the act of fertilization takes place in the intestines of the animal which 
has swallowed the trichinae, and a large brood of young (viviparous) is pro- 
duced by the female parasites. Two views are entertained in regard to the 
manner in which the young nematodes reach the muscles. According to 
one class of observers, this is effected through the blood, the animals pene- 
trating the walls of the blood-vessels and lymphatics, and after reaching the 
right side of the heart in the venous blood they pass with the latter to the 
lungs, and thence back to the left side of the heart, from which they are 
borne by the arterial current and thus find their way to different parts of the 
body. The other and more probable view is that in which the parasites are 
said to tunnel their wa}r directly through the walls of the intestines and 
through the other intervening tissues until the striated muscles are reached. 
The young trichina have no power to penetrate the tendons. Having 
reached its final seat in some muscle, the nematode makes its habitat either 
external to the muscular fibre in the intermediate connective tissue, or, as 
some assert, within the sarcolemma. The local irritation which follows the 
presence of the parasite soon develops an inflammatory transudation, which 
encapsulates the ani- 
mal. (Fig. 2011.) The 
capsule, at first trans- 
lucent, gradually be- 
comes opaque from the 
deposition of particles 
of lime and magnesia. 
The effect of the pres- 
ence of trichinae on the 
muscular fibre is very 
striking. The charac- 
teristic striations of the 
muscle-fibre are lost, 
and both the fibrilla; 
and their sarcolemma 
undergo a granular degeneration, the product of which is believed to admin- 
ister to the sustenance of the invaders. 
Fig. 2011. 
Encysted trichina spiralis. 
Fig. 2012. 
Trocar ami gimlet for extracting muscular fibre. 
The symptoms which reveal trichinosis are growing weakness, loss of 
appetite, soreness and pain on pressing or moving the affected muscles, a TUMORb. 
389 
frequent pulse, often intermittent, a puffy, swollen state of the face, feet, and 
legs, contraction of the muscles, and flexion of the limbs, followed by general 
anasarca, diarrhoea, and death. 
The diagnosis may be rendered certain by removing small portions of the 
affected muscle for microscopic examination. Dr. liarte, of this city, has 
devised an instrument which has been successfully employed for this pur- 
pose. It consists of a canula and two delicate trocars, one sharp-pointed, to 
be used for puncturing the muscle, and the other having a spiral extremity, 
to be used in extracting a fragment of the diseased muscle for examination. 
(Fig. 2012.) 
Treatment.—Little more can be done in the way of treatment than to 
sustain the system of the patient by food and tonics, and to procure rest by 
opiates, when apodynes are necessary. The prophylactic measure consists 
in thoroughly cooking all swine’s flesh before it is eaten. 
Tumors. 
Tumors of different kinds are met with in muscles. Those generally seen 
are cysts, fibromata, angeiomata, lipomata, myxomata, sarcomata, carcino- 
mata, and enchondromata. 
Non-Parasitic Cysts.—Cysts occasionally form in muscles, and may attain 
to considerable magnitude. It is not impossible that in some cases the 
origin of these growths is a clot of blood, the result of violence, and that this 
clot, provoking a localized inflammation, becomes surrounded by a capsule 
of lymph, which afterwards is transformed into the wall of the cyst. A 
very lai'ge cyst in the pectoral muscle, the sizo of a small foetal head, was 
removed at my clinic in the University. The contents of the tumor in 
appeai’ance resembled very much the ascitic fluid, having a straw color. 
The proper treatment for cystic formations in the muscles is extirpation 
by the knife. 
Fibromata.—The most common of neoplastic formations in muscles are 
fibromata. These tumors are extremely hard to the touch, have a round or 
oval form, are not painful, are rather firmly imbedded, and are produced 
generally by mechanical friction or pressure. Should these tumors continue 
to grow after being relieved from any local irritation which may seem likely 
to exert an influence favorable to their further development, they should 
be excised. 
Angeiomata, or tumors having an erectile or cavernous structure, as dis- 
tinct from varices, are sometimes found in muscles. A short time since, I re- 
moved from the side of a young woman a growth which proved to be an 
angeioma undergoing a fibrous transformation. The enlargement had ex- 
isted from childhood, and was, it is probable, congenital. These vascular 
growths in muscles may also undergo a fatty degeneration. When showing 
no tendency to increase, and giving rise to no inconvenience, they may be 
safely let alone; but when intei’ference becomes necessary, excision is the 
proper procedure. In making the necessary cut, the operator must keep 
some distance beyond the limits of the disease, so as to avoid excessive 
bleeding. 
Myxomata occasionally develop in the muscles. Tumors of this kind are 
painless, and have a soft, doughy feel, not unlike that of lipoma, with which 
they are sometimes conjoined. The overlying skin remains unchanged, and 
unless tested by the exploring needle they are difficult to diagnose. Although 
myxomata are not confined to any muscles in particular, I have met with 
them only in the muscles in front of the ulnar side of the forearm, in the 
orbicularis oris muscle, and in the cheek. Myxomata should be promptly 390 
AFFECTIONS OF THE MUSCLES, TENDONS, AND BURSsE. 
excised, as they often possess a certain degree of malignancy, conditioned on 
the amount of embryonic elements which they contain. 
Sarcomata, though not very often developing primarily in muscles, fre- 
quently make their way into the muscular substance in the course of tbeir 
growth from adjoining structures. When sarcomatous growths have their 
genesis in the muscles, the seat of the neoplastic formation is between the 
fasciculi. Though all the varieties of sarcoma have been seen in the muscles, 
the most common form is the spindle-celled. With the increase of the tumor 
tho muscular fibres undergo atrophy and fatty transformations. 
Carcinomata, of whatever form, medullary, scirrhous, melanoid, or epi- 
thelial, usually enter muscles either by extension from adjoining parts or 
as secondary deposits. If any exception to this rule exists, it is perhaps in 
the case of medullary carcinoma. The effect of the presence of these neo- 
plasms on the muscular fibres is similar to that which attends the growth of 
a sarcoma, for the disease leads to rapid atrophy and fatty degeneration. In 
carcinoma of the breast, the pectoral muscles are often found infiltrated with 
cancer-cells, which have found their way from the gland into the midst of 
the fibres. In epithelial cai’cinoma of the lip, even before tho cell-nests 
penetrate into the orbicularis muscle, the way for their entrance has been 
prepared by an antecedent formation of material, which becomes the nidus 
of a malignant cell-growth in the connective tissue between the fasciculi. 
When operations for the removal of carcinoma are proposed, after the dis- 
ease has invaded the muscle, it will be useless to operate unless the affected 
part of the muscle is removed along with other portions of the tumor. 
Enchondromata may appear in muscles much in the same manner as they 
are known to develop in the testicle and in the parotid gland. Although in 
most instances these formations only invade the muscles secondarily, their 
original site being in some adjacent structure, yet, when the necessity for 
their removal arises, the muscle with which they are incorporated may have 
to share the fate of the tumor itself. 
Osteomata.—Localized and general transformations of muscle into bone 
are described by writers, but it would be more in accord with facts to regard 
these as new formations of bone, commencing, not in tbe muscle proper, but 
in the connective tissue. Bony masses or plates are frequently discovered 
imbedded in isolated muscles of old persons. They may also bo produced 
by continuous pressure. Of this nature is the “saddle-bone,” an osseous 
transformation of fibrous tissue which sometimes takes place in tbe adductor 
muscles of persons much in the saddle, and also the “exercise bone,” spoken 
of by Virchow as occurring on the left arm of Prussian soldiers, from the 
manner in which the gun is supported. A constitutional diathesis in which 
the abnormal osseous formations begin early in life and invade a considerable 
number of the muscles of the body is very rare. I am not aware that there 
are any specimens of the kind in the pathological collections of Philadelphia. 
A gentleman from Maryland, about fifty years of age, recently consulted 
me on account of a circumscribed deposit in the deltoid and trapezius 
muscles, which had been steadily growing for over a year, and which bad 
weakened the arm so that he was no longer able to raise it towards the 
head. The case was one requiring excision of the bone. 
That these deposits are not mere aggregations of lime-salts, forming cal- 
careous masses, without an orderly arrangement of parts, has been shown 
from-the examinations made by Mr. Caesar Hawkins, in which the muscular 
growths were found to possess the structure of true bone in detail, contain- 
ing Haversian canals, lamellae, lacunae, canaliculi, and other essential elements 
of real bone. 
The treatment recommended in cases of ossification in muscles consists in AFFECTIONS OF THE TENDONS AND THEIR SHEATHS. 
391 
the use of iodide of potassium, mercury, and dilute phosphoric acid, and 
the repeated application of blisters. Isolated osteomata, when continuing 
to grow, will require operative measures for their removal. 
Affections of the Tendons and their Sheaths. 
Tendons are exposed to various accidental injuries, such as wounds, rup- 
ture, and dislocation, and these injuries may result in serious inflammation 
and consequent hypertrophy. The organs in question are rarely invaded 
by neoplastic growths. 
Repair.—After the subcutaneous division the muscular end of the tendon 
recedes from the other extremity a distance of from half an inch to two 
inches, varying according to the position, the length, and the surrounding 
attachments of the muscle to which it belongs. The delicate elastic sheath 
which invests the tendon is perhaps never entirely severed, and therefore 
remains more or less perfect, not only establishing a bond between the re- 
tracted extremities to prevent their displacement, but forming a scaffolding 
or a mould for the support and limitation of the reparative material. The 
hemorrhage following the division of a tendon, if the operation has been 
executed neatly, is very small in amount, the effused blood adhering chiefly 
to the cut ends of the tendon. The bleeding often noticed during tenotomy 
does not proceed from the tendon, but from vessels of the surrounding tis- 
sues. In from fifteen to twenty hours there is an inflammatory fullness of 
the vessels of the sheath and surrounding tissues, indicated by increased 
redness of the adjacent superficial parts. Soon after this a sero-fibrinogenous 
infiltrate, containing many leucocytes, occupies the space between the ex- 
tremities of the tendon. The ends of the latter now undergo a process of 
softening, which admits of their being penetrated by the leucocytes and 
commingled with the reconstructing material. The cell-components of the 
transudation soon begin to exhibit great activity, assuming the charac- 
teristic spindle-shape belonging to the cell-elements of connective tissue, and 
gradually acquiring the form and solidity of fibrous and tendinous structure. 
Blood-vessels appear early in the reparative material, the organization of 
which advances so rapidly that, as shown by Sir James Paget, the newly- 
repaired tendon is capable at the expiration of six days of sustaining a 
weight of twenty-five pounds, and after the lapse of twenty-one days a 
weight of fifty-six pounds,—the whole period required for the work of re- 
pair being about three weeks. Some idea may be formed of the tensile 
strength of the tendo Achillis from experiments which have been made, 
showing that, when sound, it will support from two hundred and fifty to 
four hundred pounds. 
The process of repair in tendons subcutaneously divided almost always 
proceeds quickly, and with a minimum degree of inflammation; but it is 
otherwise when the wound is an open one. In this case the inflamma- 
tion will run on to suppuration, and the reunion of the tendon then proves 
very tedious at best, while it is very likely not to occur at all, the ends be- 
coming attached to adjacent parts without their continuity being restored. 
The experimental observation of repair in tendons seems to have commenced 
with John Hunter, in 1767, whose study of the subject, it is said, originated 
in a rupture of the tendo Achillis in his own person, the accident happening 
while he was dancing. Since the time of Hunter the subject has been co- 
piously illustrated by the labors of Mayo, Von Ammon, Pirogoff, Koerner, 
Paget, Gerstaecker, Adams, and others. 
Wounds of Tendons.—The treatment of a severed tendon varies with the 
nature of the injury. If it is simple,—that is, if the tendon is divided sub- 
cutaneously,—ail that is needed is to cover the external puncture with a 
piece of adhesive plaster, relax the parts, apply a roller in order to control 392 
AFFECTIONS OF THE MUSCLES, TENDONS, AND B IRS HI. 
the action of the muscles, and enforce rest for eight or ten days. If, on the 
other hand, the injury is compound,—that is, if the tendon is exposed by 
an open wound,—after arresting the hemorrhage its ends should be brought 
together by animal sutures, the wound thoroughly sprayed or irrigated with 
carbolated water, the integument closed by interrupted sutures, and the 
parts covered with antiseptic gauze, or with lint moistened with carbolic 
acid and sweet oil. The dressing will be completed by placing the limb in 
that posture which will subject the injured tendon to the least tension, 
and by applying a roller bandage. When silver sutures are employed to 
bring together a severed tendon, their ends must be brought out of the 
external wound. This plan of treating divided tendons is too often neglected, 
and hence serious disabilities are frequently seen to follow wounds on the 
back of the hand, or on the dorsum of the foot, or behind the knee or the 
ankle, in which the tendons of the extensors of the fingers and of the toes 
and the flexors of the leg or the extensors of the foot have been cut across. 
The severe symptoms which are sometimes known to follow the puncture 
of tendons, and the overshadowing influence of Hippocratic dogmatism, 
which asserted that tendons once cut could never unite, no doubt explain the 
indisposition manifested on the part of many of the ancient surgeons to 
suture tendons. The history of the practice is an illustration of the vicissi- 
tudes attending surgical operations. Galen* condemned it; but, contrary to 
the general opinion of the time, Gui de Chauliac, Saliceto, Lanfranc, and 
some of the Arabian surgeons stitched together the ends of divided tendons. 
Pare was deterred from doing so by an apprehension of producing convul- 
sions. The practice was revived by Veslingf and Severino,| and through 
the influence of the French surgeons, particularly Maynart and Bienaise, it 
afterwards became a more generally recognized procedure. Even several 
days after the division of a tendon, the suturing was not regarded as im- 
practicable by the older surgeons, the operation in these circumstances being 
advocated by Verdue and Le Clerc. 
In old cases of ununited tendon, where important disability has followed, 
the ends should be exposed, freshened, and brought together with animal 
sutures, the surgeon observing after the operation to adhere in the strict- 
est manner to antiseptic details of dressing. 
Rupture.—The rupture of a tendon may occur in various ways, as in leap- 
ing or in dancing, or from external violence. It is not uncommon to see 
persons brought into our hospitals who have one or more tendons torn away 
directly from the periosteum or bone on which they are inserted. The ten- 
dons most frequently ruptured are the tendons of the rectus femoris and 
flexor biceps cubiti, the tendo patella}, and the tendo Achillis. 
Rupture of a tendon may be diagnosed by the sudden loss of function, 
with pain, and the presence of a gap or depression, which may be seen and 
felt, between the retracted ends, the injury being often accompanied by an 
audible snap. 
The repair of a ruptured tendon is much slower than that of one divided 
subcutaneously by a knife, and the treatment will be correspondingly pro- 
tracted. It is requisite that the ends of the broken tendon be retained in 
as close proximity as possible by the conjoined agency of position, splints, 
and elastic roller bandages applied with such a degree of firmness as can 
well be borne. The plaster roller can sometimes be advantageously sub- 
stituted for the linen or woolen bandage. When the function of the tendon 
is a very important one, and close union seems improbable, rather than resort 
to an open wound and stitches, a subcutaneous suture should be introduced. 
This plan, not difficult to execute on the cadaver, can be accomplished with 
nearly equal facility on the living subject. 
* De Comp. Medicament., lib. iii. 
f Observat. et Epist., xv. 
j De Efficaci Medic., lib. ii. cap. cxxiii. DISLOCATION OF THE TENDONS. 
393 
Assuming the ruptured tendon to be the Achillis, take a silver thread, 
armed at each end with a long, slender needle, and pass one of the needles 
directly through the integument and upper extremity 
of the tendon, from side to side; then re-insert the needle 
through the opening of exit, and carry it longitudinally 
down the leg until it reaches a point alongside of and 
below the lower end of the tendon, when it should be 
forced through and brought out of the skin directly op- 
posite. The other needle, with the corresponding end 
of the thread, is to be managed exactly in the same way 
along the opposite side. It only remains now to re-enter 
the needles at the apertures of exit and pass them in 
opposite directions through the lower end of the tendon, 
the one on the right side passing out through the opening 
vacated by the one on the left, and the latter coming out 
through the opening of the right. As the two ends of 
the wire are drawn upon, the extremities of the tendon 
will be made to approach each other, after which the 
wires can be twisted together around the limb. (Fig. 
2013.) If only allowed to remain four or five days, the 
union between the ends of the tendon would in all prob- 
ability be sufficient!}' advanced to admit of the suture being removed. 
Fig. 2013. 
Subcutaneous suturing of 
the tendo Achillis. 
Rupture of the Long Tendon of the Biceps is followed by a relaxed state of 
the outer portion of the muscle, while the inner part, or that connected to 
the coracoid origin, is contracted into a hard knot. Rupture of one of these 
tendons of the biceps, it is said, predisposes to a similar injury of the other 
tendon of the same muscle,—doubtless because the union of the first is never 
perfect. 
The treatment proper in an injury of this tendon will be the application 
of a roller to the arm, the forearm being flexed, in which position it must be 
kept by an anterior angular splint. 
Rupture of the Tendon of the Rectus Femoris or of the Tendo Patellae.— 
Twice have I seen these accidents occur, aikd in each case the rupture was 
produced by muscular action called forth to prevent a fall. The symptoms 
are characteristic. In rupture of the tendon of the rectus, the patella re- 
mains in its natural position, and the rectus femoris muscle contracts above 
into a hard bunch, leaving a depression below. In rupture of the tendo 
patellae, the patella is drawn up, leaving the trochlear surface of the condyles 
accessible to the touch, the skin alone covering it. In either case the patient 
is unable to extend the leg. 
If the rupture involves the tendo patellae, it is to be treated by extension 
and elevation of the limb, with a posterior splint and adhesive strips applied 
in the same manner as in dressing a fractured patella. 
When rupture occurs in the tendon of the rectus, it will be necessary, after 
elevating the limb, to draw the muscle down with the hands and resist its 
retraction by a roller bandage applied from above downward, after which 
the posterior splint must be placed in position, the lower fragment fixed by 
adhesive strips, and the bandage continued down around the knee and the 
splint. 
Dislocation.—The tendons most liable to dislocation are the long head of 
the biceps, where it lies in the bicipital groove, the tendons of the peroneus 
longus, the peroneus brevis, the tibialis posticus, the plantaris, the flexor bi- 
ceps cruris, and the numerous slips or digitations belonging to the muscles on 
the back along the spine. The displacement is produced by violence, and 
especially by sprains, in which the fibrous sheath which retains the tendon 
in position experiences a partial rupture. These accidents cannot be con- 394 
AFFECTIONS OF THE MUSCLES, TENDONS, AND BURSAE 
sidered very common. Though I have seen a number of supposed luxa- 
tions of the long tendon of the flexor biceps cubiti muscle, yet in only one 
case, that of a patient of Dr. J. William White, were the evidences of the 
displacement unequivocal. 
The tendons of the peroneus longus and peroneus brevis may be displaced 
from their grooves behind the external malleolus, which injury will be indi- 
cated by the projection of the tendinous cords beneath the skin along the 
outer and posterior surfaces of the external ankle, accompanied by lameness, 
inability to use the foot, and discoloration. 
The tendon of the peroneus brevis may also be displaced in that portion 
of it which lies over the outer side of the dorsum of the foot. The accident 
may occur in consequence of a rupture of its sheath. The nature of the 
accident will be revealed by the round and unnatural prominence or ridge 
felt underneath the raised integument. 
These dislocations require to be reduced by placing tbe foot in the particular 
position which will serve to relax the tendon, at the same time pressing the 
latter into its sheath or groove. Next, by the aid of compresses, rollers, and 
splints, the surgeon must keep the parts in situ. To maintain anything like 
the original security of the tendon, it will be necessary that the treatment 
be continued for seven or eight weeks. 
Dislocation of Muscles of the Back.—Dislocation of some of the tendinous 
slips belonging to the muscles along the sides of the spinal column, or even 
of isolated fasciculi of these muscles, is also a recognized surgical injury. 
Poteau was the first to describe this accident. The late Mr. Callender has 
also directed the attention of the profession to the subject. A sudden 
“ crick” or pain, attended with increased suffering on attempting certain 
movements, is believed to indicate such displacement. The correctness of 
the diagnosis will be strengthened if, on making twists or movements of the 
body opposite to those which cause suffering, accompanied by kneading over 
the seat of distress, the symptoms suddenly disappear. 
Inflammation of Tendons—Thecitis.—Inflammation of a tendon may com- 
mence primarily either in the tendon itself or in the membrane which lines 
its sheath. The tendons which, in consequence of their position and func- 
tion, most commonly suffer are the flexors and extensors of the hands, feet, 
and shoulders, and the difficulty is frequently induced by sprains or severe 
muscular exercise. Thecitis of the tendons of the wrist of a mild form is 
frequently experienced after a day spent in rowing, or in driving a carpenter’s 
plane, by persons unused to the exercise. It is also a common accompani- 
ment of fractures in the neighborhood of joints, as at the lower end of the 
radius, at the upper extremity of the humerus, and near the ankle. One form 
of paronychia, or that exceedingly painful affection which is so often seen in 
the finger-felon or whitlow, is an inflammation of one of the flexor tendons, 
or of its sheath, or of both together. 
The symptoms of thecitis are a swelling, often elongated and cylindrical 
in shape, with localized constrictions, in tho line of the affected tendon, ac- 
companied by stiffness and creaking on pressure or during movements of the 
tendon,—the tenasynite crcpitante of the French. This peculiar crepitation is 
often confounded with that of fracture, but differs from the latter in being 
moist and of a more subdued character. There is a modified form of thecal 
crepitation sometimes present at the back of the wrist, in front of the ankle, 
and in other localities where the tendons are numerous, the sound of which 
may be compared to that produced by walking upon grass crisp with hoar- 
frost. It has also been likened to that caused by compressing dry starch 
between the fingers. This variety of crepitation, long ago noticed by Vel- 
peau and other French writers, is often accompanied by sharp pain when 
the part is moved,—a symptom disclosing a previous thecitis, and one in 
which the crepitus is due to the peculiar consistence of the plastic exudation SUBCUTANEOUS BURSAE. 
395 
which lines the affected sheaths. The same condition is occasionally met 
with after articular synovitis. It is the plastic transudation into the sheaths 
of tendons contiguous to fractures which gives rise to the stiffness that so 
often follows these injuries. The helpless state of the fingers, and the pain 
experienced when they are moved, after fractures at the lower end of the 
radius, are produced by this cause, and suggest the necessity of keeping up a 
passive action of the tendons during the treatment. No more grave condition 
can exist than that of a neglected palmar abscess, in which the inflammation 
attacks the tendons and their sheaths, extending up under the annular liga- 
ment and spreading through the muscles of the forearm. There are also 
cases of rheumatic, gouty, and syphilitic thecitis. It is in such cases that 
the affected tendons are sometimes found to be enlarged in places, and hard 
and knotty, either from localized fibromata or from calcareous transformation 
of structure. 
Treatment.—In a simple case of thecitis little more will be required than 
to cover the part with a warm lotion of lead-water and laudanum, at the 
same time securing rest in an easy position. As soon as the symptoms begin 
to decline, the anodyne lotion should be laid aside, and one composed of the 
tinctures of iodine and belladonna applied freely with a camel’s-hair brush, 
the surgeon still observing the important rule of maintaining complete rest. 
When the swelling and tenderness have subsided, the time has arrived to 
commence gentle movements, in order to clear the sheath of its inflammatory 
debris and restore to the tendon its normal mobility. If the inflammatory 
symptoms do not promptly yield to the above treatment, the sheath of the 
tendon should be laid open and the exudation allowed to escape. In old and 
neglected cases of thecitis, in which the stiffness of the parts supplied by the 
tendons is great, nothing but hot baths, hot poultices at night, and long- 
continued massage and movements will effect any good. 
Thecitis of the fingers rarely undergoes resolution, and when once estab- 
lished nothing short of a free incision down to the bone will put an end to 
the inflammation. To wait until suppuration takes place is to expose a 
phalanx to almost certain death from necrosis. In all cases where suppura- 
tion is present, the earliest opportunity must be taken to liberate the pus by 
free incision. 
When there are signs of a gouty, rheumatic, or syphilitic origin in this 
disease, the proper remedies for the inflammation of the tendons will be 
iodide of potassium, colchicum, and guaiacum, preceded by a mercurial 
purge, and followed by properly-regulated diet. 
Affections of the Bursae Mucosae—Ganglions. 
Properly to understand the nature of bursal swellings it is necessary to 
consider a few points connected with the histology of the bursal membranes. 
These membranes are of three kinds,—the subcutaneous, placed over salient 
points of the skeleton ; tho tendinous, or those connected with the tendons; 
and the subtendinous, or those lying beneath the tendons and their sheaths. 
Subcutaneous Bursae.—The subcutaneous bursae exist both as normal or 
physiological sacs and as pathological productions, the result of pressure. 
Excellent examples of the latter are seen in certain varieties of talipes, 
where the patient is obliged to rest the weight of the body on the dorsum of 
tho foot. This form of bursa disappears spontaneously as soon as tbe cause 
which called it into existence is removed. The manner of its formation is 
readily understood by recalling tho anatomical peculiarities of the subcu- 
taneous connective tissue, which consists of highly elastic and extensible 
filaments with intermediate and communicating spaces which contain nor- 
mally a serous moisture. Two kinds of cells exist in these spaces, the one 
lying free, probably lymph-cells, and the other adhering to the bundles of 
connective tissue,—flat, nucleated, endothelial cells. When unusual pressure AFFECTIONS OF THE MUSCLES, TENDONS, AND BUIISJE. 
is concentrated upon a certain part of the body, the fibres of the subcutaneous 
connective tissue are pressed aside and crowded together, by which displace- 
ment the normal interfascicular spaces are enlarged. The effect of this 
pressure is a subacute inflammation, which results in an increased serous 
transudation and active endothelial proliferation. The centrifugal effect of 
this process is to enlarge still further the dilated spaces and condense more 
and more the bundles of connective tissue which surround them, until a mem- 
brane is formed. At length a number of these enlarged areolae become con- 
fluent by the absorption of intermediate bands of connective tissue at points 
where the pressure is greatest, and there results a well-formed cavity, the 
walls of which are lined by a layer of endothelial cells, from which layer, 
with the contiguous blood-vessels, is derived the viscid synovia-like secretion 
which occupies the interior of the sac. 
Bursitis.—An inflammation of one of these bursal sacs is followed by an 
increased accumulation of the normal bursal fluid, mingled with a serous or a 
sero-fibrinogenous transudation, and constitutes bursitis. 
The subcutaneous bursae which usually come under the attention of the 
surgeon are those in front of the patella, over the trochanter major, the 
tuberosity of the ischium, the olecranon process of the ulna, the acromion 
process of the scapula, in front of the hyoid bone and the thyroid cartilage, 
and occasionally over the knuckles of the fingers. 
Tendinous Bursae.—The tendinous bursae are connected with the tendons 
or their sheaths, and are formed from the delicate membrane (a closed sac) 
which invests the one and lines the other, much in the same manner as the 
pleura and the peritoneum line the walls of their respective cavities and 
cover the contained viscera. The tendinous bursae partake more of the 
nature of synovial membranes than either the subcutaneous or the subtendi- 
nous, the secretion of the former resembling very much, both in its physical 
characteristics and in its chemical constitution, the true synovial fluid, while 
the secretion in the other adventitious bursae is more like thick, ropy mucus. 
The manner in which tendinous bursae form is not entirely understood. I 
am led to believe, from my own observations, that these swellings begin in 
the same manner as do the little protrusions in a sacculated bladder. A few 
filaments of the connective tissue, which constitutes the exterior wall of the 
membranes inclosing the tendon, give way, either as a result of violence or 
from inflammatory distention, and this change allows the deeper part of the 
membrane to protrude outwai'dly. The protrusion continues to increase, 
owing to an accumulation and admixture of synovial and inflammatory fluids, 
until a tumor is formed. 
(Fig. 2014.) During 
the process described, 
the sacculated portion 
of the membrane be- 
comes thickened by 
lymph, and it may at 
the same time become 
identified with the sub- 
cutaneous connective 
tissue. 
The most common 
sites of tendinous bursfe 
are on the back of the 
wrist or in front of the 
wrist, in which cases the bursse are connected with the sheaths of the ex- 
tensor and flexor tendons of the fingers; not unfrequently they are seen in 
the course of the long head of the biceps, or on the tendons of the hamstring, 
popliteus, or peroneus longus muscles. 
Fig. 2014. 
Schematic bursa: A, tendon; li, synovial sheath diluted into a sac C 
through a rupture or thinning of the fibrous layer of tissue inclosing the 
synovial membrane at B; D, skin and subcutaneous connective tissue. INFLAMMATION OF BURSAE. 
397 
The subcutaneous bursce are very numerous. The most important in a surgi- 
cal sense are situated as follows: beneath the tendo patellae; over the tubercle 
of the radius; beneath the tendon of the flexor biceps cubiti; under the origin 
of the gastrocnemius from the posterior parts of the condyles of the femur; 
between the trochanter major and the tendon of the glutaeus maximus ; be- 
tween the ilium and the psoas magnus and iliacus internus muscles; between 
the tendon of the flexor biceps cruris and under the membranous expansion 
derived from the tendons of the sartorius, gracilis, and semitendinosus mus- 
cles, near their insertion on the tibia; beneath the tendons of the scapulo- 
humeral muscles, and between the tendo Achillis and os calcis. The possible 
communication of some of these burs® with the joints near which they are 
located must not be forgotten. Such communication is especially probable 
in the case of those sacs which are situated under the tendon of the patella 
and the heads of the gastrocnemius, communicating often with the knee- 
joint; and the tendons of the scapular muscles may in like manner have 
burs® which communicate with the shoulder-joint. 
The diseases to which the bursae are subject are inflammation, suppuration, 
fibrous transformation, and fibrous concretions. 
Inflammation of Bursae is generally produced by external or traumatic 
causes, or by excessive muscular exertion. House-maid’s knee, or inflamma- 
tion of the subcutaneous bursa in front of the patella, is an excellent illus- 
tration of traumatic inflammation, and the ganglion which appears on the 
hack of the wrist, especially in women who practice much at the piano, 
illustrates bursal inflammation due to over-exercise. 
Bursitis, if acute, is attended with great tenderness, pain, swelling, in- 
creased heat, and a slight degree of redness of the superincumbent skin, 
all the symptoms being intensified by pressure or movement. In severe 
cases of the disease the parts become dusky red, swollen, and cedematous 
for some distance beyond the inflamed sac, and the attack is accompanied 
by marked constitutional disturbance, which is evinced by an elevated tem- 
perature, headache, coated tongue, and disordered digestion. 
When the inflammation terminates in suppuration, the event is announced 
by the subsidence of the acute local symptoms and probably by the occur- 
rence of a rigor. The pus, instead of being healthy or laudable, is usually 
less consistent than it should be, straw-colored, and mingled with fragments 
of lymph. Ulceration may follow and leave a very troublesome, unhealthy 
sore to heal, or abscesses may form in the cellular tissue exterior to the 
bursae, and produce irregular sinuses or burrows through the adjoining tis- 
sues, which, unless carefully studied, are liable to be regarded as originating 
in subcutaneous openings in the sac of the bursa. 
More commonly the inflammation of burs® is of a very chronic character, 
and, except for the presence of the swelling, would scarcely be recognized 
by the patient. The changes which follow affect the sac and its contents. 
The former, like the pleura in old cases of subacute pleurisy, becomes greatly 
thickened by successive stratifications of false membrane, until the entire sac 
is converted into a pseudo-fibroma. This transformation occurs most com- 
monly in house-maid’s knee. 
Contents of bursce.—The contents of bursae are either fluid or solid. The 
bursal fluid is of a jelly-like consistence and of a white or yellow color, 
or it may have a cloudy, gruel-like appearance, sometimes resembling thin 
starch, intermingled with small masses of disorganized fibrin. Sometimes 
the fluid accumulation is large, and the fluid itself is straw-colored, viscid, 
and without admixture with other substances. Another singular effect of 
this low grade of inflammation on the contents of these sacs is the formation 
of numerous fibrous or fibro-cartilaginous concretions, some flat, others oval, 
like grains of rice (Fig. 2015), and either of a white or a faint-yellow color. 
Such bodies belong especially to those bursae which are connected with the 
tendons and their sheaths. They are particularly abundant at times in the 398 
AFFECTIONS OF THE MUSCLES, TENDONS, AND BURSAL 
great carpal bursa, from which I have removed large numbers through a 
small puncture. Their presence can he placed beyond conjecture by the 
peculiar crepitating sensation imparted to the 
lingers on pressure. 
These formations originate probably in one of 
two ways. The shapeless fragments of inflam- 
matory lymph which float loose in the sac may 
assume the characteristic forms by attrition 
under the to-and-fro play of the tendons, just as 
pebbles are rounded by the action of currents of 
water, or they may be formed by the fibrinous 
deposits on the inner surface of the sac becoming 
detached. 
The fluid contents of hursce.—Among the less 
common contents of bursse are blood-clots and 
calcareous concretions, the former the result of 
a contusion or bruise, and the latter arising from the retrogressive changes 
or degenerations which inflammatory products may undergo. 
Diagnosis.—It is usually not difficult to diagnose a bursal swelling. The 
location of the tumor, and its relation to certain tendons, the boundaries 
which circumscribe its site, its doughy, crepitating, creaking, or occasion- 
ally fluctuating feel, our ability in some cases, when the sac is connected 
with the sheaths of tendons, to dislodge the contents of the swelling, and, 
above all, the revelations of the exploring needle, will enable the surgeon to 
recognize the character of the affection beyond peradventure. 
Bursae located in the ham and in the axilla, and contiguous to the popliteal 
or the axillary artery, have been mistaken for aneurism; but if the distinction 
between pulsation and bruit is recognized,—the latter being an aneurismal 
sound, and the former communicated to any tumor by juxtaposition,—and if, 
in addition, it is found that pressure on the main artery on the cardiac side 
of the enlargement produces no effect on the size of the tumor, the idea of 
aneurism may be confidently dismissed. 
Treatment.—Acute bursitis, if taken in hand early, is a manageable 
affection. A few leeches applied a short distance from the swelling, and the 
application of a lotion of lead-water and laudanum, followed by one consisting 
of tincture of iodine and tincture of belladonna, will suffice, the surgeon at 
the same time enforcing perfect rest by the addition of a splint. 
Chronic bursal tumors demand a very different mode of management, as 
they are seldom amenable to ordinary antiphlogistic or alterative remedies. 
Tho treatment must be determined by the position of the bursa and its sur- 
rounding relations. 
Fig. 2015. 
Interior of a carpal bursa, showing 
rice-like bodies. 
House-Maid’s Knee.—This is one of the most common of the class of 
tumors under consideration, the bursa affected being that in front of the 
patella. (Fig- 201G.) It is produced by the pressure incident to occupa- 
tion. It is a prominent, hemispherical, fluctuating swelling, attended, unless 
acutely inflamed, with but little sensibility, and is inconvenient only from 
its bulk and from the effects of pressure when the patient is kneeling at her 
work. 
There are three effective means of treatment,—the seto~, injection, and 
excision. 
The use of the seton or of injection is to be preferred to excision, and I do 
not think it matters much which of the two is selected. 
In the use of the seton, it is only necessary to puncture the bursa with a 
sharp-pointed bistoury, squeeze out the contents of the sac, and, before with- 
drawing the knife, pass along its blade, as a director, a needle armed with 
three or four silk threads. A counter-puncture is made with the needle 
through the opposite side of the swelling, and the threads are then tied in 
a loop, made loose in order to allow for swelling. The subsequent treatment POSTERIOR CARPAL BURSA. 
399 
consists in placing the limb upon a posterior splint and confining the patient 
to bed in the recumbent position. The suppuration which arises is followed 
by the gradual contraction of the cavity of the bursa, until at last little more 
than a sinus remains, in which lie the threads, when the 
latter may be removed. The time required for the cure 
seldom exceeds two weeks. 
When the treatment by injection is adopted, the con- 
tents of the bursa should be pressed out as much as pos- 
sible through an opening made with a sharp-pointed 
bistoury, after which the tincture of iodine should be 
thrown into the sac by means of a syringe, carrying the 
nozzle of the latter fairly into the cavity of the bursa 
before withdrawing the knife, when the bistoury is used, 
and keeping the sides of the orifice closely against the 
nozzle ot' the instrument during the injection, in order to 
prevent the fluid from entering the surrounding cellular 
tissue. When the trocar is employed, the presence of the 
canida does not necessitate these precautions. The object 
in emptying the sac of its contents before introducing the 
iodine is to avoid the formation of a hard, insoluble com- 
pound which results from the contact of iodine with the 
bursal fluid, and which, acting as a foreign body, is liable 
to create a troublesome suppuration. During the progress 
of the cure the parts should be covered with a piece of 
lint moistened with carbolated oil; and as soon as the inflammatory tender- 
ness begins to wane, pressure, either with a roller or with adhesive plaster, 
will facilitate the cure. 
Excision will become necessary when the bursa has undergone a fibrous 
transformation, a change readily detected by the solid character of the 
tumor. When performed, it should be practiced with antiseptic precautions. 
Fig. 2016. 
House-maid’s knee. 
Posterior Carpal Bursa or Ganglion.—This very common bursal tumor, 
situated on the hack of the wrist, and connected with the extensor tendons 
of the fingers (Fig. 2017), occurs most frequently in women, and is com- 
monly followed by some 
degree of weakness and 
disability in the wrist and 
fingers. 
The operations performed 
for the cure of the tumor 
are pressure, subcutaneous 
irritation conjoined with 
pressure, rupture, and the 
seton. 
When the ganglion is 
recent and small, pressure 
alone, assisted by rest, will 
often effect a cure. A piece 
of coin or lead wrapped in 
a single ply of old linen, laid upon the swelling and made secure by slipping 
over the wrist an elastic armlet composed of silk and gum, will answer; and 
after the application the hand is to be placed on a palmar splint and sup- 
ported by a sling. 
When subcutaneous irritation is practiced along with pressure, before ap- 
plying the latter an exploring needle should be introduced into the sac and 
its interior well scratched. 
Rupturing the sac and allowing the contents to escape into the cellular 
tissue is an old and a very effectual method of disposing of wrist-ganglia. 
While the hand is strongly flexed, so as to render the walls of the sac tense, 
Fio. 2017. 
Posterior carpal bursa.  AFFECTIONS OF THE MUSCLES, TENDONS, AND BURSAE. 
400 
the tumor is to be forcibly struck: a book is generally used for this purpose. 
The operation is appropriate to thin-walled cysts. 
I find, however, in nry own experience that the seton is entitled to most 
confidence. The surgeon, placing the open hand on a table and making the 
tumor tense by firmly supporting its sides between the thumb and the middle 
finger, or by flexing the hand, thrusts a straight, sharp-pointed bistoury into 
its interior, squeezes out the vitreous-looking contents, and then with a needle 
slid along the blade of the knife introduces two or three fine silk threads, 
the ends of which are knotted loosely together. The hand and forearm are 
immediately laid on a splint and supported by a sling. Twenty-four hours 
after the operation, one of the threads is to be withdrawn ; after the lapse of 
another twenty-four hours, a second; and on the third or fourth day, the 
remaining thread. By this time sufficient inflammation will have been de- 
veloped to insure the removal of the bursa. After the removal of the last 
{>ortion of the seton, a compress and roller applied over the bursa, or, in 
ieu of the latter, a strip of adhesive plaster, will favor the cure, during 
the progress of which the splint must not be laid aside. 
Excision, if done under strict antiseptic precautions, may be adopted when 
other measures fail. 
Anterior Carpal Bursa is a formidable affection, inasmuch as the synovial 
sheath is common to all the tendons passing under the annular ligament 
except that of the long flexor of the thumb. The swelling, when large, pro- 
jects chiefly above the annular ligament. In time the palmar fascia yields, 
and then the bursa assumes an 
hour-glass form, the central con- 
striction being made by the carpal 
ligament. (Fig. 2018.) There will 
be no risk of confounding the dis- 
ease with any other. A good diag- 
nostic mark is afforded by the soft, 
crepitating, compressible nature of 
the swelling, which can, by press- 
ure applied alternately above and 
below the annular ligament, be 
forced into the palm of the hand 
and back again to the wrist. 
When the bursa is connected 
with the tendon of the flexor lon- 
gus pollicis, the swelling assumes somewhat the shape of the ball of the 
thumb. (Fig. 2018.) 
The treatment of anterior carpal bursa is often very perplexing. Any 
attempt to lay open the sac or dissect it out would be rash in the extreme. 
I have seen a hand lost in consequence of such a procedure; and death has 
been known to follow it, the inflammation and resulting suppuration extend- 
ing into all the tubular prolongations of the bursa and entirely disorganizing 
the member. When the swelling becomes inconveniently large, 1 am con- 
tent to puncture tbe sac and force out its contents (which are particularly 
rich in rice-like bodies), following up the operation by pressure and rest. 
ITnder repeated tappings, followed by pressure, these sacs will often sensibly 
diminish, and sometimes will entirely disappear. 
Fig. 2018. 
Anterior carpal bursa, and bursa of the long flexor tendon 
of the thumb. 
Bursae of the Extensor Muscles of the Thumb.—A remarkable case of this 
kind occurred in an elderly woman who applied for relief at the clinic of 
the University. The tumor, which involved the synovial membrane of the 
extensor ossis metacarpi pollicis and the extensor primi internodii pollicis, 
resembled in shape an immense sausage, having several constrictions, and 
extending from the proximal end of the last phalanx of the thumb three and 
a half inches up the posterior surface of the radius. The hand was entirely BURSA TENDINIS PATELLAE. 
401 
useless. (Fig. 2019.) Under the circumstances, excision seemed to be the 
only resort. The sac was removed by a careful dissection, and recovery fol- 
Fig. 2019. 
Bursa of the extensor muscles of the thumb. 
lowed, although there resulted some impairment of the normal functions of 
the thumb. 
Subdeltoid Bursa.—The sac placed beneath the deltoid muscle is liable to 
become diseased in consequence of blows, sprains, and other injuries. The 
disease causes more or less stiffness and soreness of the shoulder, with im- 
paired movements of the arm. When the contents accumulate to any great 
degree, the swelling may be detected projecting into the axilla, but receding 
when the arm is elevated and the deltoid relaxed. 
As this bursa not unfrequently connects with the shoulder-joint, no med- 
dling is desirable unless the tumor by its size produces a degree of disability 
in the arm which necessitates interference, and then the surgeon’s efforts 
should be limited to simple tapping. 
Anterior Femoral Bursa.—This bursa, which lies under the muscles in 
front of the thigh and extends between the latter and the synovial mem- 
brane of the knee-joint, is liable to be mistaken, when it becomes enlarged, 
for intra-articular effusion or hydrops articuli. In enlarged anterior femoral 
bursa, however, the swelling never obliterates the depressions on each side of 
the patella, nor does it extend down below the upper border of that bone. 
The fluctuation will also be differential, being recognized only in front of the 
thigh, and not down the sides of the joint. 
The treatment demanded is rest, with the leg in the extended position, the 
affected member being placed on a postei’ior splint, with blisters over the an- 
terior surface of the swelling,—the blisters to be followed by the local use of 
tincture of iodine and compression. 
Bursa Tendinis Patellae.—This bursa lies between the tendon of the patella 
and that portion of the tibia above its tubercle. The relation of this bursa 
to the knee-joint is such that no hasty or radical measures of an operative 
kind are permissible. The character of the swelling will be apparent from 
the manner in which the sac presses out on each side of the tendon of the 
patella. Chronic inflammation, when once located in this bursa, yields very 
slowly to treatment, often requiring several months for its removal. The 
disease entails considerable weakness of the knee, incapacitating the patient 
for taking much exercise either on foot or on horseback, since any flexion 
of the limb is attended with discomfort. 
To treat this affection successfully, the joint must be fixed by encasing it 
in either a leather or a plaster splint. If the plaster roller is used, a trap 
should be cut in the bandage, after it hardens, in front of the tendo patellae, 
through which external applications can be made. A succession of small 
blisters may next be applied alternately on the two sides of the tendon. 
After this treatment has been continued for six or eight weeks, the tinc- 402 
AFFECTIONS OF THE MUSCLES, TENDONS, AND BURSAE. 
tures of iodine and belladonna may be freely painted over the surface. 
Though walking is to be interdicted, the patient need not be confined to the 
house during the treatment. Should the disease not yield, it will be neces- 
sary to make a new impression upon the interior of the sac, displacing one 
form of inflammation by creating another. This can most safely be done by 
introducing into the bursa a stout needle and scratching the inner surface of 
the sac in different directions. This operation will probably be followed by 
some increase of heat, swelling, and soreness, during the period of which both 
local and general rest become imperative. As soon as these symptoms begin to 
subside, an ointment consisting of mercury, iodine, and iodoform (unguentum 
hydrargyri, unguentum iodinii, aa gss, iodoformi, gr. xl) should be rubbed into 
the parts daily: this should be followed by compression with adhesive strips. 
Trochanteric Bursa.—Enlargement of this bursa, placed between the great 
trochanter and the tendon of the gluta?us maximus, is attended with swelling, 
tenderness on pressure, and pain on internal rotation of the thigh. The 
patient soon acquires the habit of walking with the toes everted, and with a 
slight inclination of the pelvis towards the affected side, positions which, by 
relaxing the gluteeus maximus muscle, relieve the bursa from pressure. The 
disease has in most cases an acute origin, and, if detected early, is generally 
amenable to treatment. 
Eest, blisters, and pressure includo the therapeutic means for cure. Should 
suppuration occur,—a result to be avoided, if possible,—the pus should be 
evacuated by incision, and the sac washed with a solution of iodoform. 
Chronic cases which resist other treatment require that the bursa be 
punctured with a trocar, its contents evacuated by pressure, and one or 
two fluidrachms of the tincture of iodine thrown into the sac through the 
canula. After the operation the patient must remain quiet for twelve or 
fourteen days, pressure in the mean time being made over the bursa as soon 
as the acute symptoms following the injection have begun to disappear. 
Bursae beneath the tuberosities of the ischii are to be treated on the same 
principles as those over the trochanter major. 
Popliteal Bursa.—It has already been stated that certain bursae in this 
region, as those beneath the heads of the gastrocnemii, especially the inner 
head, may communicate with the knee-joint,—a fact which must have an 
important practical bearing upon their treatment. The chief interest, there- 
fore, connected with these formations centres in the diagnosis, or in our 
ability to differentiate those which do and those which do not communicate 
with the knee-joint. In the very beginning of the disease the locality of 
the swelling possesses a differential significance; but, as in most cases the 
surgeon is not consulted for some time after the trouble appears, this feature 
loses much of its value, inasmuch as all these bursee have a tendency ulti- 
mately to reach the middle of the popliteal space. The most reliable sign of a 
popliteal bursa having a continuity with the synovial membrane of the joint 
is its reducibility. If on pressure, with the knee flexed, the swelling dis- 
appears, the evidenco is strongly in favor of such a connection. This evi- 
dence will be still more conclusive if on emptying the popliteal sac there 
follows an appreciable enlargement of the articulation, indicating that the 
synovial membrane has been distended in order to accommodate the contents 
of the tumor. 
The treatment of extra-articular burs® in the popliteal region does not 
differ from that applicable to bursa? in general. As they are usually the re- 
sult of some extraordinary muscular effort or sprain, they may be expected 
to recover under rest, blisters, and compression. 
Those bursa?, however, which extend into the joint are on no account to 
be made the subjects of operation. I have found that by attaching to a 
twilled muslin knee-cap a chamois pad in such a position that when the AFFECTIONS OF THE APONEUROSES. 
403 
former is laced around the joint firm pressure will be made over the swell- 
ing, and enjoining caution in the use of the limb, patients get along without 
any serious inconvenience. 
Bursae beneath the Sartorius, Gracilis, and Semitendinosus Muscles.—On the 
inner surface of the tibia, external to the tubercle, there is a remarkable 
fibrous expansion, derived from the tendons of the aforementioned muscles, 
beneath which is situated a bursa which is subject to inflammation from 
contusions, and these, if neglected, may end in suppuration. When in- 
flamed, there will be experienced a certain amount of swelling and tender- 
ness, circumscribed by the limitations of the tendinous expansion, and the 
limb will be comfortable only when in the flexed position. 
The remedies are rest, with the leg semiflexed, leeches, anodyne lotions, 
blistering, and, finally, the tinctures of iodine and belladonna brushed daily 
over the region of the bursa. 
Bursa of the Tendon of the Peroneus Longus Muscle.—Where the tendon 
of the peroneus longus enters the groove of the cuboid bone there exists a 
synovial membrane which accompanies the tendon to its destination. This 
membrane is often the seat of inflammation, producing an obscure kind of 
lameness, the cause of which, unattended as it is by swelling, is frequently 
overlooked, or not even suspected. A curious coincidence in connection 
with bursa of the limbs occurred in the course of my professional work 
during the winter of 1881-82. A lady, while riding in the streets of Rome, 
Italy, was thrown from her carriage by the horses attached to it taking 
fright. Another lady, who witnessed the accident, jumped from her own 
conveyance in order to render assistance to the stranger. In this friendly 
encounter both were injured, though not disqualified for travel or study. 
On their return to Philadelphia, some months later, I was consulted at the 
same time by these ladies, both of whom were quite lame. In one, the source 
of the disability was an enlarged bursa beneath the tendo patellae; in the 
other, an inflammation of the synovial membrane of the tendon of the pero- 
neus longus muscle. The latter difficulty may be suspected when, in the 
absence of any sore on the outer side of the sole, the patient is observed to 
walk on the inner border of the foot, a position which relaxes the affected 
tendon in the cuboid groove. If, in addition to this sign, pain is experienced 
on pressing over the latter region, the diagnosis will be assured. 
Rest, with the foot in the position of abduction, and the application of 
blisters over its outer border, constitute the remedial management. In one 
case, that of a patient who from force of. circumstances could not be in- 
duced to remain quiet, I effected a cure by compelling her to wear a shoe 
the sole of which was made high on the outside, thus throwing the weight 
of the body on the inner border of the foot. 
Calcaneal Bursa.—This bursa is interposed between the os calcis and the 
tendo Aehillis. It is exposed to contusions, and when inflamed is attended 
with tenderness on pressure, and with pain when the foot is flexed on the leg. 
The pain and tenderness compel the patient to walk with the leg flexed, rest- 
ing the weight of the body on the toes, positions which relax the muscles of 
the calf of the leg and relieve the bursa from pressure. 
The treatment consists in blistering and rest with the leg partly flexed. 
Affections of the Aponeuroses. 
The aponeuroses play a very important part in the human economy, and 
have considerable interest for the surgeon, not so much from any special 
inherent tendency to disease which they possess, as from their power to 
limit morbid action, from the influence they exert on the products of inflam- 
mation and on the action of muscles. It cannot be doubted that strong 404 
AFFECTIONS OF THE MUSCLES, TENDONS, AND BURSAE. 
fibrous membranes like the fascia lata of the thigh or the deep cervical 
fascia, possessing little vascular connection with the parts which they sepa- 
rate, must offer an important barrier to the extension of inflammation or 
suppuration from the superficial tissue-planes to the deep parts of these 
regions. At the same time, it must not be forgotten that for the same reason 
these membranes, by resisting the passage of inflammatory productions 
towards the surface, often conceal and favor a vast amount of disorganiza- 
tion in progress below. 
Punctured wounds of the aponeuroses are regarded as notably dangerous, 
on account of the violent nervous symptoms which often follow their inflic- 
tion. I do not think these phenomena depend so much on the mere fact of 
the aponeurosis having been injured as on the resistance which it offers to 
the inflammatory products that accumulate beneath. 
The practical lesson which the peculiarity of structure of the aponeuroses 
inculcates in various injuries is the necessity on the part of the surgeon of 
always being on the alert to detect possible deep or hidden mischief. He 
must not forget the importance, in case of the development of nervous 
symptoms following punctures of these membranes, of converting the 
punctured into an incised wound. 
Another accident which will demand surgical attention is rupture of an 
aponeurosis, giving rise to muscular displacement or hernia. Should the 
fascia lata on the outer portion of the thigh be torn, the vastus externus 
muscle on contracting will start out from its bed, and the displacement will 
defeat the legitimate action of the muscle. The same will happen to any 
muscle not securely united to adjoining parts, when the resistance of its 
fibrous case is lost. The important part the aponeurosis plays in the proper 
application of muscular force will be apparent when we consider that the 
principal aponeuroses are always supplied with a specific muscular tensor. 
Rheumatic and gouty inflammation must be recognized as one of the dis- 
eases of the aponeuroses. The contracted finger of Dupuytren, in which the 
palmar fascia undergoes contraction and thickening, is a case in point. CHAPTER XXXIII. 
SURGICAL AFFECTIONS OF THE NERVES. 
The nerves are not more exempt from diseases and injuries than are 
the other tissues of the body. There is a relation subsisting between defi- 
nite portions of the central nervous system and the outstanding organs in 
respect to motion, sensation, and nutrition. This relation is maintained by 
the intermediate nerves, and it is a well-established fact that in many cases 
of nerve-injury the consequent ill effects are not limited to the seat of the 
lesion, but are manifested in distant parts of the body. The secondary or 
induced lesion, for example, may be situated in the gray matter of the ante- 
rior and posterior columns of the medulla spinalis, inducing various incura- 
ble symptoms or maladies, such as infantile paralysis, wasting of the mus- 
cles, sclerosis, locomotor ataxia, etc. These physiological and pathological 
facts, taken in connection with the not less important fact of the union 
through nervous communications of very distant portions of the body in 
sympathetic relations, confer a peculiar interest on injuries of the nerves,—a 
class of lesions which may not only entail great physical disability and suffer- 
ing, but may lead to the saddest condition of mental impotency. 
The subjects proposed for consideration in the present chapter as belong- 
ing more particularly in the province of the surgeon are neuritis, wounds 
and contusions of the nerves, neoplastic growths, neuralgia, chorea, tetanus, 
epilepsy, infantile paralysis, and sclerosis. 
Neuritis.—The symptoms which attend neuritis differ according to the 
function of the inflamed nerve. When a sensory nerve is affected, the pain 
(which, as a rule, is referred by the patient to the terminal expansion of the 
nerve) may amount only to an exalted degree of sensibility, or it may be 
extremely acute, and lancinating, tearing, or burning. This peripheral 
locating of pain in cases of disease where the nerves suffer, even if they 
are not actually inflamed, is a very important feature in surgical pathology. 
Its misinterpretation has often led to serious errors in diagnosis. Thus, 
the painful but undiseased knee and ankle have many times been the sub- 
jects of active treatment when the remedies should have been directed to 
the acutely-diseased but painless hip. The urethra also has been often 
treated when the bladder or the kidney was at fault, and the face or the 
neck when a diseased tooth was the real seat of the mischief. 
The pain of neuritis, though not of an intermittent character, has periods 
of remission and exacerbation. When the severity of the inflammation has 
been sufficiently great to produce disorganization and finally destruction of 
the nerve-tissue, the destructive process will be announced by the gradual 
subsidence and final cessation of all pain, and possibly of all feeling, in the 
part to which the nerve is distributed. I say possibly, because it may be 
that branches from other sensory nerves are distributed over the region 
hitherto supplied in part by the destroyed nerve, in which case the sensi- 
bility would not be entirely lost. 
When a motor nerve is inflamed, there will be disturbances of function, in 
the form of spasms or spastic rigidity; and should the neuritis lead to the 406 
SURGICAL AFFECTIONS OF THE NERVES. 
disorganization of the nerve, the interruption of the nervous current from 
the centre will be followed by paralysis of the muscles or muscle supplied by 
the damaged nerve. 
In acute inflammation of nerve-trunks there is commonly present some 
constitutional disturbance, manifested by elevation of temperature, a frequent, 
vigorous pulse, and disorder of the secretions. 
Jn neuritis of nerves containing both sensory and motor filaments (like 
the spinal trunks or their branches) symptoms of a mixed character may be 
expected. There is usually present pain of varying intensity, along with 
disturbances of motion, such as involuntary twitchings or spasmodic con- 
tractions. 
In chronic neuritis the same sj'mptoms are present as in the acute form of 
the disease, but in a very subordinate or less pronounced degree. 
Neuritis is liable to extend by continuity of structure along the affected 
nerve both in ascending and descending directions, particularly the former, 
and it is to this central tendency of the inflammation (ascending neuritis) 
that Leyden and others ascribe the myelitis which occasionally follows old 
cases of pelvic inflammatory diseases, wounds, and contusions. It is not 
improbable that vesical paralysis following chronic originates in 
this manner. The theory of a continuously-ascending neuritis is at least 
as probable as that of Leyden and Feimberg, which ascribes certain inflam- 
matory conditions of the medulla spinalis to a remote neuritis, the inter- 
mediate portion of nerve between the latter and the spinal cord remaining 
unaffected. 
Causes.—Among the causes of neuritis are cold and damp curi’ents of air 
continuously directed upon a part for some time. Neuritis may arise from 
altered states of the blood, such, for example, as occur in syphilis, typhoid 
fever, scarlatina, and diphtheria. It may arise secondarily by an extension 
of inflammation from the adjoining parts. Such a neuritis is sometimes seen 
after fractures of the vertebrae or of the ribs, or it may occur in caries of the 
same structures. Malignant growths, while pushing their way into every 
accessible space, may also produce neuritis. 
Diagnosis.—As the phenomena which we have detailed as symptoms of 
neuritis in sensory and motor nerves may also be produced by reflex causes or 
by pathological changes in the brain or the spinal marrow, it will be necessary 
to differentiate these conditions, and to trace the disturbances of function to 
their proper source. In neuralgia the pain may be as severe as that of acute 
sensory neuritis, but in the latter affection there are no periods of complete 
intermission, nor is there that tolerance to external pressure over the line of 
the region of the inflamed nerve which exists in neuralgia. 
Pathology.—Among the pathological changes seen in neuritis are a hyper- 
semic condition of the blood-vessels and a resulting transudation which takes 
place into the inter-fascicular connective tissue of the nerve. The increased 
vascularity imparts a red color to the inflamed nerve, and the interpenetrating 
transudation (which has a serous, sero-fibrinous, or sometimes a sanguinolent 
character, with leucocytes) separating the fasciculi gives to the cord a swollen 
appearance. 
The power of the nerves to resist the effects of inflammation is in a great 
measure due to anatomical peculiarities, their sheaths being laminated and 
their blood-vessels remarkable for freedom of inosculation. The lamination 
of the nerve-sheaths is unfavorable to the wide diffusion of inflammatory 
products, while the free inosculation of the blood-vessels insures a proper 
supply of pabulum. If resolution occurs, the inflammatory products are 
mostly removed, the liquid portions of the exudation being returned into the 
blood-vessels, and the more consistent portion disposed of by fatty and other 
metamorphoses, while the structure of the nerve escapes without damage. 
If, on the contrary, the morbid action continues, one of two changes is 
likely to follow. The first change is in a great measure attributable to a 
mechanical cause; that is, to pressure from the accumulation of the inflam- WOUNDS OF NERVES. 
407 
matory infiltrate, which so affects the nutrition of the contents of the neuri- 
lemma that the wThite substance and the axis-cylinder undergo softening 
and granular degeneration. The other change favored by inflammation of a 
chronic character is a new formation of connective tissue developed from 
the cell-components of the infiltrate, which, assuming the characteristics of 
cicatricial tissue, produces a form of sclerosis. Either of these changes is 
likely to prove destructive to the functions of the nerve. 
Treatment.—The principal therapeutical resources at the command of the 
surgeon for the treatment of neuritis are local blood-letting, blistering, ca- 
thartics, veratrum viride to control the circulation, and anodynes to relieve 
pain or control spasm. If the patient has at any time been a subject of 
rheumatic gout or of syphilis, the probability of such a complication should 
suggest the propriety of administering iodide of potassium, with colchicum 
and belladonna. 
Wounds. 
Wounds of nerves may bo contused, lacerated, punctured, or incised. 
Contused injuries of nerves vary in severity from a slight compression or 
packing together of their fibres to complete crushing, and are followed by 
numbness, tingling, and pain, and by loss of power if the nerve is a motor 
one. What may be called a modified contusion of nerves may result from 
the pressure of growing tumors ; and this pressure in time may seriously im- 
pair the functions of the injured nerves. The pressure may be exerted in 
two ways, either by the neoplasm resting upon the nerve or by the latter 
overlapping the growth. The former relation is more dangerous to the 
structure of the nerve than the latter. It is remarkable to what an extent 
a nerve may be expanded or flattened and yet afterwards recover itself. 
Twice have I removed tumors from the forearm in which the median nerve 
was spread out over the growth. In one of the cases the expansion had 
gone on to such a degree that all traces of nerve-tissue had disappeared: in 
fact, the nerve had been expanded into a thin membrane which resembled a 
layer of fascia, the nature of which could be determined only by finding it 
to be continuous with the nerve-trunk above and below the tumor. Not- 
withstanding the fact that the power of the muscles supplied by the median 
nerve had in this case been largely lost, yet after the removal of the tumor 
the muscles recovered their wonted energy, care having been taken to pre- 
serve the layer of flattened nerve-tissue. Nerves are frequently contused in 
luxations by the head of the displaced bone. The numbness felt in the 
fingers and in the foot in certain varieties of luxation of the htunerus and 
of the femur is due to nerve-contusion and pressure. 
Ligature.—There is another kind of contusion, of a very concentrated or 
intense character, from which a nerve occasionally suffers,—namely, that 
arising from inclusion by ligature. This condition is generally accidental, 
and is produced during the ligation of arteries. This accident, I doubt not, 
occurs much more frequently than is generally supposed. The symptoms 
which may follow the ligation are pain, spasm, and at times tetanus. I re- 
member the case of a man whose leg had been amputated, and who some 
days after the operation was seized with lock-jaw and died. On examining 
the stump, one of the tibial nerves was found included in the ligature along 
with the artery. The patient had suffered severe pain after the amputation. 
Numerous instances of a similar nature have been recorded by surgical 
writers. 
Dr. Thomas G. Morton has described a painful condition of the ante- 
rior cushion of the foot, which, without doubt, is to be attributed to compres- 
sion of a digital nerve between the heads of contiguous metatarsal bones. 
Pain is experienced on walking, which can be very accurately referred to 
its proper source by firm pressure made over the metatarso-phalangeal part 408 
SURGICAL AFFECTIONS OF THE NERVES. 
of the sole of the foot, or by crowding together the anterior extremities of 
the metatarsal bones. The disability is induced by wearing too narrow 
shoes. 
Laceration of nerves is a common occurrence in railroad injuries and in 
the accidents which take place in manufacturing establishments: it some- 
times happens also in forcible attempts to reduce old dislocations. 
Punctured wounds of nerves are produced by needles, spicula of bone, 
splinters of wood, pieces of glass, and sharp-pointed instruments; and such 
injuries are often followed by serious consequences. The immediate sensa- 
tions following the injury are sharp, lancinating pains darting up or down 
the course of the nerve and its branches, often succeeded by tingling, mus- 
cular spasms, tremblings, etc. 
Incised wounds of nerves are either complete or incomplete. Complete 
division is followed by loss of sensibility or motion, or of both,—according to 
the functions of the injured nerve,—together with diminution of heat over 
the terminal distribution of the nerve. 
When the division is incomplete, tingling, numbness, and diminished power 
will be experienced in the region to which the nerve is distributed. 
The relation between inflammation in particular organs and nerve-injury is 
illustrated by the broncho-pneumonia following wounds of the pneumogastrie, 
and by the sclero-keratitis and conjunctivitis sometimes succeeding division 
of the ophthalmic branch of the fifth pair of nerves. 
Nerves of Special Sense.—Injuries to nerves of special sense may be fol- 
lowed by suspension or complete loss of function. Contusion of the olfactory 
bulbs by a blow on the nose is frequently followed for a time by loss of smell. 
Loss of hearing may result from violence applied to the head, in which case 
the cranial vibrations reach the seat of the auditory nerve and produce some 
lesion in it. A wound of the optic nerve deprives the patient of sight on the 
injured side, and a like injury to the lingual branches of the inferior maxil- 
lary and the glosso-pharyngeal nerves will prove destructive to the sense of 
taste on one side of the tongue. 
The sensations which accompany Avounds in nerves of special sense are 
of a different character from those which attend similar accidents to other 
nerves. When partial or incomplete, the resulting phenomena consist in 
eccentric disturbances of function, but, as a rule, pain is not present. Thus, 
coruscations of light, double vision, etc., may be experienced when the injury 
involves the optic nerve; when the auditory nerve is injured, the patient per- 
ceives muffled and explosive sounds; and when the olfactory or the gustatory 
nerve is involved, perverted smell or taste may result. 
Healing of Nerves.—The division of a nerve is followed by retraction of 
its ends, but not to the extent of that which follows the severing of a tendon 
or of a great blood-vessel. The subsequent process of healing, whereby the 
divided ends are again united, is still a subject of controversy, many ob- 
servers believing that it differs materially from the process of repair in other 
tissues. Until a comparatively recent period the regeneration of nerve-tissue 
once destroyed was believed never to take place, the bond of union between 
the ends of cut nerves being supposed to remain permanently fibrous. The 
occasional restoration of function, however, is undeniable, and, this being 
the case, there is a strong presumption in favor of the occurrence of a 
new formation of nerve-tissue. It has been assumed that the connective 
tissue which occupies the gap between the extremities of the cut nerve may 
by contraction gradually bring the nerve-elements of the two ends either in 
contact or so nearly together that the nervous influence will pass across, just 
as a conductor, within certain limits, will take the electricity from the points HEALING OF NERVES. 
409 
of an electric machine. Such an explanation, however, is based upon the 
supposed identit}7 or close analogy of electricity and the nerve-current; and 
in any event the explanation could scarcely apply to those cases where, some 
months after the excision of a portion of a nerve-trunk, the restoration of 
function has followed. The phenomena which have been observed in con- 
nection with the reunion of divided nerves appear to place the repair of this 
tissue in a separate category, the process being quite distinct from the ordi- 
nary modes of healing. The studies of Wagner, Muller, Strieker, and Gun- 
ther have thrown considerable light on the subject of repair in nerves. Yery 
soon after the division the ends of the cord begin to degenerate. There is 
a fibrinous exudation, containing cells, which not only penetrates some dis- 
tance into the inter-fascicular spaces, but is deposited around and between the 
cut ends of the nerve. At the same time there is a degeneration in progress 
at the peripheral portion of the nerve, which results finally in the destruction 
of the medullary substance by segmentary installments, each successive por- 
tion undergoing a granular and fatty metamorphosis. At the end of fifteen 
or sixteen days the exudation, through the agency of its cells, has been trans- 
formed into connective tissue, which now establishes a bond between the 
extremities of the cord : still, the essential element of the nerve has not 
taken its place in the new tissue. When examined microscopically, the axis- 
cylinder, the net-work of the medullary layer, and Schwann’s sheath are 
found converted into new morphological elements, from which the new nerve- 
constituent of the connecting cord appears to be formed. The existence of 
chronic inflammation seems necessary for the reformation of nerve-tissue, 
and it is probable that the centre with which the injured nerve is connected 
is a factor in the process. 
Treatment.—No wound can be inflicted on the body without injury to 
nerves ; but it is only wounds of principal trunks or large branches that are 
considered to be subjects for special treatment. When the injured branches 
are not essential to the functions of sensation, motion, or both,—that is, when 
there are other branches of a like nature distributed to the same parts,—the 
treatment will not differ from that for an ordinary wound, and it will, ordi- 
narily, involve the removal of any foreign substance which may be present, 
the arrest of hemorrhage, and closure by sutures or adhesive straps, the sur- 
geon using the ordinary dressings employed in the management of wounds 
in general. Should the wound become inflamed and painful, a few leeches, 
followed by warm lotions of lead-water and laudanum, or a flaxseed-meal 
poultice, together with enforced rest, will constitute the treatment best 
adapted to meet the complication. 
if there is complete division of a nerve on which a certain group of mus- 
cles depend entirely for their nerve-supply, such as the ulnar, median, mus- 
culo-spiral, or sciatic trunk, the divided extremities of the cord should be 
brought together by sutures, very fine animal or carbolized silk threads 
being the best. The sutures should include chiefly the sheath, although if 
any doubt is entertained in regard to their security they may penetrate a 
little more deeply between the bundles of the fasciculi. Whether the animal 
or carbolized silk thread be used, the ends should be cut off close to the 
knots. The approximation of the retracted ends of a divided nerve will be 
favored by position, and that posture which best conduces to this end must 
be maintained by a splint until the union has been accomplished. When the 
case is one of nerve-contusion, like that described as occurring at the heads 
of the metatarsal bones, the end of the offending piece should be excised. 
Strict antisepsis must be observed in all these operations. 
Gluck and Vanlair, believing that suppuration about a wounded nerve, 
especially where a portion has been lost, tends to defeat its union and the 
reformation of nerve elements, have employed decalcified drainage-tubes with 
alleged success. 
Compression of nerves resulting from growing tumors is to be relieved by 
extirpation of the neoplasm. When the compression arises from contact 410 
SURGICAL AFFECTIONS OF THE NERVES. 
with the head of the humerus or of the femur in old irreducible luxations of 
these bones, a subcutaneous section through the surgical neck of the bone, as 
practiced by Mears, or excision, will bring relief. 
When a considerable portion of an important nerve is destroyed, say two 
or more inches, it is possible to supply the defect by bridging the gap with a 
nerve borrowed from a lower animal, for example, the rabbit, and, after 
freshening the ends of the injured trunk, stitching the former to the latter. 
Evil Effects following Injuries of the Nerves. 
In view of the part which the nerves play in the complicated processes of 
nutrition, and in the functions of sensation, motility, circulation, and respi- 
ration, it is not surprising that many singular phenomena should follow their 
accidents and diseases. This subject has been elaborately treated by Earle, 
Romberg, Hutchinson, Charcot, Ranaud, Brodie, Duehenne, and particularly 
by Mitchell, Morehouse, and Keen, of Philadelphia. 
Loss of Temperature.—In paralysis following the division of a principal 
nerve-trunk or resulting from central disease, the temperature of the parts 
to which the branches of the nerve are distributed is materially lowered, and 
cannot, either by natural or by artificial agencies, be elevated to the normal 
standard. Even when attacked by inflammation, as shown by Hutchinson,* 
the paralyzed parts do not attain the normal standard of heat. This loss of 
heat-producing power is often accompanied by the absence of common sensi- 
bility ; and these conditions necessarily render the paralyzed part very suscep- 
tible to external impressions, such as those produced b}r cold and pressure. A 
short exposure of a limb in this state to a low temperature may be followed 
by frost-bite and ulceration ; and if the limb is allowed to remain too long 
in one position, sloughing may follow. Hence the propriety of clothing the 
paralyzed part with additional covering, and of relieving the soft parts from 
pressure by cushions placed under the disabled member and occasionally 
moved from place to place. Frictions with the bare hand, or with stimu- 
lating liniments, will serve to maintain the temperature, by improving the 
capillary circulation of the part. 
Nutrition of the Paralyzed Part.—The changes which occur in the nutri- 
tion of a part paralyzed by the division of a communicating nerve are very 
striking, and may extend to all the tissue-components within the affected area. 
In a patient in the Pennsylvania Hospital whose sciatic nerve was cut 
by Dr. Morton for the cure of elephantiasis, the limb rapidly diminished in 
size, the skin becoming dry and covered with abundant bran-like epidermic 
scales. 
Eruptions frequently appear on the skin of a part thus paralyzed, and the 
nails become curved. 
The muscles gradually waste, and as the atrophy progresses and the sar- 
cous elements of the muscular structure disappear, its connective tissue con- 
tracts, causing shortening and rigidity ; or there may be a spastic contraction 
of the muscles without any marked atrophy, the latter being prevented by 
the irritation to which the muscular tibres are subjected. In either event 
the contraction is liable to produce permanent deformities, such as flexion 
and distortion of the articulations. 
The extent and progress of nerve-lesion maybe recorded with considerable 
accuracy by studying or testing the electrical reactions of the nerves and 
muscles,—the increasing degeneration being indicated by the lessening 
excitability of the nerves and muscles on the application of galvanic and 
faradic currents. The most hopeless cases are those in which no muscular 
contraction can be excited by the galvanic current. 
* London Hospital Reports, vol. iii. NEURALGIA. 
411 
To counteract the bad effects of these sequels of nerve-lesions it is neces- 
sary to employ repeated faradizations, frictions, and movements to improve 
the circulation and nutrition of the muscles, and splints to prevent deformi- 
ties. When muscular contractility is entirely lost, faradization is useless; 
but, as this may return after repair of a nerve, the electric test should be 
resorted to from time to time. 
Swelling of Joints.—Sudden swelling of an articulation after nerve-injury 
is sometimes observed. The most striking case of this nature which I have 
seen occurred in a lady of this city who had received a nerve-injury of the 
right leg. On two occasions, while feeling perfectly well, she was seized with 
pain in the knee, followed in a few minutes by a large effusion into the joint, 
which rendered her unable to walk. There was no local heat, tenderness, 
or redness about the articulation. The recovery after these attacks was very 
slow. I have been disposed to regard this effusion—a neuro-hydrops, as it 
might he termed—as due to a loss of power in the vaso-motor nerves which 
supply the blood-vessels of the articulation, in eonsequenco of which the 
vessels become suddenly distended with a large accumulation of blood, the 
serous portion of which is poured into the joint. 
Antiphlogistic treatment is useless in such cases, as the phenomena have 
not an inflammatory origin. Rest, compression, blistering, and tonics are 
indicated. 
Eemak and Mitchell both describe a condition of the joints, depending on 
disorder of the nerves, which resembles that arising from rheumatism, hut 
which doubtless has a chronic inflammatory basis, as would seem to be clearly 
announced in the tendency to terminate in anchylosis. 
After nerves have been punctured or only partly divided, it is not unusual 
to find the skin becoming smooth, polished, red or mottled in color, wasted, 
and hairless, the trouble being accompanied by a burning sensation and great 
hypersesthesia. Many cases of helpless, painful finger of this kind come under 
the care of the surgeon, often following what at the time appeared to be a 
very trivial injury, such as a wound from the prick of a needle or from a 
fragment of glass. The whole arm may participate in the suffering of the 
finger, its fat disappearing and the muscles becoming wasted. 
The treatment of such conditions is generally extremely tedious, and often 
discouraging. If, on examination, any localized thickening at the seat of 
the original injury can be discovered, the part should be laid open and the 
indurated portion of nerve excised. In other cases, where the burning 
pain harasses the patient, the digital nerve on each side of the finger will 
require to be exposed, and a portion of its trunk removed. The finger 
should be subjected to douches, frictions, and inunctions with belladonna 
ointment. When all these measures prove unavailing and the health of the 
patient begins to break down under the constant suffering, amputation may 
be resorted to; but even after this operation it is not impossible that the 
pain may be transferred to the parts above. 
This painful affection may result from injury or inflammation, or from 
other causes, both local and general. Among the traumatic causes are 
wounds, bruises, and irritation from spicula of bones, needles, ligatures, or 
other foreign bodies. The origin of the disease may often be traced to 
neuritis in a diseased tooth, to an old cicatrix, to the presence of a morbid 
growth pressing upon the nerve, to calculus, to anal fissures, and the like. 
The principal general causes which are concerned in producing neuralgia are 
gout, syphilis, antemia, malaria, and exposure to sudden atmospheric changes 
and alterations of temperature. Various derangements of the digestive 
organs may also produce neuralgia. 
Males and females are alike liable to attacks. Age exerts some influence, 
Neuralgia. 412 
SURGICAL AFFECTIONS OF THE NERVES. 
the young and those who are far advanced in life suffering less than the 
middle-aged. The disease is most common during the damp, cold weather 
of winter and spring. 
Symptoms.—The prominent symptom, pain, is present in neuralgia in 
varying degrees of severity and kind, sometimes being fixed and intensely 
severe, sometimes darting or shooting and radiating in one or more directions 
along the nerve or its branches; at other times dull and aching, or pungent 
and burning. Frequently the arteries are seen to throb violently and the 
veins to become distended at the seat of pain. The pain often manifests a 
tendency to periodicity, coming on at a particular time of the day, and 
either ceasing suddenly as the day declines, or wearing away in the night. 
The parts, after the subsidence or the disappearance of an attack, remain for 
some time tender to the touch. Neuralgia may appear simultaneously in 
different portions of the body, particularly when the exciting cause is a 
general one. 
Pathology.—Although nothing is positively known in regard to the path- 
ological conditions in neuralgia, it can scarcely be doubted that in many 
cases of the disease there exists some disorder of the blood-vessels of the 
affected nerve, such as congestion of its sheath, its connective tissue, or its 
neurine. At the same time, it is not difficult to comprehend how internal 
irritations, reflex or otherwise, may be communicated to a nerve-trunk and 
create a paroxysm of pain in the same manner as will an external irritant, 
like the prick of a needle or a thorn : in either case the suffering is quite 
independent of inflammatory conditions. 
Diagnosis.—It is important to distinguish between neuralgia and neuritis, 
as the treatment of the two affections is very unlike. The differential 
features of the two diseases may be contrasted as follows: 
Sudden in its onset. 
Marked remissions or complete intermissions. 
Often darts from one branch of a nerve to an- 
other. 
Rendered worse by antiphlogistic remedies. 
Relieved by firm pressure. 
Terminates suddenly. 
NEURALGIA. 
Gradual in its onset. 
Slight remissions ; no intermissions. 
Confined to the inflamed trunk or branch. 
Benefited by antiphlogistic remedies. 
Aggravated by firm pressure. 
Terminates gradually. 
NEURITIS. 
Treatment.—The treatment of neuralgia must proceed on a clear under- 
standing of the cause of the disease. Sometimes this is patent to the senses, 
and at other times it defies detection. When, however, it can be discovered 
and removed, the disorder will generally quickly disappear. 
If, therefore, a foreign substance can be detected irritating a nerve, as 
sometimes happens in neuralgia following or accompanying wounds or bone 
disease, its extraction must take precedence of all other measures. If a de- 
cayed tooth is suspected to be the cause, it must receive attention, either by 
having the dental pulp destroyed and the cavity filled, or by the removal of 
the tooth itself. If a sensitive cicatrix is present, it must be excised. Neu- 
ralgia depending on gastro-intestinal disorders will require a mercurial pur- 
gative and a properly-regulated diet. When the disease is a result of anaemia, 
some one of the different preparations of iron will be required. If the neu- 
ralgia proceeds from malarial poison, quinine, piperine, and arsenic are indi- 
cated. No internal remedy compares with quinine when the disease is 
characterized by periodicity. From fifteen to twenty grains, with six or 
eight grains of piperine, given during the interval between the attacks, will 
rarely fail to interrupt the paroxysm, and, if continued two or three days, 
this treatment will cure the disease. If the neuralgia shows a disposition 
to recur, three drops of liquor potassii arsenitis, with a pill consisting of 
two or three grains of quinine and half a grain of capsicum, given three 
times daily, and continued for two or three weeks, will constitute the most 
reliable prophylactic. During the severity of an attack of neuralgia the NER VE-STRETCHING. 
413 
suffering can be greatly mitigated by the hypodermic use of morphia intro- 
duced over the seat of the pain. Relief may also be obtained by rubbing 
into the skin over the painful region an ointment of veratria (veratria, gr. 
vi, simple cerate, 5ij), or by keeping over the parts a linen rag wet with the 
tincture of aconite (saturated tincture of the root). Dry heat locally is 
always most grateful. 
In cases of chronic neuralgia, after instituting a searching inquiry into 
the state of the different organs of the body and failing to discover a suffi- 
cient cause for the disease, as a prophylactic I know of no combination of 
remedies which promises better results than one consisting of quinine, arsenic, 
capsicum, and belladonna (R quinise sulphatis, gr. lxxx, acidi arseniosi, gr. iss, 
capsici, gr. xii, extracti belladonnse, gr. vi. M. Div. in pil. no. xliv. Sig.—One 
three times daily). 
Electricity will often break in upon the morbid habit which is sometimes 
influential in keeping up the tendency to recurring attacks. Indeed, in 
very many cases of idiopathic neuralgia the most satisfactory results are 
obtained by a treatment of this kind. The electro-galvanic current is to be 
preferred, and the continuous current is best, the anode being placed as near 
as possible to the root of the affected nerve, and the cathode over the seat 
of pain. Sometimes the descending current proves more efficient, and then 
the poles must be reversed, the cathode near the root of the nerve, and the 
anode over the painful points. Should a rheumatic or a syphilitic element 
be suspected, iodide of potassium, with or without colchicum, as may be 
deemed necessary, will be indicated. 
In old cases of sciatic neuralgia there is no remedy which affords such 
prompt relief as the hypodermic use of atropia, one-seventieth to one-sixty- 
fifth of a grain, introduced into the back of the thigh over the course of the 
nerve. It often acts with magic power in removing pain and lameness from 
the limb. 
In defiance of all the therapeutical resources wrhich have been mentioned, 
a certain number of cases of neuralgia will remain incorrigible, and in con- 
sequence the lives of many patients are rendered distressing in the extreme. 
Two resources are left to the surgeon with wThich to combat these otherwise 
hopeless cases,—nerve-excision and nerve-stretching. 
By excision the trunk of the nerve is exposed and a portion or the whole 
of its distal extremity removed. In ordbr to perform neurectomy success- 
fully, the surgeon is often obliged to carry his incisions into what would seem 
the most inaccessible regions, so as to cut the trunk at a point which will 
include all its peripheral branches; for example, the inferior maxillary is 
sometimes cut in the spheno-maxillary space. American surgeons have 
worked this mine with singular boldness and success. Operations for tho 
cure of neuralgia affecting the branches of the trifacial are described in vol. 
i. page 315 of the present work. 
Nerve-stretching.—Nerve-stretching was first performed by Nussbaum in 
1872, and has been done very often for neuralgic and other painful conditions 
of the nerves after all ordinary measures for relief have been exhausted. 
Just what place this operation is to occupy in surgical therapeutics is not yet 
positively determined, as there is a discrepancy of opinion among writers 
on the subject. The following cases, collected for me by Dr. Harte from 
various medical journals, may serve to throw some light upon this vexed 
question. It is unfortunate that so many cases have been placed on record 
before sufficient time had elapsed after the operation to enable the perma- 
nency of the cure to be determined. Nevertheless, a sufficient number have 
been sifted from the aggregate of cases to place the procedure in a Very 
favorable light. 414 
SURGICAL AFFECTIONS OF THE NERVES. 
No. 
Operator. 
Sex and 
Age. 
Disease. 
Nerve Stretched. 
Time under Ob- 
servation. 
Result. 
Authority. 
Remarks. 
1 
2 
3 
4 
Bell. 
Bern ays. 
Blum. 
M., 45. 
Sciatica. 
Sciatic. 
Not stated. 
Sciatic. 
Doubtful. 
Temporarily impr’d. 
Failure. 
Cured. 
Chandler, N.Y. Sled. Rec., Sept. 9,1882. 
Ibid. 
Ibid. 
Le Progres Medical, No. 11, 1882. 
Pain relieved for 6 days. 
Peroneal and ext. sa- 
phenous nerve excised. 
1 5 
44 
M., 33. 
44 
“ 
44 
Chandler’s Table. 
6 
“ 
M., 39. 
44 
“ 
Improved. 
Ibid. 
7 
8 
Buttner. 
M., 36. 
« 
About 9 months. 
Cured. 
Ibid. 
Ibid. 
9 
“ 
M„ 40. 
44 
“ 
About 2 months. 
44 
Brit. Sled. Jour., June 19, 1880. 
10 
B ram well. 
M., 27. 
44 
6 months. 
44 
Ibid. 
11 
“ 
M., 46. 
44 
“ 
2 months. 
44 
Ibid. 
12 
“ 
F., 28. 
44 
About 2 years. 
Ibid. 
Operated on twice, year 
13 
« 
M.,ad. 
«• 
«« 
6 weeks. 
« 
Ibid. 
apart. 
14 
44 
“ 
1 year. 
Ibid. 
15 
Boyd. 
M., 56. 
44 
“ 
44 
Chandler’s Table. 
Anaesthesia foi six weeks. 
16 
Cameron. 
M., 39. 
u 
Not stilted. 
« 
Ibid. 
Cure perfect. 
Stretched twice. 
17 
Charcot. 
M., 40. 
44 
Sciatic. 
44 
Gazette des Hopitaux. 
18 
Chambers. 
M., 53. 
Double sciatica. 
Both sciatics. 
Great relief. 
Md. Sled. Jour., vol. viii. p. 298. 
19 
Cheyne. 
40. 
Sciatica. 
Sciatic. 
22 days. 
Relief. 
Practitioner, 1877, p. 417. 
20 
44 
M., 40. 
44 
44 
Cured. 
Chandler’s Table. 
21 
44 
M., 41. 
44 
44 
44 
Ibid. 
22 
Davidson. 
M., 62. 
44 
3 months. 
44 
London Lancet (Am. Rep.), April, 1882. 
23 
44 
M., 65. 
44 
44 
Ibid. 
24 
44 
M., 31. 
44 
44 
Relieved. 
Ibid. 
25 
Dougherty. 
M., 43. 
44 
“ 
Temporarily impr’d. 
Chandler’s Table. 
Is to be operated on again. 
26 
27 
Esmarch. 
Fenger. 
F., 45. 
“ 
36 days. 
Cured. 
Improved. 
Ibid. 
Gray’s Table, Jour. Neurol, and Psyc., 
Death from cancer of 
28 
F., 35. 
u 
« 
Over 8 weeks. 
Cured. 
Slay, 1882. 
Chandler’s Table. 
pelvic bone. 
29 
Findlay. 
M., 28. 
44 
“ 
“ 
Edinburgh Med. Jour., vol. xxv. p. 210. 
30 
Gillette. 
F., 43. 
44 
ti 
“ 
Chandler’s Table. 
31 
44 
F. 
44 
ti 
Ibid. 
32 
Gainger. 
M., 41. 
44 
it 
44 
Not stated. 
33 
Hammond. 
M. 
44 
(( 
Considerable time. 
44 
Chandler’s Table. 
34 
44 
M. 
44 
t t 
44 
Ibid. 
35 
44 
F. 
44 
it 
44 
Ibid. 
36 
44 
F. 
44 
( 
44 
44 
Ibid. 
37 
Hildebrandt. 
F., 32. 
44 
ti 
18 months. 
44 
Deut. Sled. Wocli., Sept., 1880. 
38 
39 
40 
K lister. 
Langenbeck. 
Traumatic sciatica. 
Sciatica. 
“ 
3 months. 
“ 
Chandler’s Table. 
Ibid. 
Ibid. 
Operated on twice. 
Table I.—Sciatica. NER VE-STRETCHING. 
415 
No. 
Operator. 
Sex and 
Age. 
Disease. 
Nerve Stretched. 
Time under Ob- 
servation. 
Result. 
Authority. 
Remarks. 
41 
Langenbeck. 
Sciatica. 
Sciatic. 
18 months. 
Cured. 
Chandler's Table. 
42 
Maag. 
29. 
44 
58 days. 
Gray's Table, Jour. Neurol, and Psyc., 
May, 1882. 
43 
44 
19. 
“ 
“ 
54 days. 
44 
Ibid. 
44 
45 
McFarlane. 
F., 39. 
8 months. 
London Lancet, July 6, 1878. 
46 
Massing. 
M , 12 
Traumatic sciatica. 
« 
8 months. 
Improved. 
Loudon Medical Record, 1879. 
47 
Morton. 
M., 33. 
Sciatica. 
“ 
3 months. 
Cured. 
New York Medical Record, April 4, 1882. 
48 
Nasmith. 
M , 54. 
“ 
“ 
London Lancet, vol. i., 1881, p. 782 
49 
50 
Neuber. 
it 
3 months. 
Gray’s Jour. Neurol, and Psyc., 
Mav, 1882. 
Chandler’s Table. 
Ibid. 
Gray’s Table, Jour. Neurol, and Psyc., 
May, 1882. 
Die Nervendehnung, p. 80. 
51 
52 
53 
Pallas. 
Patrubau. 
M. 
Traumatic sciatica. 
Sciatica. 
it 
“ 
Improved. 
Relieved. 
54 
Pierson. 
M., 39. 
it 
ii 
About 2 months. 
Cured. 
Chandler’s Table. 
55 
Pooley. 
M., 30. 
it 
44 
30 days. 
“ 
New York Medical Record, Aug. 14, 1880. 
56 
57 
Purdie. 
Pye. 
M. 
it 
ii 
it 
Improved. 
Chandler's Table. 
Ibid. 
58 
59 
60 
61 
Richard. 
Richardson. 
Spencer. 
Trendelenburg. 
M., 45. 
ii 
ii 
ti 
it 
it 
ii # 
22 days. 
Relieved. 
Cured. 
Partial relief. 
London Lancet, April 10,1880. 
Chandler’s Table. 
Ibid. 
Ibid. 
Pain due to spinal injury. 
Of the above cases, 46 were cured, 13 improved, 2 unimproved; total, 61. 23 were kept for some time under observation. 
Table I.—Sciatica.—( Continued.) 416 
SURGICAL AFFECTIONS OF THE NERVES. 
No. 
Operator. 
Sex and 
Age. 
Disease. 
Nerve Stretched. 
Time under Ob- 
servation. 
Result. 
Authority. 
Remarks. 
1 
Agnew. 
M. 
Neuralgia. 
Sciatic. 
6 months. 
Cured. 
2 
“ 
F. 
“ 
18 months. 
3 
Andrews. 
Tonic spasm and pain in 
legs. 
Both sciaticsand crurals. 
7 months. 
44 
Chandler, N. Y. Med. Rec., Sept. 9,1882. 
a sailor. 
4 
Ashhurst. 
F., ad. 
Traumatic neuralgia. 
Musculo-spiral. 
3 months. 
Improved. 
University Hospital Notes, 1879. 
Nerve afterwards re- 
sected. 
5 
M., 33. 
Median ulnar musculo- 
6 months. 
Phila. Med. Times, Feb. 11, 1882. 
spiral. 
6 
F., ad. 
Median. 
About 18 months. 
Cured. 
Children’s Hospital Notes, 1880. 
7 
Bartlett. 
Painful stump. 
Brachial plexus. 
44 
Birmingham Med. Review, April, 1880. 
8 
m.; 17. 
44 
9 
Byrd. 
Callender. 
Failure. 
Cured. 
10 
M., 20. 
Neuralgia after ampu- 
tation. 
Median. 
Londou Lancet, June 26, 1875. 
11 
Neuralgia after injury. 
Traumatic neuralgia. 
44 
12 
Crede. 
Radial, ulnar, external 
24 days. 
Great relief. 
Med.-Chir. Centralbl, No. 31. 
cutaneous. 
13 
Estlander. 
Ad., 27. 
Median. 
24 hours. 
Temporarv relief. 
Gray, Jour. Neurol, and Psyc., May, 1882. 
Disease returned. 
14 
Esmarch. 
Neuralgia after castra- 
tion 
External spermatic. 
Unimproved 
Ibid. 
15 
Golding-Bird. 
Hammond, G. M. 
Neuralgia of stump. 
Neuralgia, traumatic, 
No relief. 
Cured. 
Nerve excised. 
16 
M., 45. 
Ulnar. 
1 year. 
Chandler’s Table. 
hand and arm. 
17 
18 
Hodge. 
Hoover. 
F., ch’d. 
Neuralgia, traumatic. 
Neuralgia, traumatic, 
left leg. 
Median. 
Sciatic. 
“ 
Relieved. 
Children’s Hospital Notes. 
19 
Morton. 
F, ad. 
Neuralgia, traumatic. 
Ulnar. 
7 months. 
Cured. 
Am Jour. Med. Sci., Jan. 1878, p. 155. 
20 
“ 
M., 52. 
Sciatic. 
12 days. 
No relief. 
Ibid. 
Nerve excised. 
21 
Maag. 
Ptirdie. 
37. 
«« 
Cured. 
Gray, Jour. Neurol, and Psyc., May, 1882. 
London Lancet, vol. i., 1880, p. 249. 
22 
Neuralgia after felon. 
Digital. 
7}4 months. 
23 
Neuralgia, traumatic. 
Die Nervendehnung, p. 80. 
N. Y. Med. and Surg. Rep , July 16, 1881. 
Gray. Jour. Neurol, and Psyc., Mav, 1882. 
London Lancet, June 30, 1879. 
24 
M., ad. 
25 
(4 
44 
26 
Spence. 
M., ad. 
Neuralgia after felon. 
Digital. 
7 months. 
44 
27 
Van Kleef. 
Neuralgia, mammary 
Neuralgia, traumatic, 
forearm. 
4th, 5th, 6th intercostals. 
Ulnar. 
11 days. 
44 
Gray, Jour. Neurol, and Psyc, May, 1882. 
Ibid. 
28 
Vogt. 
44 
F. 
<4 
29 
White. 
Neuralgia. 
Sciatic. 
Of the above cases, 20 were cured, 5 improved, 4 unimproved ; total, 29. Number carefully observed after the operation, 25. 
Table IT.— Traumatic Neuralgia. NER VE-STRETCHING. 
417 
No. 
Operator. 
Sex and 
Age. 
Disease. 
Nerve Stretched. 
Time under Ob- 
servation. 
Result. 
Authority. 
Remarks. 
1 
2 
3 
Ashhurst. 
Bardeleben. 
Blake. 
M., ad. 
Traumatic tetanus. 
Median, musculo-spiral. 
Sciatic. 
Death and failure. 
Temporarily impr’d. 
Death. 
Episcopal Hospital Notes. 
Chandler, N.Y. Med. Rec., Sept. 9,1882. 
Not stated. 
Death, 12 days. 
4 
Clark. 
F., 24. 
“ 
Popliteal. 
Over 2 weeks. 
Cured. 
Glasgow Med. Jour., July, 1879. 
5 
Drake. 
M„ ad. 
Sciatic. 
12 days. 
Death. 
Medical Times, 1879. 
Convulsions ceased for 3 
days. 
6 
Feuger. 
M., 29. 
Ulnar, radial, musculo- 
spiral. 
12 hours. 
“ 
Chandler’s Table. 
No benefit from the op- 
eration. 
7 
M., 43. 
Median, ulnar. 
7 months. 
Cured. 
Ibid. 
Chloral used, etc. Paral- 
ysis of median and ul- 
narnervesfor7 months. 
8 
9 
10 
11 
12 
Hahn. 
Heath. 
M., 55. 
:: 
Brachial plexus. 
Ulnar. 
Sciatic, crural. 
Ulnar. 
2 days. 
Death. 
Ibid. 
Ibid. 
Ibid. 
Ibid. 
Medical Times, October 23,1880. 
Slight relief for the time. 
Operation a failure. 
13 
14 
15 
16 
Hutchinson. 
Klin and Knie. 
Kocher. 
K lister. 
M., 22. 
“ 
Sciatic. 
Brachial plexus. 
Tibial. 
Crural. 
7 days. 
Not stated. 
Death. 
Loud. Med. Times, June 7, 1879. 
Ceutralbl. f. Chirurgie, No. 2, 1880. 
Die Nervendehnung, p. 80. 
Chandler’s Table. 
17 
Morris. 
Ch„ 7. 
“ 
Sciatic. 
1 day. 
“ 
Brit. Med. Jour., June 21,1879. 
18 
Mudd. 
M., ad. 
Median, ulnar, musculo- 
spiral. 
44 
Dublin Sled. Jour., vols. vi. and vii., 1879, 
p. 285. 
19 
Nankiville. 
M., 28. 
“ 
Median. 
4 days. 
“ 
London Lancet, March 2, 1878. 
20 
44 
M., 46. 
44 
44 
12 hours. 
“ 
Ibid. 
21 
D’Ollier. 
M., 52. 
44 
44 
Cured. 
Chandler’s Table. 
22 
23 
Omboni. 
Ch., 7. 
Sciatic. 
Death. 
Ibid. 
Ibid. 
Ibid. 
24 
Owens. 
Ch., 6. 
« 
Brachial plexus. 
„ 
25 
Pepper. 
“ 
Median and radtal. 
3 days. 
<( 
Ibid. 
Relieved for 2 days. 
26 
27 
28 
29 
30 
31 
Ramschoff. 
Rat ton. 
Schneider. 
Child. 
44 
“ 
Post-tibial. 
Not stated. 
7 days. 
Cured. 
Death. 
Cured. 
Death. 
Ibid. 
Ibid. 
Ibid. 
Ibid. 
Ibid. 
Ibid. 
Calabar bean, 4 days. No 
benefit until stretched. 
Five elongations. 
32 
33 
Smith. 
Sonnenberg. 
M., 54. 
44 
Median. 
Cured. 
Death. 
Ibid. 
34 
Thomas. 
M., 28. 
Median. 
Brit. Med. Jour., March 29, 1879. 
Leaped from a window, 
killing himself. 
35 
Tiffany. 
Boy. 
44 
Median and radial. 
44 
Maryland Med. Jour., November, 1881. 
36 
Verneuil. 
M., 39. 
“ 
Ulnar and median. 
Cured. 
St. Barthol. Ilosp. Rep., vol. xiv., 1878. 
37 
38 
39 
40 
“ 
Vogt. 
M., 60. 
« 
Musculo-cutaneous. 
Brachial plexus. 
Death. 
Cured. 
Cincinnati Lancet, 1879. 
Die Nervendehnung, p. 80. 
Chandler’s Table. 
Ibid. 
41 
Watson. 
M., 16. 
Musculo-cutaneous, mus- 
cular, spiral, ulnar aud 
median. 
London Lancet, February 16, 1878. 
42 
43 
44 
M., 35. 
Brachial plexus. 
(( 
Ibid., 1878. 
44 
Wier. 
M., 11. 
“ 
Ulnar. 
•* 
Ibid. 
45 
M., 29. 
Posterior tibial. 
44 
Ibid. ' 
Short time after operation 
spasms less frequent. 
46 
Wheeler. 
F., 8. 
Popliteal. 
Cured. 
Proc. Surg. Soc. Ireland, 1881. 
Of the above cases, 9 were cured, 1 result not stated, 36 died; total, 46. Cases in which the time during which they were kept under observation is stated, 11. 
Table ITT.— Traumatic Tetanus. 418 
SURGICAL AFFECTIONS OF THE NERVES. 
No. 
Operator. 
Sex and; Disease. 
Age. 
Nerve Stretched. 
Time under Ob- 
servation. 
Result. Authority. 
Remarks. 
i 
Cured. Med.-Chir. Centralbl. No. 31. 
pair. 
2 
Croft. 
Infraorbital. 
About 1 year. 
Chandler, N.Y. Med. Rec., Sept. 9,1882. 
3 
Czerny. 
M., 60. Ophthalmic neuralgia. 
Frontal. 
Failure. Ibid. 
4 
“ 
M.( 63. Supraorbital neuralgia. 
Frontal and supraorbi- 
Relieved. Ibid. 
5 
tal. 
to 
Hahn. 
Temporarily impr’d. 1 Ibid. 
All these cases relapsed 
13 
in from six to eight 
months. 
14 
Inferior maxillary. 
Improved. i Ibid. 
Also resected. 
i illary. 
15 
*< 
infraorbital. 
16 
“ Ibid. 
illary. 
17 
Higgins. 
M., 62. Infra- and supraorbital 
Infra- and supraorbital. 
2 months. 
Cured. Brit. Med. Jour., June 14, 1879. 
neuralgia. 
18 
“ 
M., 53. Supraorbital neuralgia. 
Supraorbital. 
3 weeks. 
“ Ibid. 
19 
Janny. 
Epileptiform neuralgia. 
Supra- and infraorbital, 
Not stated. 
“ Gray, Jour. Neurol, and Psyc., May, 1882. 
infra-alveolar. 
20 
Kocher. 
M., 32. Neuralgia. 
Supraorbital, 3 branches. 
“ Correspondenzblattftir Schweitzer Aerzte. 
21 
LttHge. 
M., 63. Neuralgia, 5th pair. 
Infraorbital. 
4 months. 
“ Chandler’s Table. 
Two resections of the 
nerve failed to give re- 
lief. 
22 
Massing. 
Supraorbital. 
“ St. Petersburg Med. Woch., Februarv, 
1881. 
23 
“ 
M., 69. 1 “ 
“ Med. Woch., December 20,1879. 
24 
Nussbaum. 
Right and left supra- 
Several weeks. 
Improved. Chandler’s Table. 
infraorbital. 
and infraorbital. 
25 
Polaillon. 
M., 62. Spasmodic facial neu- 
Inferior dental. 
Cured. 1 L’Union Med., November 8,1881. 
ralgia. 
26 
! 27 
i 28 
Quinqnarii. 
Adult. Supraorbital neuralgia. 
Supraorbital. 
“ Le Progri-s M5d., 1881, p. 217. 
29 
Exterior frontal. 
Failure. Chandler’s Table. 
30 ! 
Spence. 
Frontal. 
months. 
Cured. London Lancet, 1880, vol 1. p. 249. 
Two stretchings. 
31 
Stewart. 
M.,76. Neuralgia, superior 
Infraorbital and mental. 
7 months. 
“ i Brit. Med. Jour., May 31, 1879. 
maxillary. 
32 
33 | 
34 
35 
Walsham. 
M.,50. Epileptiform neuralgia. 
Infraorbital. 
2 months. 
“ Brit. Med. Jour., December 25,1880. 
Of the above cases, 19 were cured, 12 improved, 4 unimproved; total, 35. Seven of these had their time of observation stated. 
nable IV.—Neuralgia, Different Branches of Fifth Pair of Cranial Nerves. NER VE-STRETCHING. 
419 
No. 
Operator. 
Sex and 
Age. 
Disease. 
Nerve Stretched. 
Time under Ob- 
servation. 
Result. 
Authority. 
Remarks. 
1 
Baum. 
F„ 35. 
Facial spasm. 
Facial. 
3 months. 
Cured. 
Ilerl. Klin. Woclienschrift, No. 40,1878. 
2 
3 
4 
5 
Benedikt. 
Bernhardt. 
Adult. 
Convulsive tic. 
Tic non-douloureux de 
la face. 
Mimic facial spasm. 
“ 
8 days. 
Temporary relief. 
Unimproved. 
Ibid. 
Gray, Jour. Neurol, and Psyc., May, 1882. 
Ibid. 
Eight days in hospital. 
Was seen some time 
after operation. No 
pain. 
Relief for two days; no 
return of paralysis. 
6 
Davidson. 
M., 53. 
Infraorbital. 
Cured. 
Ibid. 
7 
Euleuberg. 
27. 
Facial. 
Unimproved. 
Ibid. 
Temporary paralysis. 
8 
9 
Germon. 
Tic non-douloureux de 
la face. 
Tic non-douloureux de 
la face. 
• 
5 months. 
Cured. 
Chandler, N.Y. Med. llec., Sept. 9, 1882. 
Ibid. 
10 
Sturge and God lee. 
F., 72. 
Facial spasm. 
“ 
3 months. 
“ 
Ibid. 
11 
12 
Godlee. 
Hahn. 
M. 
Tic non-douloureux de 
la face. 
Tic non-douloureux de 
la face. 
“ 
Improved. 
Brit. Med. Jour., Nov. 20,1880. 
Chandler's Table. 
Ibid. 
Temporary paralysis. 
13 
“ 
Tic non-douloureux de 
la face. 
6 mouths. 
Slight improvement. 
Ibid. 
Relapsed at the end of 
six months. 
14 
Le Dentu. 
F., ad. 
Tic douloureux de la face 
Inferior dental. 
Not stated. 
Jour.de Med.et de Cliir.,December, 1881. 
15 
Putnam. 
M., ad. 
Clonic spasm of face. 
“ 
3 months. 
Cured. 
Boston Med.andSurg. Jour., Oct. 21,1880. 
16 
Schussler. 
F., 39. 
Facial spasm. 
“ 
months. 
“ 
Bell. Klin. Woclienschrift, No. 46, 1879. 
17 
Southam. 
F., 53. 
Clonic facial spasm. 
“ 
6 weeks. 
London Lancet, May 28, 1881. 
18 
F., 32. 
Tic non-douloureux de 
la face. 
Over 1 month. 
Chandler’s Table. 
Of the above cases, 12 were cured, 3 improved, 2 unimproved, 1 result not stated; total, 18. Cases in which the duration of observation is stated, 9. 
Table V.—Mimic Spasm, etc. 420 
SURGICAL AFFECTIONS OF THE NERVES. 
No. 
Operator. 
Sex -and 
Age. 
Disease. 
Nerve Stretched. 
Time under Ob- 
servation. 
Result. 
Authority. 
Remarks. 
1 
Agnew. 
M., 54. 
Neuralgia. 
Sciatic. 
10 week s. 
Greatly improved. 
Pennsylvania Hospital Notes. 
Under observation two 
months. 
2 
“ 
44 
Median. 
3 months. 
Permanent relief. 
3 
Ashhurst. 
M.,ad. 
44 
Brachial plexus. 
About 5 months. 
Great relief. 
Philadelphia Medical Times, Feb. 11,1882. 
4 
Bartlett. 
M., 31. 
Pain in thigh. 
Sciatic. 
Cured. 
Birmingham Medical Record, April, 1880. 
5 
Blum. 
M., 18. 
Hysterical tumor, thigh. 
44 
La France Sled., May, 1881. 
6 
Neuralgia. 
Le Med , No 11 188° 
7 
Boldt. 
F., 26. 
Anterior crural. 
“ 
Chandler, N.Y. Med. Rec., Sept. 9, 1882. 
8 
Czerny. 
24. 
Ulnar neuritis. 
Dinar. 
14 days. 
Relieved. 
Gray, Jour. Neurol, and Psyc., May, 
1882. 
9 
Duplay. 
M., 29. 
Painful paralysis of arm. 
Radial and median. 
Cured. 
London Medical Record, Jan. 15,1879. 
10 
“ 
M., 26. 
Painful tumor over pisi- 
Ulnar. 
44 
Ibid. 
form bone. 
11 
Neuralgia. 
a 
12 
Hammond. 
M„ 45. 
Ulnar. 
« 
New York Medical Record, Aug. 13,1881. 
13 
F., ad. 
Pain inside arm and fore- 
“ 
44 
Ibid. 
14 
Hildebrandt. 
M.,32. 
Neuritis, brach. plexus. 
Brachial plexus. 
5 weeks. 
Deutsch. Sled. Woch., September, 1880. 
Langenbeck. 
Brachial neuralgia. 
16 
(t 
Ibid 
17 
(i 
Neuralgia. 
Ibid 
18 
it 
Ibid. 
19 
C< 
Ibid. 
20 
Le Dentu. 
F.,oid. 
Tic douloureux. 
Inferior dental. 
Not stated. 
Jour, de M6d.et de Chir.,December, 1881. 
21 
“ 
44 
Neuralgia. 
Lingual. 
Cured. 
Chandler’s Table. 
22 
Ibid. 
23 
Massing. 
M., 37. 
« 
Both sciatica and left 
6% months. 
« 
St Petersburg Med. Woch., March 4,1878. 
anterior crural. 
24 
25 
Omboni. 
F„ 39. 
Neuralgia and contrac- 
Brachial plexus. 
« 
London Medical Record, April 15, 1880. 
tion of arm. 
26 
I’olaillon. 
Adult. 
Neuralgia. 
Inferior dental. 
44 
L'Union Sled., November 8,1881. 
27 
Schussler. 
F., 53. 
Occipital neuralgia. 
Occipital. 
9 days. 
44 
Berl. Klin. Wochenschr., SI arch 9,1880. 
28 
Von Kleef. 
Intercostal. 
4th,5tli, 6th intercostals. 
1882. 
29 
Vogt. 
Neuralgia. 
Inferior dental. 
44 
Die Nervendehnung, p. 80. 
30 
W barton. 
F., 46. 
44 
Musculo-cutaneous, ex- 
3 weeks. 
Improved. 
University Hospital Notes. 
ternal saphenous. 
If the above eases, 23 were cured, 6 improved, and 1 result not stated; total, 30. Cases carefully observed subsequent to operation, 3. 
Table VI.—Miscellaneous Neuralgic Affections. NER VE-STRETCHING. 
421 
No. 
Operator. 
Sex and 
Age. 
Disease. 
Nerve Stretched. 
Time under Ob- 
servation. 
Result. 
Authority. 
Remarks. 
1 
Bastian. 
|M.,40. 
Locomotor ataxia. 
Both sciatica. 
Improved. 
Brit. Med. Jour., July 2, 1881. 
Pain ceased for a time. 
2 
“ 
M., 39. 
(4 
Sciatic. 
About 3 mouths. 
Ibid. 
3 
4 
5 
Beuedikt. 
44 
M. 
(4 
44 
« 
« 
Chandler, N.Y. Med. ltec., Sept. 9,1882. 
Ibid. 
Ibid. 
6 
7 
Berridge. 
Berger. 
Billroth. 
Blum. 
F., 37. 
44 
“ 
Unimproved. 
Failed. 
Slight improvement. 
No benefit. 
Brit. Med. Jour., April 2,1879. 
Chaudler’s Table. 
Ibid. 
Le Progrfes Med., No. 11, 1882. 
Ibid. 
Chandler’s Table. 
8 
9 
10 
M., 29. 
Multiple sclerosis. 
Ataxia. 
Locomotor ataxia. 
Both sciatica. 
Sciatic. 
10 days. 
Died on the tenth day. 
11 
Boldt. 
3 months. 
Temporary relief. 
This patient walked 
home, a distance of 
three miles, the same 
day that he was oper- 
ated on. 
12 
F., 45. 
44 
Anterior crural. 
Relieved. 
Ibid. 
13 
14 
50. 
44 
44 
Sciatic. 
44 
Temporary relief. 
Ibid. 
Ibid. 
15 
Buchanan. 
M., 51. 
“ 
1 year. 
Improved. 
Glasgow Med. Jour., April 4,1882. 
16 
Bardeleben (Nocht) 
M., 42. 
Both sciatica. 
6 weeks. 
Gray, Jour. Neurol, and Psyc., May, 1882. 
17 
“ 
40. 
44 
Brachial plexus. 
8 months. 
“ 
Ibid. 
18 
Cavafy. 
M., 48. 
44 
Sciatic. 
months. 
Temporary relief. 
Brit. Med. Jour., Dec. 10,1881. 
19 
Czerny. 
M. 
Congenital hemiplegia 
with contracture. 
Axillary plexus. 
1 year. 
Improved. 
Gray, Jour. Neurol, and l’syc., May, 1882. 
Spasm ceased for one 
year. 
20 
M. 
Myelitis by compres- 
sion. 
Both sciatics. 
Aggravated. 
Chandler’s Table. 
Patient found to have 
Pott’s disease. 
21 
Debove. 
M. 
Locomotor ataxia. 
Sciatic. 
2 weeks. 
Relieved. 
Le Progr&s Med., No. 50, 1880. 
22 
23 
24 
Debove 4 Gillette. 
M., 56. 
ML 58. 
M., 30. 
44 
44 
44 
For some time. 
Improved. 
Chandler’s Table. 
Ibid. . 
Ibid. 
25 
Davidson. 
M.; 36. 
44 
Both sciatica. 
“ 
N. Y. Med. and Surg. Rep., Oct. 29,1881. 
26 
M., 34. 
44 
“ 
Slight improvement. 
Ibid. 
27 
Erlenmeyer. 
40. 
Sciatic. 
Unimproved. 
Ceutralbl. f. Nervenkr., No. 21,1880. 
28 
29 
Esmarch. 
M., 30. 
44 
44 
Both sciatics. 
Brachial plexus. 
Failed'. 
Improved. 
Chaudler’s Table. 
Ibid. 
30 
Ewart. 
M., 67. 
44 
Slight relief. 
Ibid. 
31 
32 
Fenger. 
Fischer and Schwe- 
ninger. 
36. 
54. 
Both sciatics and crurals. 
Sciatic. 
6 weeks. 
Died. 
Improved. 
Gray, Jour. Neurol, and Psyc., May, 1882. 
Ibid. 
Pyaemia. 
33 
Gerster. 
M., 45. 
Locomotor ataxia. 
Both sciatics. 
Unimproved. 
N. Y. Medical Record, March 4, 1882. 
34 
Gillette. 
F., 6. 
Ataxia. 
Median and radial. 
Slight relief. 
Le l’rogres Med., Feb. 5, 1881. 
In upper, but worse in 
lower extremities. 
35 
Gussenbauer. 
46. 
Locomotor ataxia. 
Sciatic. 
1 mouth. 
Temporarily impr’d. 
Gray, Jour. Neurol, and Psyc., May, 1882. 
36 
“ 
35. 
“ 
Both sciatics. 
1 month. 
Died. 
Ibid. 
37 
Hammond. 
44 
30 days. 
Relieved. 
Jour, of Nerv. and Ment. Dis., July, 1881. 
38 
“ 
“ 
“ 
12 days. 
“ 
Ibid. 
Table VII.—Central Disease. 422 
SURGICAL AFFECTIONS OF THE NERVES. 
No. 
Operator. 
Sex and 
Age. 
Disease. 
Nerve Stretched. 
Time under Ob- 
servation. 
Result. 
Authority. 
Remarks. 
39 
40 
41 
42 
Hammond. 
F., 50. 
M., 45. 
Locomotor ataxia. 
Both sciatics. 
“ 
Temporarily impr’d. 
Improved. 
3 months. 
Ibid. 
Ibid. 
M. 
F., 35. 
M., 38. 
it 
Left sciatic. 
Sciatic. 
Ibid. 
Anterior sclerosis. 
Locomotor ataxia. 
Temporary relief. 
Unimproved. 
Ibid. 
43 
44 
Hammond, G. M. 
Ibid. 
45 
to 
53 
54 
55 
56 
57 
58 
59 
60 
61 
62 
63 
64 
65 
66 
67 
68 
Hahn. 
Hirschfelder. 
Israel. 
Disease of nerve-centres. 
Locomotor ataxia. 
it 
No permanent im- 
provement. 
Died. 
Ibid. 
Two deaths. 
Both sciatics. 
4 days. 
Gray, Jour. Neurol, and Psyc., May, 1882. 
Sciatic. 
Unimproved. 
Chandler's Table. 
U 
Ibid. 
Jewell. 
it 
Improved. 
Ibid. 
ii 
Ibid. 
Johnston. 
Knlenkampff. 
Ktister. 
Sciatic. 
Both sciatics. 
u 
Brit. Med. Jour., July 2,1881 
Aggravated. 
Improved. 
Unimproved. 
Ibid. 
M. 
M. 
M., 43. 
M., 66. 
M., 31. 
M., 40. 
M., 40. 
M., 45. 
M., 53. 
u 
Ibid. 
Kummel. 
Lamarre. 
Langenbach. 
Ataxia. 
Cancer of cord. 
Ataxia. 
Locomotor ataxia. 
« 
Berl. Klin. Wochenschrift, No. 48,1882. 
From cystitis. 
Sciatic. 
Sciatic and ant’r crural. 
Both sciatics & crurals. 
Improved. 
Berl. Klin. Wochenschrift, No. 48,1880. 
Berl. Klin. Wochenschrift, No. 48, 1879. 
Berl. Klin. Wochenschrift. 
Some time. 
Tabes dorsalis. 
Sciatic and ant’r crural. 
Ibid. 
Improved. 
Failed. 
Ibid. 
69 
70 
71 
72 
73 
74 
75 
76 
77 
78 
79 
80 
81 
82 
83 
84 
85 
86 
87 
88 
89 
90 
Larger. 
Marshall. 
Massing. 
Miiller and Ebner. 
Morgan. 
Mikulicz. 
Locomotor ataxia. 
Chandler’s Table. 
M., 40. 
Both sciatics. 
Improved. 
Great relief. 
Ibid. 
Myelitis. 
Locomotor ataxia. 
Lateral sclerosis. 
Locomotor ataxia. 
St. Petersburg Med. Woch., No. 34, 1878. 
50. 
62. 
36. 
M., 46. 
M., 44. 
Bight crural. 
Left crural. 
Sciatic. 
34 days. 
23 days. 
Improved. 
Temporarily impr’d. 
Gray, Jour. Neurol, and Psyc., May, 1882. 
Ibid. 
U 
Ibid. 
u 
U 
it 
Ibid. 
« 
Both sciatics. 
it 
Ibid. 
Unimproved. 
Slightly improved. 
Improved. 
Ibid. 
Ibid. 
Both sciatics. 
Ibid. 
Morton. 
Nicaise. 
Nusshaum. 
Osborn. 
M., 43. 
Adult. 
M., 64. 
M., 50. 
Paralysis agitans. 
Athetosis. 
Chronic myelitis. 
Lateral sclerosis. 
Hemiplegia & contract. 
Traumatic myelitis. 
Locomotor ataxia. 
Sciatic. 
Ulnar and median. 
Both sciatics. 
Left sciatic. 
30 days. 
38 days. 
5}/£ months. 
7 months. 
Relieved. 
Improved. 
Failed. 
New York Medical Record, April, 1842. 
Ibid. 
Ibid. 
Ibid. 
Chandler’s Table. 
Improved. 
Ibid. 
Spasms ceased, paralysis 
Right sciatic. 
Ibid. 
no better. 
Cable VII.—Central Disease.—( Continued.) NER VE-STRETCHING. 
423 
No. 
Operator. 
Sex and 
Age. 
Disease. 
Nerve Stretched. 
Time under Ob- 
servation. 
Result. 
Authority. 
Remarks. 
91 
92 
Kemak. 
Riedel. 
M., 30. 
Locomotor ataxia. 
Railway spine. 
Both sciatics. 
39 days. 
Unimproved. 
Slight relief. 
Chandler’s Table. 
Gray, Jour. Neurol, and Psyc., 51ay, 1882. 
9a 
Socin. 
M., 33. 
Locomotor ataxia. 
Sciatic. 
4 days. 
Death. 
Le Progres Sled., 1881, p. 166. 
Two operations; death 
four days after last. 
94 
Simon. 
5. 
Infantile paralysis. 
“ 
2 months. 
Improved. 
British 5Iedical Journal, Feb. 25, 1882. 
95 
Schussler. 
51.,ad. 
Tabes dorsalis. 
Both sciatics. 
Cured. 
Ceutralbl. fiir Nervenkr., May, 15,1881. 
96 
Sonneulierg. 
M. 
Locomotor ataxia. 
Right sciatic. 
5 weeks. 
Temporarily impr’d. 
Cliandler’s Table. 
97 
Sou th am. 
51., 51. 
“ 
Left sciatic. 
Improved. 
Ibid. 
98 
“ 
51., 35. 
Lateral sclerosis. 
“ 
11 weeks. 
Ibid. 
99 
Spence. 
51., 50. 
Locomotor ataxia. 
Sciatic. 
Unimproved. 
British 5Iedical Journal, Dec. 8,1882. 
100 
Spencer. 
51., 30. 
“ 
New York Sledical Gazette, April, 1882. 
101 
Sury-Bieuz. 
33. 
“ 
“ 
14 days. 
Improved. 
Gray, Jour. Neurol, and Psyc., Slay, 1882. 
Died from pulmonary 
102 
Thiersch. 
M., 35. 
Spastic spinal paralysis. 
Both sciatics. 
“ 
Boston Sled, and Surg. Jour., May, 1882. 
trouble. 
103 
104 
M.,49. 
M., 45. 
Tabes dorsalis. 
Locomotor ataxia. 
Temporarily impr’d. 
Ibid. 
Chandler’s Table. 
Gray, Jour. Neurol, and Psyc., May, 1882. 
Chandler’s Table. 
105 
106 
Wiltrubsky. 
Wyeth. 
46. 
Both sciatics. 
Improved. 
Of the above cases, 1 was cured, 59 improved, 22 temporarily improved, 17 unimproved, 2 aggravated, and 5 died; total, 106. Duration of improvement observed in 24 cases. 
No. 
Operator. 
Sex and 
Age. 
Disease. 
Nerve Stretched. 
Time under Ob- 
servation. 
Result. 
Authority. 
Remarks. 
1 
2 
3 
Aunandale. 
Bernhardt. 
lilum. 
F., 24. 
F., 18. 
Torticollis. 
Hysterical tremor. 
Spinal accessory. 
Sciatic. 
Unimproved. 
Cured. 
Gray, Jour. Neurol, and Psyc., May, 1882. 
Ibid. 
Chandler, N.Y. Med. Rec., Sept. 9,1882. 
4 
Hansen. 
F., 31. 
Torticollis. 
Spinal accessory. 
“ 
Ibid. 
Afterwards excised. 
5 
6 
7 
8 
9 
Kiister. 
Morgan. 
30. 
“ 
ti 
(1 
Relieved. 
Cured. 
Ibid. 
Gray, Jour. Neurol, and Psyc., May, 1882. 
Chandler’s Table. 
Ibid. 
Southam. 
F., 53. 
« 
(C 
6 weeks. 
Temporary relief. 
London Lancet, May 28, 1882. 
Subsequent excision. 
10 
“ 
M., 14. 
7 months. 
Improved. 
Ibid. 
11 
Studsgaard. 
F., 30. 
“ 
(i 
Cured. 
Chandler’s Table. 
Stretched and excised. 
12 
F., 31. 
Rotary movement of 
head. 
«( 
Ibid. 
13 
Yon Mosengeil. 
56. 
Torticollis. 
Both accessories. 
Gray, Jour. Neurol, and I’syc., May, 1882. 
Of the above cases, 7 were cured, 3 improved, 3 unimproved; total, 13. Time during which they were observed stated in 2 cases. 
Table VII.— Central Disease.—( Continued.) 
Table VIII.— Torticollis, etc. 424 
SURGICAL AFFECTIONS OF THE NERVES. 
No. 
Operator. 
Sex and 
Age. 
Disease. 
Nerve Stretched. 
Time under Ob- 
servation. 
Result. 
Authority. 
Remarks. 
1 
Paralysis, incised w’nd. 
Anaesthetic leprosy. 
Improved. 
Cured. 
Le Progres Med., No. 11,1882. 
Calcutta Med. Gaz., 1878. 
2 
Bomford. 
Both ulnars. 
Sensation begau to re- 
turn in two days. Left 
nerve broken; sutured 
with catgut. 
3 
Infantile paralysis. 
External popliteal. 
Failed. 
Chandler, N.Y. Med. Rec., Sept. 9,1882. 
Ibid. 
4 
5 
Gartner. 
Paralysis. 
Brachial plexus. 
Not stated. 
Die Nervendehnung, p. 80. 
6 
Paralysis after fracture. 
Paralysis of right hand. 
Paralysis and spasm. 
Anaesthetic leprosy. 
Gray, Jour. Neurol, and Psyc., May, 1882. 
7 
McLeod. 
M., 26. 
Improved. 
Cured. 
Improved. 
8 
Die Nervendehnung, p. 80. 
Calcutta Med. Gaz., Sept. 1878. 
9 
to 
Lawrie. 
Ulnar. 
41 
sation soon returned, 
as also the muscular 
42 
Wallace. 
u 
Not stated. 
Cured. 
Indian Med. Gaz., 1878. 
Ibid. 
Die Nervendehnung, p. 80. 
strength. 
43 
U 
44 
Vogt. 
Paralysis. 
Ulnar. 
(t 
Adhesion to nerve. 
No. 
Operator. 
Sex and 
Age. 
Disease. 
Nerve Stretched. 
Time under Ob- 
servation. 
Result. 
Authority. 
Remarks. 
1 
2 
3 
4 
Czerny. 
Gillette. 
Morton. 
Nussbaum. 
Epilepsy. 
Congenital epilepsy. 
Reflex epilepsy. 
Ulnar. 
Median and ulnar. 
Brachial plexus. 
Post-tibial and peroneal. 
Slight improvement. 
Great relief. 
Improved. 
Cured. 
Chandler, N.Y. Med. Rec. Sept. 9, 1882. 
Ibid. 
N. Y. Med. Rec., April 4,1882. 
Die Nervendehnung, p. 80. 
Attacks reduced in fre- 
quency from ninety to 
eighteen monthly. 
Of the above cases, 6 were cured, 35 improved, 2 unimproved, 1 result not stated; total, 44. 
Of the above cases, 3 were improved, 1 cured; total, 4. 
Table IX.—Paralysis, etc. 
Table X.—Epilepsy. NER VE-STRETCHING. 
425 
No. 
Operator. 
Sex and 
Age. 
Disease. 
Nerve Stretched. 
Time under Ob- Result, 
servation. 
Authority. Remarks. 
1 
2 
3 
to 
6 
: 7 
8 
Kura mol. 
Wecker. 
F., 9. 
M., 44. 
Blind 2 years. 
Atrophy of the nerve. 
Both eyes. 
Neuritis and atrophy of 
the nerve. 
Optic. 
Deutsch. Med. Wochensclirift. 
Ibid. 
Ibid. 
Chandler, N.Y. Med. Rec., Sept. 9,1882. 
Ibid. 
No. 
Operator. 
Sex and 
Age. 
Disease. 
Nerve Stretched. 
Time under Ob- 
servation. 
Result. 
Authority. 
Remarks. 
1 
2 
3 
4 
5 
Billroth. 
Berridge. 
Israel. 
Thiersch. 
Nussbaum. 
Spasm of legs. 
Painful contracture of 
lower limbs. 
Spasm of limbs, with 
contracture. 
Disease of lumbar spine. 
Contraction of muscles 
of thorax and arm. 
Sciatic. 
Both sciatics. 
Brachial plexus. 
Cured. 
Failed. 
Unimproved. 
«( 
Cured. 
Die Nervendehnung, p. 80. 
Chandler, N.Y. Med. Rec., Sept. 9,1882. 
Boston Med. and Surg. Jour., May, 1882. 
Of the above cases, 5 experienced no benefit, 1 was improved, 2 result not stated; total, 8. 
Table XI.—Diseases of the Optic Nerve. 
Of the above cases, 2 were cured, 3 unimproved; total, 5. 
•Table XII.—Contracture and Spasm. 426 
SURGICAL AFFECTIONS OF THE NERVES. 
Summing up the material of the foregoing tables, and rejecting in the an- 
alysis all those cases of which, owing to the short period that they remained 
under observation, nothing positive could be affirmed, the following results 
are obtained: 
1. Sciatic.—Sixty-one cases of nerve-stretching were done for sciatic ; and 
of the 46 reported cured and 13 improved, 19 can be accepted as cured and 4 
as improved. 
2. Traumatic neuralgia.—Twenty-six similar operations were performed for 
traumatic neuralgia on different nerves. Of the 17 reported cured and 5 
improved, 8 may be accepted as reliable cures and 2 as permanently improved. 
3. Traumatic tetanus.—Fort37-six nerve-stretchings were done for traumatic 
tetanus, and 11 reported cured. As internal remedies were also administered 
in these cases, the successes cannot be justly attributed to the operations; 
and yet, as the proportion of cures is greater than ordinarily occurs under 
internal medication alone, it is scarcely fair to conclude that the nerve- 
stretching had no favorable effect. 
4. Neuralgia of the fifth pair of nerves.—Thirty-five stretchings of the differ- 
ent branches of the trifacial nerve are recorded, with 19 cures and 12 improve- 
ments. Seven of this number, from the time they were under observation, 
are entitled to be accepted as cures. 
5. Mimic spasms.—Eighteen cases of mimic spasm appear in the tables, for 
which the facial, the supraorbital, or the inferior dental nerve was stretched, 
with 12 cures, 9 of which may be received as permanent. 
6. Miscellaneous neuralgic affections.—Thirty cases of neuralgia affecting 
various nerves are tabulated, with 23 cures and 6 improvements. Three of 
the former and 3 of the latter can be regai’ded as permanent. 
7. Central disease.—Under this head are included locomotor ataxia, lateral 
and anterior sclerosis of the cord, paralysis agitans, etc. One hundred and 
six cases are tabulated, with 1 cured and 59 improved. Those represented to 
be improved were cases in which for the most part the sciatic was stretched, 
24 of which operations appear to have afforded permanent relief. There 
are, however, 5 deaths to be placed to the account of this table. Whether 
chargeable altogether to the operation, it is impossible to determine. Death 
having here occurred in a class of cases which usually run a very chronic 
course, it is probable that the nerve-stretching had some share in the fatal 
result. 
8. Torticollis.—Thirteen nerve-stretchings are made for torticollis, with 7 
cured and 3 improved. Only 1 of these, and that one under the head of 
improvement, can, in consideration of the time the cases were kept under 
notice, be accepted. 
9. Paralysis.—Under this head are included infantile paralysis, anaesthetic 
leprosy, paralysis after fracture,—44 cases,—with 6 cured and 35 improved. 
As the element of time is omitted, no conclusion can be drawn. 
10. Epilepsy.—Four cases of epilepsy are collected, with 1 cured and 3 
improved. As the time during which they were kept under observation is 
omitted in the history of the cases, no inference can be drawn. 
11. Disease of the optic nerve.—Eight cases, and only 1 improved; a result 
which might have been expected. 
12. Contracture and spasm.—Five cases, with 2 cures. Here, again, from 
omission in regard to the time during which the cases were observed, no 
opinion can be ventured as to the permanency of the cures. 
Of the 350 cases analyzed, 143 are recorded cured and 151 improved. 
Subjecting the reported results to a rigid analysis, 47 cures and 33 permanent 
improvements must be regarded as unquestionable facts. It is not fair, how- 
ever, to conclude that the 96 represented cures and 118 improvements, which 
have been excluded from the analysis because the time during which they 
were kept under observation is not stated, were failures. Reasoning from the 
doctrine of probabilities, we may suppose that one-third of these two classes— 
cured and improved—remained as they are recorded, and, even after excluding NER VE-STRETCHING. 
427 
the cases enumerated under the headings of locomotor ataxia, paralysis, epi- 
lepsy, disease of the optic nerve, spasm, etc., we are thus forced to recognize 
the operation of nerve-stretching as a remedial measure of considerable value. 
Even on the supposition that relief only from severe suffering was obtainable 
by nerve-stretching after other measures had failed, the operation would be 
entitled to a place among regularly-recognized surgical procedures, resting 
as it would do on the same basis as that claimed for other remedies employed 
every day by the physician to alleviate, not to cure, disease. The argument 
which is sometimes used as condemnatory of nerve-stretching might be urged 
with equal force against the administration of opium in cancer, or of tonics 
in consumption. 
A very careful collection and analysis of cases of this operation published 
in the Neurological Journal for May, 1882, constitutes an excellent contribu- 
tion to the literature of this subject, and corroborates the conclusions reached 
from the analysis given of ray own table. The writer classifies the cases under 
the following heads, sifting out all doubtful ones: 
1. Sciatica.—Twenty-five cases of nerve-stretching are recorded as having 
been done for sciatica. After rejecting those which were not kept under 
observation for a sufficient length of time, this table retains 10 cases out of 
24 alleged cures, and 3 out of 6 recorded as relieved. This result is so much 
better than has ever been obtained from the usual remedies employed, that 
it demonstrates the value of the operation. 
2. Traumatic neuralgia, 10 cases are recorded, 6 of which are admitted as 
entitled to acceptance; 1 was followed by great relief, and 1 by fair relief. 
There were cured and relieved 53 per cent. This may be considered an 
excellent result. 
3. Idiopathic neuralgia, 3 cases, all reported as cured ; 1 admitted as entitled 
to credit. 
4. Chronic trigeminal neuralgia, 8 cases, all reported as cured ; 3 of these are 
accepted. In the 54 cases of functional neuralgia there were 20 certain cures 
and 5 relieved, or 40 per cent. 
5. Tic douloureux, or trigeminal epileptiform neuralgia, 4 cases, all claimed as 
cures; 1 is admitted as certain. 
6. Mimic facial spasm, 6 cases, all reported as cured; 1 excluded. 
7. Torticollis, 6 cases; 1 cured, 2 relieved, 1 relapsed, 1 slightly relieved, 1 
result unknown. The case recorded as cured was not under observation suf- 
ficiently long to justify its unqualified acceptance. Therefore nerve-stretching 
for torticollis, to the extent of the cases reported, cannot be regarded as suc- 
cessful. 
8. Spastic affections, 9 cases ; 3 cures, 1 doubtful, 3 great improvement, and 
2 slight relief. 
9. Locomotor ataxia, 21 cases; 5 deaths, only 3 cases of alleged relief, and 
these under observation only twenty days. The mortality, 35 per cent., 
with the reputed relief in only 3 cases, is sufficient to justify the unqualified 
condemnation of the operation in ataxia. 
10. Myelitis, 4 cases; no cures. 
11. Traumatic myelitis, 3 cases; no cures. 
12. Spastic spinal paralysis, 3 cases ; no cures. 
The value of the operation in the last three classes of cases is self-evident. 
13. Tetanus, 28 cases; 5 cures, being about the same result as that ob- 
tained from the ordinary mode of treatment; and, as other measures were not 
neglected in these cases, nothing can be claimed for the operation. 
14. Optic nerve, 7 cases; no encouraging results. The application of nerve- 
stretching of this particular nerve was introduced by Kummel. 
The manner in which the process of stretching a nerve acts in curing 
or relieving painful affections is not understood. Several explanations have 
been suggested, such as the lessened capacity of the nerve to receive or 
transmit painful impressions after being subjected to such force, the break- 
ing up of adventitious adhesions, a new impression made on the spinal 428 
SURGICAL AFFECTIONS OF THE NERVES. 
centres and the movement realized by the spinal cord and medulla oblon- 
gata from the nerve-traction,—a movement rendered not improbable by the 
experiments of Vogt and Gussenbauer. 
Another method of nerve-stretching is that of forcible flexion and extension 
of the limbs. 
This plan was practiced in the sixteenth century by Fabricius ab Acqua- 
pendento for the cure of chronic rheumatism, and, it is said, with excellent 
success. Eecently it has been tried by Trombetta, Clark, Fieber, and others, 
with asserted success. Any one at all familiar with anatomy knows that 
neither by flexion nor by extension of the limbs can the nerves be subjected 
to any but the most insignificant stretching, unless such nerves are bound 
by adhesions to surrounding parts. If, therefore, the benefit alleged to have 
been obtained in these cases of nerve-stretching by extreme flexion or ex- 
tension of the limb was real, it constitutes a strong argument in favor of 
the theory that the modus operandi of cure by exposing nerves and pulling 
upon their cords is through the rupture of inflammatory bands or adhesions 
which tie them to adjacent tissues. 
Operation.—The first step in the operation is the exposure of the main 
trunk of the nerve whose branches supply the painful region. In doing 
this, after dividing the skin, the different strata of tissues should be raised 
on a director preliminary to their being incised. The same accurate ana- 
tomical knowledge is required for exposing a nerve-trunk as for finding a 
great artery. When the nerve has been reached and isolated from the sur- 
rounding parts by the end of a director or the handle of the scalpel, its 
trunk should be raised and forcibly stretched,—in the case of a large trunk, 
such as the sciatic or the median, by the finger, and in smaller neiwes by the 
director or handle of the scalpel. The exact amount of force to be used must 
be determined by the magnitude of the nerve and the judgment of the sur- 
geon. The limb can even be raised from the table on which it rests by the 
nerve, without danger, in case the sciatic or the median is being stretched. 
The degree of force which may be safely employed in the operation of nerve- 
stretching must be determined by the particular nerve stretched. Trom- 
betta has furnished a table, based on experiments, which shows the amount 
of force necessary to rupture different nerves. The kilogramme, which he 
uses to express the weight, is equal to about two and a quarter pounds 
avoirdupois. It is safe to say that the force used in sti’etching should not 
exceed one-half that which causes the rupture of the nerve. 
Table showing the Force necessary to Rupture Nerves. 
To rupture the sciatic 
“ “ internal popliteal 
“ “ crural 
38 
kilogrammes. 
U 
it 
t( 
a 
« 
cubital 
27 
(( 
a 
a 
radial 
27 
ti 
a 
a 
brachial plexus (neck) 
u 
a 
a 
brachial plexus (axilla) 
16-17 
a 
a 
a 
infraorbital 
■ it 
(( 
it 
supraorbital 
it 
a 
“ 
mental 
a 
Central Affections induced by Irritation of Peripheral Nerves. 
Various convulsions and other central affections may be caused by tlie 
irritation of nerves. Among these are epilepsy, tetanus, neuralgia,—already 
considered,—local spasms, contractures, amaurosis, anaesthesia, and, less fre- 
quently, chorea, and different forms of palsy. 
Epilepsy.—The cases of epilepsy the origin of which has been traced to 
nerve-injuries are numerous. In most of these the evidence in favor of the 
reputed cause seems to bo conclusive. In one instance, the case of Dr. 
Laing, of Scotland, the disease followed a lacerated wound of the hand. CENTRAL DISTURBANCES. 
429 
The late Dr. Hodge reported a case which arose from a sensitive cicatrix 
of the scalp, in which the excision of the cicatrix put an end to the dis- 
ease. 
In a case of severe and progressive epilepsy, associated with an old painful 
cicatrix of the scalp, operated upon at the Philadelphia Hospital by Dr. J. 
William White, the result was an immediate improvement and finally an 
almost complete cure. No other treatment than free excision of the scar 
was employed, so as fairly to test the relation of cause and effect. 
Chorea.—Violent and very general choreic movements of the muscles are 
frequently observed following surgical injuries and operations. They may 
develop shortly after the injury, or may not appear until the patient has recov- 
ered from the proper effects of the operation or injury. Involuntary twiteh- 
ings or muscular spasms depending on neuritis or other diseased conditions of 
the nerves of stumps are not included among those designated as choreic. The 
latter may readily be distinguished from the former by the absence of any 
unusual local hyperaesthesia. One of the most striking examples of the class 
of reflex irritations under consideration occurred in the case of an aged 
judge from Western Pennsylvania, whoso hand I had previously removed on 
account of a large epithelioma. When the attacks came on, the entire body 
became violently convulsed with jerking movements, the spasm lasting until- 
the patient was greatly exhausted. 
Contracture of muscles following injury of peripheral nerves is no uncom- 
mon occurrence. Similar contracture in the walls of the blood-vessels of a 
part has also been observed. In the case of muscles, the contracture may 
be limited to a single muscle, or it may affect an entire group of muscles. 
From this cause various distortions of the toes, feet, fingers, hands, and other 
parts of the body take place. 
When the contracture affects the blood-vessels, their calibre is diminished 
to such a degree as notably to affect both the temperature and the nutrition 
of the tissues lying within the region involved, the former being materially 
lowered and the muscles and other textures becoming wasted.* There can 
be no doubt that many cases of muscular atrophy, if carefully studied, would 
be found to depend on this kind of starvation. 
Hypertrophy.—While atrophy is the more common result of nerve-injuries, 
hypertrophy may occur, the increase being due, not to excessive nutrition of 
the muscles of the part, but to hyperplasia of its connective and even of its 
osseous tissues.f 
Other reflex phenomena depending on irritation of peripheral nerves are seen 
in the ophthalmia following injuries of the# terminal branches of the fifth pair, 
in traumatic hysteria and delirium, and in several bizarre exhibitions of per- 
verted sensibility, both in the nerves of common and in those of special sense. 
Treatment.—The treatment of all cases of central disturbances of motility 
and sensation arising from irritation of peripheral nerves should be both local 
and general. 
Local.—In slight cases the local irritation may disappear under the use 
of hot anodyne lotions; or an opposite course will sometimes afford greater 
relief,—namely, lowering the sensibility of the part by applying the ice-bag 
or directing upon it a spray of ether or of rhigolene. Similar good results 
will occasionally follow counter-irritation, either by blisters or by the actual 
cautery. Morphia employed hypodermically will always secure temporary 
alleviation or exemption from pain. Painful cicatrices should be excised, 
and in obstinate cases, when the disease can be traced to a particular nerve, 
the nerve should be stretched or a portion excised. 
Instead of dividing the nerve after its exposure, it has been suggested by 
Clark to try the effect of local anaesthesia by directing upon the trunk, from 
time to time, the ether spray. The effect, I am inclined to think, would not 
be equivalent to that produced by the more radical measure of division, 
* Gazette M6dicale do Paris, 1847, p. 687. 
f Dr. Lande, Archives de M6decine, p. 311, July, 1854. 430 
SURGICAL AFFECTIONS OF THE NERVES. 
which ought to be tlone at some distance from the seat of pain, at a point 
where the nerve will probably be free from any inflammatory complications. 
Electricity constitutes a valuable agent in many cases in which a neu- 
ralgic element is suspected, and is also serviceable when muscular atrophy 
is present. Splints and rollers secure absolute quiet of the muscles and 
serve to remove one of the exciting causes of attacks. Amputation becomes 
necessary only when the part has been rendered useless or has become an 
incumbrance from the results of antecedent injury or disease. 
General remedies.—The constitutional remedies from the use of which the 
greatest benefit may be expected are those which are known to lower central 
excitability, such as the bromides, belladonna, ergot, morphia, Calabar bean, 
chloral, etc. 
Scrivener’s Palsy. 
This name has been given to a variety of paralysis, with loss of co-ordina- 
tion, affecting chiefly certain muscles of the hand. This affection is the 
result of long-continued use of the fingers in the execution of a series of un- 
varying and monotonous movements. It is not exclusively a clerical disease, 
or one confined to persons whose official or literary duties necessitate the 
constant use of the pen, but is met with also among musicians, needle-women, 
milkmaids, compositors, and other persons whose occupations demand the 
constant action of the same muscles in the same manner. 
Writers do not agree in regard to the exact seat and nature of the disease. 
Some regard it as being only an expression of exhaustion or fatigue in the 
affected muscles, while others attribute it to a deeper or central origin,—a 
reflex neurosis,—a disturbance of the co-ordinating mechanism ; and this last 
is the more probable view, since it receives corroboration from the permanent 
nature of the disability, and also from the liability of certain unfatigued or 
unexhausted muscles of the arm to participate in the paralysis. 
Symptoms.—The approach of the disease is generally announced by a tired 
feeling in the thumb and index finger, with occasional cramps. These symp- 
toms soon disappear after laying aside for a short time the use of the pen, 
to be renewed after a variable period on resuming the accustomed work. 
With the frequent recurrence of these attacks the patient finds the ability 
to grasp and direct the movements of the pen materially7 lessened, and with 
this increasing weakness there is often a feeling of pain or uncomfortable 
ache extending to the muscles of the forearm, either preceded or followed 
by numbness and tingling sensations. Sometimes the pen is placed between 
the middle and ring fingers,—an expedient which soon fails, however. The 
symmetrical sympathy which prevails between corresponding muscles of the 
two sides is strikingly exemplified in this variety of palsy7, and the mere 
attempt to use those of the affected hand is sometimes followed by’ painful 
sensations in those of the sound one. 
This disease of disordered muscular co-ordination does not invariably 
exhibit uniform phenomena. Variations will be noticed in which some 
symptomatic peculiarity is present. This may be constant or intermittent 
cramp, tremor, or paraly7sis. Each one of these, when dominant, will betray7 
itself whenever the patient attempts to write. If spasm or cramp prevails, 
the index finger and thumb will suddenly become straight and rigid, or alter- 
nately straight and flexed, causing the pen to drop from the grasp, or, if 
there is power enough left to hold it, the patient is sometimes unable to give 
the proper shape to the letters, and the writing is disfigured by staggering 
angular lines. (Fig. 2020.) Tremor often shows itself, giving to the letters 
a zigzag, undulatory, or serpentine outline, resembling in some respects the 
well-known signature of Stephen Hopkins affixed to the Declaration of Inde- 
pendence (Fig. 2021) ; and when paralyrsis prevails, the manuscript shows, by 
the interruption and unequal thickness of the lines, how helpless and shorn 
of its strength and cunning is the hand. (Fig. 2022.) 
In some instances, along with the local weakness impairment of the gen- TETANUS. 
431 
eral health appears ; the digestion becomes disordered ; and there is a lack of 
strength, often accompanied with depression of spirits, which latter, however, 
may be only the moral effect of the feeling of disqualification for work. 
Fig. 2020. 
Fig. 2021. 
Fig. 2022. 
Spasmodic. 
Tremor. 
Paralytic. 
Jt would be fortunate if the patient would only take warning from the 
early signals which betoken the approach of the disease, and either muster 
the other hand into service, or, what would be better, stop work entirely and 
give to the weary member a long rest. This rest should include the entire 
arm, and can be fully attained only by placing the member on a splint and 
suspending it in a sling from the neck. After two or three weeks of quiet, 
the muscles should be shampooed daily and treated with electricity, with the 
threefold object of improving their nutrition, of preventing waste, and of 
restoring nerve-power. 
As the occupations of those who are the subjects of this palsy are gener- 
ally sedentary and in-door, the general health must not be overlooked. Ex- 
ercise in the open air, good food, the compound syrup of the phosphates, and 
an ample amount of sleep will contribute to the improvement of the local 
weakness. 
For those who are driven by the inexorable force of necessity to ply their 
vocations in spite of the infirmity, or those who only desire to sign a check 
or to indite an occasional letter, there are mechanical contrivances which will 
give some degree of satisfaction. In one of theso devices the instrument 
consists of three rings,—two large, to receive the middle and ring fingers, 
and a small one for the passage of the pen-holder, with a button-screw to 
fix the latter in place. (Fig. 2023.) Another apparatus consists of a pen- 
Fig. 2023. 
Fig. 2024. 
Instruments for scrivener's palsy. 
holder attached to a plate having two rings for the index finger and a guard 
for the thumb. (Fig. 2024.) 
Tetanus. 
Tetanus may be defined to be a disease characterized by violent and painful 
tonic spasms of the voluntary muscles. The spasms attack different groups 
of muscles, which continue in a state of constant contraction without any 
intermission, although there maybe periods during which the motor impulses 
are less intense and succeed one another less rapidly at one time than at 
another, when a very partial relaxation will be experienced. 
Varieties.—Several names have been introduced into the literature of teta- 432 
SURGICAL AFFECTIONS OF THE NERVES. 
lius, descriptive of local, postural, or other phenomena observed in the course 
of the disease. These are trismus, or “ lock-jaw,” the local spasm of the 
muscles of mastication; opisthotonus, a spasm in which the body becomes 
arched, with an anterior convexity; emprosthotonus, the convexity of the arch 
being turned posteriorly; and pleurosthotonus, when the curve or arch is 
lateral. Trismus nascentium, or trismus neonatorum, is a variety of tetanus 
which attacks new-born children. The varied distortions of the body are 
the result of unequal tonic contractions of different groups of muscles, the 
spasm being more violent in some groups than in others. 
Other divisions of tetanus are the traumatic and the idiopathic, and the 
acute and the chronic. 
Symptoms.—In the department of symptomatology the ancient medical 
writers were pre-eminently distinguished. Their descriptions of diseases are 
in many instances exceedingly graphic, and they are generally true to nature. 
The portrait of tetanus, drawn by the hand of Aretseus, both in accuracy of 
detail and in splendid coloring, has never been surpassed. 
The invasion of traumatic tetanus, that variety which comes peculiarly 
within the province of surgery, is sometimes sudden, coming on a few hours 
after an injury, though ordinarily the onset is gradual, the disease not ap- 
pearing until after the lapse of eight or twelve days succeeding the exciting 
cause. Twice I have seen the disease set in at a very unusual period; in 
one of the cases, a crush of the foot, in four weeks after the injury, and in 
the other, a laceration of the hand, after the wound was almost closed, and 
when the patient was out attending to his business. 
The earliest signs announcing an attack of tetanus are at first a slight 
stiffness and soreness of the muscles of the jaws and the neck, with some 
difficulty in swallowing, often referred to cold or to some trivial exposure. 
These sensations are, after a short time, followed by cramp or spasmodic 
contraction of the muscles of mastication, which lock the jaws tightly 
together. The precedence usually taken by the masseter, temporal, and 
pterygoid muscles in the chain of morbid phenomena is probably due to 
their great normal irritability. In very exceptional cases the abdominal 
muscles have first become affected. This was so in the case of a judge in 
this city, who some years ago perished from tetanus produced by a lacerated 
wound of a thumb. Occasionally the stiffness and muscular cramp are pre- 
ceded by feelings of general indisposition or malaise. The increasing and 
unremitting spasm of the masticatory and cervical muscles renders it impos- 
sible for the patient to separate the jaws or to convey even liquids into the 
mouth, except when drawn through the crevices between the teeth, and the 
act of swallowing is accomplished only at the expense of violent convulsive 
muscular contractions. The muscles of the abdomen are seized with cramp, 
becoming rigid and hard as iron to the touch. A peculiar retraction or 
cord-like constriction is also experienced, extending from the end of the 
sternum to the spine, and along the cartilaginous border of the thorax, 
answering to the origins of the diaphragm, and giving a sunken appearance 
to the epigastric region. The spasmodic rigidity extends to the muscles of 
the back and to those of the extremities, especially the lower ones, until 
finally the entire voluntary muscular system is involved in the same dreadful 
spasm. The exemption of the forearm and hand from the general cramp, 
alleged by Rose to be unvarying, is not always observed. I attended a 
manufacturer in the northern part of this city with chronic tetanus, in whom 
the muscles of these parts were affected in common with the other muscles 
of the body. 
The prevailing distortion in tetanus—in fact, the only one which I have 
seen—is one in which the head is drawn back and the body arched in the same 
direction. In this condition, with the limbs and trunk rigidly stiff, straight, 
and unyielding, the patient can bo turned from side to side, as one -would 
handle a jointless automaton. Larrey, who saw large numbers of tetanic 
patients among the French soldiers during the Egyptian campaign, remarks TETANUS. 
that when the wound preceding the disease was located on the anterior as- 
pect of the body, emproslhotonus was the usual form assumed. The well- 
known graphic delineation of a patient of Sir Charles Bell's, who was repre- 
sented resting on the occiput and the heels, resembling a strongly-drawn 
bow, portrayed an acrobatic rather than a pathognomonic posture. 
As the disease progresses, the jaws become more and more rigidly locked, 
the teeth firmly set, the eyes fixed and staring, the angles of the mouth 
retracted, the nares dilated, the lips strongly compressed and flattened, dis- 
closing the teeth between, and the facial lines strongly marked, the combina- 
tion of which imparts to the face an expression of hopeless anguish and suffer- 
ing horrible to contemplate. Fig. 2025, engraved from a photograph taken 
from one of my hospital patients suffering from 
tetanus, gives a faint idea of the tetanic face. 
The pharyngeal secretions often accumulate, 
and, churned into a froth, are forcibly ejected 
from the mouth between the teeth by expulsive 
expirations, and such discharges adhering about 
the chin have caused tetanus to be confounded 
with hydrophobia. The spasms, sometimes from 
central exhaustion, relax and allow the jaws to 
separate a little for a brief interval, but they re- 
turn suddenly with renewed energy, often lacer- 
ating the tongue, which is liable to be caught 
between the teeth. When, from exhaustion or 
from the effect of anodynes, the patient falls into 
a short doze, the spasms subside, returning with 
the moment of awaking. 
Secretions.—The bowels are constipated, the 
urinary secretion is diminished and retained, 
and the surface of the body is usually bathed 
in perspiration. 
Circulation.—The circulation varies, the pulse 
ranging from 80 to 00 beats per minute ; but as tne disease approaches the 
fatal crisis it will often run up to 140 or 160 per minute. Dr. O’ Bierne is 
reported by Poland as saying that in 200 cases of tetanus he never saw any 
signs of fever. 
Temperature.—The temperature, at first not materially atfected, will, a short 
time preceding death and for some time‘after, rise to 110° or 112°. This 
excessive heat which has been frequently noticed after death from tetanus 
is attributed by Frick and others to the coagulation of myosin during the 
stiffening of the muscles. 
Reflex irritability.—With the approach of death the muscular hyperes- 
thesia becomes exalted, so that a strong light or any slight movement in the 
room sends a convulsive wave through the whole muscular system, so sudden 
and violent, indeed, that in some cases the patient seems to be raised bodily 
by an invisible power, and may require the restraint of an attendant to pre- 
vent his falling from the bed. 
Respiration.—The breathing at first is not materially disturbed, seldom 
exceeding twenty or twenty-two respiratory acts a minute ; but when the 
muscles of the thorax begin to participate in the spasm it grows more fre- 
quent and shallow, from an inability to expand the chest, and at length 
becomes convulsive; during the thoracic spasm the patient becomes cyanosed, 
finally expiring either from exhaustion or from cardiac paralysis. Through- 
out the entire progress of the case the intellect remains unclouded. 
The duration of tetanus rarely extends beyond three or four days : when 
it is longer, and the disease exhibits a tendency to become chronic, the hope 
of recovery will increase with each additional day. 
Trismus nascentium, or infantile tetanus, presents very much the same 
symptoms as those of the disease already described. It develops between 
Fig. 2025. 
Tetanus—taken from nature. 434 
SURGICAL AFFECTIONS OF THE NERVES. 
the seventh and fourteenth days afterbirth. In the negro population of the 
West Indies the mortality among new-born children from this cause was at 
one time very great. In St. Domingo, according to Fourcroy, 80 per cent, 
of the negro children died before they reached the age of nine years. In 
Louisiana, Rainal states that the same class died at the rate of 50 per cent. 
Dr. Clark says that of 17,500 children born in the Dublin Lying-in Hos- 
pital, 2945, or 17 per cent., perished from tetanus. That atmospheric condi- 
tions are largely concerned in producing the disease is evident from another 
fact stated by the same writer, that after improving the ventilation of the 
institution the malady fell to 5 per cent., or 419 deaths in 8033 children. 
Causes.—In the bodies of those dying from tetanus there has been dis- 
covered a micro-organism which some pathologists regard as the cause of 
the disease. Inoculations with cultures made from portions of the spinal 
marrow of persons who have died from tetanus have produced the malady 
in animals otherwise sound. The most commonly accepted cause of tetanus 
is traumatism. Under this head are included compound fractures, and con- 
tused, lacerated, punctured, incised, and gunshot wounds. A very slight 
abrasion or scratch has in many instances been followed by the disease. A 
colored lad was brought into the Pennsylvania Hospital supposed to be suf- 
fering from idiopathic tetanus, there having been no history of wound or 
other violence to account for the attack. After death, a small splinter, not 
exceeding one-fourth of an inch in length, was found in the sole of the foot. 
Tetanus has followed cupping, the ligation of piles, burns, excision of the 
mammary gland, dislocations, caries of bones, tooth-extraction, and frost- 
bite. During the disastrous campaign of Napoleon in Russia many soldiers 
perished from tetanus brought on by exposure to an intense degree of cold. 
A current of cool air blowing over a recent wound is always fraught with 
danger. Lacerated wounds, particularly of the lower extremities, are most 
likely to cause tetanus. Compound fractures come next in the order of 
causation. 
Tetanus in shot wounds.—During the Peninsular War there was 1 case of 
tetanus in every 200 wounded ; during the Crimean War the proportion was 
the same; in our own late war there was 1 case in every 450 wounded. 
Climate.—In four years at Bombay, among 26,719 sick, Peat saw 195 cases 
of tetanus; and in the same place for three years the fatal cases of tetanus 
were 3.9 per cent, of the whole number of deaths from all causes. Com- 
paring this with the records of the disease in temperate climates, it appears 
from the reports of Guy’s Hospital and of the Vienna General Hospital, 
during a period of thirty-two years for the former and nine years for the 
latter, that out of 352,931 patients there were only 122 deaths from tetanus. 
The ratio in Guy’s Hospital is 1 case of tetanus to 1570 patients, and in the 
Vienna General Hospital 1 in 4798 patients. In England the proportion of 
deaths from tetanus to the entire population is estimated at only 0.0031 per 
cent. In Berlin, with a population at the time of the observation of 682,673, 
there were in one year (1867) 275 deaths from tetanus, but of this number 
only 9 were adults, the remainder, 266, being new-born children. 
In hot climates the native population is more prone to tetanus than the 
European. Referring to the statistics of Peat on this subject, it appears 
that in Bombay there were 161 deaths from the disease among a population 
of 11,929 natives, and 21 deaths among 2733 Europeans. 
Atmospheric changes are among the agencies predisposing to attacks of 
tetanus after wounds. The experience of military surgeons is particularly 
valuable on this point. Larrey says that in Egypt wounded soldiers were 
most liable to suffer from the disease during sudden changes of temperature 
or the occurrence of cold, damp storms. Ilennen’s testimony is to the same 
effect. Following the capture of Joppa, many cases of tetanus occurred 
among the wounded, who were compelled to lie on the damp ground, though 
covered by tents. After the batle of Ticonderoga, 9 of the wounded, who 
lay in boats, exposed to the cold, damp night-air, died from tetanus. TETANUS. 
435 
Sex.—It is difficult to determine the effect of sex on the prevalence of 
tetanus. Males, being so much more exposed than females to the ordinary 
casualties which are most potent in developing the disease, furnish, necessa- 
rily, more examples of tetanus. In Thamhayri’s collection of 397 tetanic 
cases, 329 were males and 68 females. Of 375 cases collected from different 
sources, 80 per cent, were males. In 34 cases of idiopathic tetanus, 70 per 
cent, were males. Of males, 44 per cent, recovered; of females, 58 per cent.— 
or, excluding puerperal tetanus, 63 percent.—recovered. Through the kind- 
ness of Dr. Ford, a member of the Board of Health of the city of Philadel- 
phia, I learn that during the five years from 1877 to 1881, inclusive, 281 
cases of death from tetanus are recorded among the interments in this city. 
Of this number, 240 wore males and 41 females. 
Aye.—Excluding trismus nascentium, tetanus is most common between the 
ages of eighteen and thirty-five years,—the relative frequency of the disease 
during this as compared with other periods of life being about 60 per cent. 
Of the 281 deaths from tetanus occurring in the city of Philadelphia, already 
cited, 180 were adults, 86 boys, and 15 girls. 
Effect of age on mortality.—In a collection of 375 cases of tetanus, the first 
decade furnished 7 per cent, of all cases, of which number 6.25 percent, died. 
Between ten and twenty years the cases amounted to 20 per cent., and the 
mortality fell to 38 per cent. Of 449 cases of tetanus analyzed by Poland, 
and arranged in four categories, there were 29 cases under ten years of age, 
261 between the tenth and thirtieth, 122 between the thirtieth and fiftieth, 
and 37 cases over the fiftieth year. 
Influence of particular kinds of injury.—The character of the injury exercises 
a controlling influence in determining tetanic disease. In 187 cases of tetanus 
tabulated with reference to this subject the vulnerating cause is stated as 
given below, in which lacerated wounds are first in order of frequency, next 
crushes, next amputations for injuries, and next burns. Compound fractures, 
though they rank fifth in the table as a determining cause, would be found 
to rank second, I am disposed to believe, in a larger analysis of cases. 
Cases. 
Died. 
1 
1 
Abrasions 
2 
Amputations, primary, for injury 
11 
3 
3 
Burns 
14 
Contusions *. 
4 
3 
Crush 
20 
Dislocations, compound 
6 
Dog-bite 
1 
0 
8 
5 
“ componnd 
11 
9 
3 
2 
Wounds, incised 
1 
contused 
4 
2 
" lacerated 
18 
“ punctured 
10 
8 
“ gunshot 
7 
3 
“ penetrating abdomen 
1 
0 
3 
l 
Twist of knee 
1 
1 
Total 
187 
110 
Nature of Injury. 
Wounds made in operations are seldom followed by tetanus, the proportion 
not exceeding one case in a thousand. An unusual frequency of the dis- 
ease after operations appears in the records of the Pennsylvania Hospital, as 
analyzed by Dr. Roberts. Out of 19 cases of tetanus treated in the wards, 
6 occurred after operations. 
Period of development after injury.—Of 133 cases collected by Dr. Baum 
with reference to the time elapsing between the injury and the development 436 
SURGICAL AFFECTIONS OF THE NERVES. 
of the disease, 6 occurred within twenty-four hours; from the second to the 
tenth day, inclusive, 84 cases; from the eleventh to the seventeenth day, 37 
cases; from the twentieth to the twenty-seventh day, 5 cases; and 1 six 
weeks after the injury. 
In a collection of cases analyzed to determine the percentage of deaths 
based on the period of invasion, the result was as follows: of those cases 
which occurred within two weeks after the injury, 196 cases, 62.5 per cent, 
died; from the fourteenth to the twenty-first day, 17 per cent, of 81 cases 
died; from the twenty-first to the forty-fourth day there were 17 cases, of 
which 17 per cent. died. 
In cases occurring within seventy-two hours after injury the recoveries 
exceeded the deaths in the proportion of 14 to 11; in those occurring between 
the fourth and the ninth day the recoveries were 33, the deaths 73, or 69 
per cent. In cases beginning on the thirteenth day the deaths stood to the 
recoveries as 7 to 3; but where the tetanic symptoms did not set in until the 
fourteenth day the recoveries wTere considerably in excess of the deaths,— 
viz., 23 per cent. 
Effect of duration of symptoms on mortality.—When the disease continued 
four days, 18 cases gave a death-rate of 58 per cent.; continuing nine days, 
131 died to 39 who recovered ; in 105 cases continuing from nine to twenty- 
three days there were 82 recoveries; in 74 cases surviving beyond twenty- 
three days only 3 died, death in each case occurring on the twenty-eighth 
day. The largest number of deaths, 31, occurred on the second day; on the 
fourth day there were 21, and on the fifth day 11. 
Effect of time of development on mortality.—In 654 fatal cases of tetanus, 
366 died before the fifth day; 180 between the fifth and the tenth day; 86 be- 
tween the tenth and the twenty-second day; and 22 after the twrenty-second 
day. The mortality, therefore, steadily diminishes as the disease is prolonged. 
Professor D. W. Yandell, in analyzing Dr. Cowling’s statistics with a viewr 
to ascertain the bearing of time on the mortality of tetanus, found that the 
prospect of recovery after the tenth day was greatly enhanced. 
General mortality.—Of 380 cases of tetanus collected by Frederick and 
Curling, 198 died and 182 recovered. I)r. Cowding has tabulated 415 cases 
of tetanus, 182 of which died and 233 recovered. The mortality of tetanus 
at Guy’s Hospital and the Hospital at Glasgow, according to Poland, amounts 
to 84.2 per cent, for the former and 87.5 per cent, for the latter institution. 
A proper estimate, based on a large number of cases, is about 1 death to every 
7£ cases in civil surgery. In military surgery the mortality is greater. Of 
363 cases reported during our late civil war, 313 died.* 
Of 19 cases treated in the wrards of the Pennsylvania Hospital from April 
1, 1873, to April 1, 1877, and tabulated by Dr. John B. Boberts, only 3 re- 
covered. Of these 19 cases, 18 developed in the Avards of the hospital, and 
1 was admitted suffering from the disease. 
At St. George’s Hospital, from 1865 to 1879, inclusive, there wrere 53,271 
admissions and 4936 deaths, or 9.29 per cent. During the same period 44 
cases of tetanus were treated in the institution, 35 of whom died, or 75 per 
cent. Of these 44 cases of tetanus, 16 were admitted on account of the dis- 
ease, 1 being idiopathic; 15 of these were due to traumatic causes, of which 
number 11 died and 4 recovered. The one reported as idiopathic survived. 
In 28 of the cases the disease originated in the wards; of these 24 died and 
4 recovered. 
In St. Bartholomew’s Hospital the admissions for nineteen years, from 
1860 to 1880, inclusive,—one year, 1868, not being included, the particulars 
of tetanus being defective,—the total admissions were 103.209, with a death- 
rate of 9.92 per cent. The admissions for tetanus during the same time were 
57, with 47 deaths, or 82.5 per cent; 40 of the cases were admitted for the 
* The complete statistics on the subject of tetanus among soldiers during >the late civil war have 
not yet been made public. TETANUS. 
437 
disease, 30 of whom died, or 75 per cent.; 17 developed in the wards, with 
17 deaths, or a death-rate of 100 per cent. 
In St. Thomas’s Hospital, from 1866 to 1877, inclusive, the admissions were 
28,816, the deaths 12.15 per cent. The cases of tetanus treated in the insti- 
tution during the same period were 24, with 19 deaths, or 79.16 per cent.; 
13 of the 24 cases entered the hospital suffering at the time with the disease, 
9 of whom died, or 69 per cent.; 11 were attacked while in the wards, 10 of 
whom died, or 90.9 per cent. 
The aggregate number of cases of tetanus, therefore, in the three last- 
named hospitals is 125, with 101 deaths, or a death-rate of about 79 per cent. 
Comparing this with the mortality from all other causes in the same hos- 
pitals, it will be seen that in 185,296 patients there were 18,671 deaths, or 7.12 
per cent. 
The mortality from idiopathic tetanus appears to be less than that from 
the traumatic disease. Of 225 cases of tetanus collected from different 
sources, 9 were idiopathic, or 8.6 per cent., and 216 traumatic, or 91.4 per 
cent. Of the 9 idiopathic cases, 5 recovered and 4 died, or 44.7 per cent.; 
while of the traumatic cases, 59 recovered and 157 died, or 72.7 per cent. 
Diagnosis.—Tetanus, in some of its aspects, resembles hydrophobia, hys- 
teria, and especially poisoning from strychnia. Between tetanus and rabies 
there are several well-pronounced differences. 
Spasms are tonic. 
Rarely preceded by a bite; at lea3t, prevails 
without any precedent wound of this nature. 
Develops in a few days after an injury. 
Eyes fixed and staring, without any extraordi- 
nary excitement. 
Vomiting, with gastric pain, rare. 
No aversion to fluids. 
Risus sardonicus. 
Recovery frequent. 
TETANUS. 
Spasms are clonic. 
Always preceded by the bite of a rabid animal. 
Requires a period of incubation of three, four, 
or many weeks. 
Eyes glistening, and great excitement. 
Vomiting, with gastric pain, quite common. 
Patient often thrown into violent paroxysms 
by the approach of water. 
Facial expression one of mingled horror and 
fear. 
Always fatal. 
HYDROPHOBIA. 
The differences between tetanus and hysteria are so palpable that to con- 
found the two affections would seem impossible. 
The phenomena attending poisoning by strychnia in some respects resemble 
the symptoms of tetanus. 
TETANUS. 
STRYCHNIA-POISONING. 
Invasion gradual. 
Violence increases with time. 
Affecting muscles of the limbs last. 
No intermission to convulsions. 
No loss of consciousness. 
Fatal termination after some days. 
Invasion sudden, a few minutes after taking 
the poison. 
Violent from the first moment of onset. 
Chiefly affecting muscles of the extremities. 
Convulsions intermitted. 
Loss of consciousness. 
Fatal termination in a few hours. 
Pathology.—Some light has been thrown on the pathology of tetanus by 
the examinations which have been made of the bodies of those dying from 
the disease. The changes which have been observed are increased vascu- 
larity, congestion, and granular degeneration and softening of the medulla 
oblongata and of the gray substance of the spinal cord. In some instances, 
in addition to extreme congestion of the vessels of the cord, particularly in 
the gray matter of the posterior horns, there has been observed a transparent 
transudation interpenetrating the neuroglia around the blood-vessels, and 
even lacerating the surrounding tissue. Whether these structural alterations, 
indicative of myelitis, are anything more than the effect of an extraordinary 
exaltation of the functions of the cord produced by the disease, is not deter- 
mined. The presence of similar pathological phenomena in other affections, 438 
SURGICAL AFFECTIONS OF THE NERVES. 
for example, infantile paralysis, entirely disassociated with spasm, proves that 
these phenomena alone are not sufficient to explain satisfactorily the material 
cause of the disease. 
Whatever may bo the essential or central condition capable of producing 
such extraordinary phenomena of motility, there can be little doubt that the 
surgeon has it in Ids power to prevent in a great measure the occurrence of 
tetanus by adopting such modes of treatment as will protect patients against 
those external agencies which are known to constitute determining forces in 
its causation. Among things to be avoided may be mentioned irritating 
dressings to wounds, cold, moist currents of air, bad ventilation, sudden 
alternations of temperature, damp rooms, and defective nourishment. 
The very small number of cases of tetanus (363) reported during our late 
war, as compared with those which have been recorded in the conflicts of 
former times in which military operations were conducted on a scale of 
similar magnitude, furnishes conclusive evidence of the prophylactic value of 
well-appointed medical and commissary stores, with a rigid observance of the 
established principles of hygiene. 
Treatment.—The various remedies which have been employed at different 
times to combat this formidable disease show how entirety empirical the 
treatment has been, and that it must continue to be so until the pathological 
secret of the affection shall be disclosed. Without stopping to enumerate 
the various articles which have been used for this purpose, I shall speak of 
those which both theoretically and practically seem to have yielded the most 
satisfactory results. 
The first indication in tetanus is the removal of all local causes of irrita- 
tion, under which will be included the extraction of any extraneous matters 
which may have entered the wound in a traumatic case, enlarging the 
wound to secure the escape of purulent and other accumulations, establish- 
ing free drainage, and applying warm anodyne and antiseptic dressings, as 
carbolated water and laudanum or hot poultices. Other local treatment has 
been advised, as amputation of the wounded part, excision of nerves, and 
nerve-stretching. 
Amputation was at one time practiced, but with results so unsatisfactory 
that it met with the unqualified condemnation of surgeons, chiefly through 
the influence of Sir Astley Cooper in England and Dupuytren in France. I 
removed on one occasion the damaged foot of a patient in the Philadelphia 
Hospital on the first appearance of tetanus, but without modifying in the 
slightest degree the progress of the disease. 
Division of nerves, practiced by Kicks in cases of tetanus, has been per- 
formed several times, with reputed success. 
Among the various affections for which nerve-stretching has been per- 
formed is tetanus. 
Mr. Langston* stretched the popliteal nerve in a male, aged 43, suffering 
from tetanus caused by an injury of the lower extremity, but without benefit, 
as the case proved fatal. 
M. Yerneuilf performed a similar operation on the median and ulnar 
nerves of a male patient, aged 39, suffering from tetanus, the result of a 
crush of the right hand ; recovery followed. A case of unsuccessful stretch- 
ing of the musculo-cutaneous nerve for tetanus following the removal of a 
recurrent carcinoma of the breast with the axillary glands is also given. 
The brachial plexus was exposed and stretched both centrally and periph- 
erally in a case of tetanus following luxation of the thumb. The paroxysms 
ceased for three days, but then returned and destroyed the patient.^ 
Hutcbinson§ stretched the great sciatic nerve in a case of tetanus arising 
after a gunshot wound of the leg, but without avail. 
* St. Bartholomew’s Hospital Reports, 1878, vol. xiv. p. 193,—Callender, 
f Ibid. 
j Philadelphia Medical Times, 1880, vol. ix. p. 277; from St. Petersburg Med. Wochenschrift. 
£ Medical Times and Gazette, 1879, vol. i. p. 619. TETANUS. 
439 
Smith* performed a like operation on the median nerve of a patient who 
had a lacerated wound of the arm, exposing the flexor tendons, the injury 
being followed in twenty days by tetanus. The man recovered. 
Heathf stretched the ulnar nerve for tetanus caused by a punctured 
wound of the hand, but without success. 
Another case of nerve-stretching (sciatic) was reported by Morris,J the dis- 
ease following an injury of the foot. Death followed in twenty-four hours. 
Clark,§ in a case of tetanus from a crush of the great toe, stretched the 
sciatic. The patient recovered. 
A successful case|| is reported in which the posterior tibial nerve was 
stretched. The same writer records five other cases of nerve-stretching for 
tetanus,—3 by Vogt, with 2 successes, 1 by Drake, with temporary relief, 
and 1 by Yerneuil, which has been noted above. 
The sciatic was stretched in a case of tetanus following a wound 
on the back of the thigh. The nerve was exposed and stretched in the 
wound. Death followed. 
Of the 13 cases, there were 7 deaths and 6 recoveries; but, as other meas- 
ures were employed besides the stretching of the nerves, it would not be just 
to give the operation the whole credit of the cure. 
The constitutional treatment must be of a character calculated to allay 
both central and peripheral irritation. Various antispasmodics and anodynes 
have been commended, such as camphor, assafoetida, musk, opium, aconite, 
conium, Calabar bean, and Indian hemp. Ether and chloroform are also to 
be included in the list of therapeutical remedies. 
In two cases of traumatic tetanus I kept the patients, one for two days 
and the other not so long, in a state of moderate anaesthesia. While under 
the influence of the agent there was a very sensible relaxation of the cramp, 
but immediately on the patient’s coming out of the anaesthetic sleep the 
spasms regained their original violence. 
The remedy which appears to possess the greatest efficacy in tetanus is 
chloral hydrate. It must be administered in full doses, and repeated accord- 
ing to the urgency of the symptoms. To an adult twenty to thirty grains 
may be given every two hours, or until the reflex excitability of the cord has 
been controlled, after which the drug should be administered in such doses 
and at such intervals as will maintain whatever advantage has been gained 
over the disease. When the medicine cannot be taken by the mouth, it 
should be given by enema, mixed with flaxseed-tea. 
The importance of sustaining the general strength in a disease which so 
rapidly exhausts the vital powers of the system is evident. As the disease 
seems to move onward through a series of stages of ascension, culmination, 
and declination, if the system can be sustained during this terrible struggle 
between the recuperative forces of the body and the disease until the climax 
has been passed, the chances of recovery will be enhanced. I believe that 
many patients perish from too much medication and too little feeding. 
Milk, beef-essence, and eggs are to be given as long as the patient is able to 
swallow, and when deglutition becomes impossible resort must be had to 
rectal alimentation. 
During the entire course of the disease the reflex irritability of the cord is 
so marked that everything calculated in any way to increase this source 
of exaltation should be sedulously avoided. Hence it will be proper to keep 
the room of the patient moderately dark, to have as few attendants about 
as possible, and to allow no loud conversation. 
Atrophy.—Nerves undergo atrophy, in common with other tissues and 
* Medical Times and Gazette, 1880, vol. ii. p. 216. 
f Ibid., 1882, vol. i. p. 4. 
J British Medical Journal, 1879, vol. i. p. 933. 
| Glasgow Medical Journal, N. S., 1879, vol. ii. p. 10. 
|| Cincinnati Lancet and Clinic, N. S., 1879, vol. ii. p. 41. 
St. Bartholomew’s Hospital Reports, 1877. 440 
SURGICAL AFFECTIONS OF THE NERVES. 
organs of the body, when from insufficient nourishment or chronic wasting 
diseases general emaciation takes place. Atrophy also follows blows, press- 
ure from tumors, chronic inflammation, and central disease. The same is 
true when all connection between the nerve-trunk and its centre has been 
destroyed. With the cessation of function there follows nerve-degeneration. 
The role of degeneration is not the samo in all forms of atrophy. When 
primary-, and not the result of inflammatory, traumatic, central, or trophic 
causes, the fibrils gradually disappear, and at the same time there is hyper- 
plasia of the connective tissue, with the appearance of amylaceous corpuscles. 
On the other hand, when the wasting is secondary- to any of the causes above 
named, fatty metamorphosis is a prominent feature in the degeneration. The 
medullary sheath of Schwann gradually disappears, and along with it the axis- 
cylinder, until finally there remains only the shrunken neurilemma, or nerve- 
sheath, with increase of the connective tissue, in which there is an infiltrate 
of cells and a sero-fibrinous transudation. The appearance of nerves which 
have undergone atrophic degeneration is very- unlike that which normally- 
belongs to these cords. Instead of being opaque, round, and faintly red in 
color, they are translucent, collapsed, and gray- or drab-colored. 
Any success which may be expected to follow treatment will depend on 
the possibility of restoring the continuity- of the nerve with its centre, where 
that has been interrupted, and on removing any cause of pressure. If con- 
nection with the nerve-centres is continuous, electro-therapeutic treatment 
will constitute the best stimulus tending to the regeneration of the wasted 
neurine. 
Hypertrophy.—Except in cases of neuroma, we can scarcely- speak of hy-per- 
trophy of nerves, although instances are recorded by Heller, Moxon, and 
others, where there was a marked increase in the nerve-fibres, as well as of 
the medullary sheath and neuroglia. 
Pseudo-Hypertrophic Muscular Paralysis.—This form of paralysis, first 
described by J)uchenne in 1858, is met with in early childhood. It has been 
the subject of several interesting studies by a number of German writers, as 
Griesemeyer, Cohnheim, Heller, Eulenberg, Oppolzer, and others. The sub- 
jects of the disease are not only physically weak and unable to walk, except 
with difficulty, and then with a swaying, rolling movement, but they are also 
weak-minded and often idiotic. In standing, the attitudo is peculiar, the 
peculiarity being due to the anterior curve in the lumbar spine, which gives 
an unusual prominence to the abdomen and chest. The hypertrophic feature 
of the disease appears some time, it may be several months, after the partial 
paralysis has begun. It begins in the gastrocnemius and soleus muscles, 
and extends to those of the nates and loins, all becoming greatly increased 
in magnitude. With the increase in bulk the weakness or paralysis of 
the limbs increases, and is accompanied by imperfection of circulation and 
diminution of temperature. After a variable period the paralytic element 
of the disease becomes more pronounced and general, extending to the mus- 
cles of the upper extremities, and with it the hypertrophied muscles begin 
to waste, in common with those of other portions of the body, until after 
lingering for several years the patient dies, often from some disease not 
directly related to the paralysis. The investigations of Duchenne and those 
of Eulenberg and other Germans who have written upon the subject do not 
furnish much light on the pathology of the disease. The morbid changes 
observed consist chiefly" in the diminished size of the muscular striae, the 
local accumulation of fat, and an increase in the interstitial connective tissue. 
From the latter fact ai’ises the term myo-sclerosis sometimes used to designate 
the disease. Nothing unusual has been observed either in the blood-vessels 
or in the nervous system. That an affection characterized by such extraor- 
dinary disturbances of the nutritive processes in muscles can exist without 
some structural change in the gray matter of the cord seems very- improbable. IN FA NTILE PA RALYSIS. 
441 
Treatment.—Except early in the course of the disease, and even then very 
exceptionally, remedies are powerless for benefit. In the two or three cases 
of reported cure the treatment consisted in local faradization and massage. 
Infantile Paralysis.—Another affection, very unlike the preceding one, is 
infantile paralysis. The attack comes on suddenly at some period between 
birth and the first dentition. It is sometimes preceded by a convulsion or 
by a few days of feverish indisposition, but more frequently it begins without 
any premonitory signs. The child retires to bed in the evening apparently 
well, and in the morning on awaking, or after a disturbed sleep, is unable to 
walk, or, if not thus completely disabled, it can at best move wTith great diffi- 
culty, often dragging the affected limb. Children with a slight limp, inver- 
sion of tho foot, or inability to advance the limb properly in walking are 
frequently brought to me, under the suspicion of having incipient coxalgia, 
when in reality they have had paralytic attacks, so slight as to have attracted 
no notice until the old trouble has been brought to light by the activities of 
advanced childhood. Many cases of lateral curvature of the spine are really 
examples of local paralysis. 
This form of paralysis occurs in the lower extremities, the upper limbs 
being in a marked degree exempt. It may involve both limbs or only a single 
one. At first the paralytic seizure often appears to include the muscles gen- 
erally, but after a short time the disease becomes localized, fixing upon a 
definite group of muscles. When the upper extremity suffers, the paralysis 
will be particularly marked, either in the flexors of the fingers and carpus, 
the supinators, or the deltoid. The muscles of the lower limb most com- 
monly attacked by the disease are those in front of and on the outer side 
of the leg,—the tibialis anticus, extensor longus digitorum, and the three 
peronei muscles. On the thigh the quadriceps extensor muscle is the one 
which generally suffers. There is no paralysis of sensation. In a few months 
after the attack, in consequence of defective nutrition from the withdrawal 
of nerve-force, the paralyzed muscles begin to waste, and may in time be 
reduced to mere ribbons, nothing remaining but the original connective-tissue 
elements. The non-paralyzed muscles, deprived even of the stimulus in- 
sulting from the imperfect movements of the limb, participate in the atro- 
phy of the affected ones, and, indeed, so deeply does the disability implicate 
nutrition that all the components of the extremities share to some extent a 
similar fate. The general health does not appear to be materially disturbed 
by the disease, except in so far as the latter may interfere with exercise in 
the open air. It is, however, the deformity wrhich the disease entails that 
brings infantile paralysis more especially under the notice of the surgeon, 
the most prominent being those different forms of club-foot which have been 
considered in the present work under the head of talipes. 
The prognosis considered with reference to the life of the patient is favor- 
able, few children dying from this cause; but with regard to recovering the 
use of the paralyzed muscles, it is decidedly unfavorable, complete restoration 
rarely taking place. 
Pathology.—The morbid changes which give rise to infantile paralysis 
take place in the gray matter of the spinal cord. 
Treatment.—The treatment is local, general, mechanical, and operative. 
Much can be done to counteract and prevent fatty degeneration and atrophy 
of the paralyzed muscles by supplying to them through artificial means the 
stimulus which has been denied them from the central source of power. 
Hence massage, flagellations, faradization, and passive movement of the dam- 
aged muscles and those of the entire limb should be daily practiced. Sys- 
tematic and persistent treatment of this nature, by coaxing the blood into 
the paralyzed muscles, will not only prevent their waste, but will contribute 
to their development. 
Volitional concentration of nerve-force on the disabled muscles constitutes 
a valuable adjuvant to the local treatment. Even though at first no visible 442 
SURGICAL AFFECTIONS OF THE NERVES. 
response may follow these mandates of tho will, the fibres after a time will 
begin to show signs of renewed life. As soon, therefore, as the little patient 
can bo made to understand what is required, this discipline of the will should 
be enforced. 
Constitutional treatment ought not to be neglected, as it too often is in 
this variety of paralysis. To be of value, it must be adopted soon after the 
seizure. The remedies which I believe to be capable of doing good are iodide 
of potassium, one grain, and bichloride of mercury, one-hundredth of a grain, 
administered three times a day in about a hall-drachm of tincture of cin- 
chona. Frictions with stimulating liniments along the spine may be em- 
ployed at the same time. At a more advanced period of the disease strychnia 
in minute doses should be tried ; and when the patient is feeble and ana'mic, 
cod-liver oil and lime will prove useful. 
Mechanical treatment will be required whenever deformity begins to ap- 
pear, and such treatment may serve to correct unusual attitudes arising from 
muscular weakness. (See Club-foot.) 
Operative measures, like tenotomy, will sometimes be required in order to 
render mechanical appliances effective. 
Tumors of Nerves. 
Tumors found in connection with nerves often pass under the general ap- 
pellation of neuromata. These are comparatively rare neoplasms. They 
have been divided into true and false neuromata; but, as the false neuromata 
have attached to them no constant or definite histological characters, the 
division should be rejected, and the so-called false neuromata should be classed 
as morbid growths elsewhere, according to the tissue-series to which they 
may belong. 
The tumors generally found connected with the nerves are'neuromata, 
fibromata, sarcomata, myxomata, gliomata, and cystomata. 
Neuromata.—A veritable fasciculated neuroma is a comparatively rare 
growth. The tumor is usually small, and is found as an enlargement in the 
course of a nerve: its surface is regular in outline and unbroken by irregu- 
larities. When several exist at the same time, they may appear along the 
course of the same nerve or of different nerves. The cut extremities of nerves 
at the end of a stump sometimes become the seat of these enlargements. In 
some instances these growths appear to be the result of a diathesis. A 
patient of my own, the mother of several children, consulted me for an ex- 
ceedingly painful but small neuroma, deeply seated at the bend of the arm, 
which had developed in the median nerve. It was removed, and in about 
a she returned with another of a similar character in the anterior 
tibial nerve, which was also extirpated. In less than two years after this 
she came to the city suffering from a third tumor like the others, located in 
the peroneal nerve. 
When examined, neuromata are found to possess the same elements as the 
nerve in which they grow. 
Treatment.—No local applications are of any value in the treatment of 
neuromata. Removal by the knife alone can effect a cure, and this generally 
is permanent, unless when their cause is a general one, as in the lady whose 
case has just been noticed. 
Fibromata.—These growths are not uncommon. They are sometimes 
seated in the subcutaneous tissue (“painful tubercles”), sometimes they 
grow in the inter-fascicular connective tissue of a nerve-trunk, and in other 
cases they enter the nerve by outgrowth from adjoining parts. 
Subcutaneous fibromata are among the most painful affections. The slightest 
touch on a little body of this nature, not lai'ger than a grain of rice under 
the skin, is sufficient to cause acute suffering. A lady, the wife of a clergy- TUMORS OF NERVES. 
443 
man, from Lancaster County, Pennsylvania, from whose leg I removed some 
years ago one of these subcutaneous fibromata, had become pale, thin, and 
broken down in health in consequence of the intense pain experienced from 
accidental touches, and finally from the pressure of the stocking. These 
tumors are not unfrequently multiple, appearing on different and widely- 
separated portions of the body. 
The diagnosis of these sensitive fibromata is a matter of no difficult}", they 
being easily recognized as small nodules under the skin, endowed with ex- 
traordinary sensibility, and sending, on the gentlest touch, shooting pains in 
different directions up and down the limb. Excision is the only remedy. 
Sarcomata are occasionally seen in nerve-tissue. Many of the tumors 
which originate in the fundus of the eye and protrude from the orbit are 
sarcomata of the retina. When this neoplasm affects nerve-structure, it is 
no less infectious than when it involves other tissues. 
Myxomata are also met with in nerves. They have the soft gelatinous 
consistence belonging to mucous tissue, such as characterizes this class of 
tumors. They are commonly lobate in form. 
Carcinomata of nerves are not often met with as primary affections. 
The encephaloid or more rarely the melanoid variety is the form in which 
the disease appears. An extension of malignant neoplasms from adjoining 
tissues into nerve-trunks is more common. 
The diagnosis of nerve carcinoma must necessarily be uncertain, as the 
symptoms attending the disease in its early history do not differ from those 
common to other growths. Rapidity of growth, irregularity of form, and 
the existence of malignant neoplasm in other parts of the body would 
materially aid the surgeon in forming a correct opinion. 
Cystomata.—Primary cysts of the nerves are uncommon. Those which 
are ordinarily seen are the result of degeneration in other neoplastic forma- 
tions, as sarcoma, myxoma, or glioma. 
Glio-Sarcomata are growths which frequently develop in nerve-tissue, 
particularly in the cranial nerves, as the auditory and the optic, as well as 
in the brain, spinal cord, and retina. 
The symptoms which accompany nerve-tumors are far from being uniform. 
While in many cases there is severe neuralgia, with intense, darting or 
tearing pain, or with numbness and heat in the area over which the 
branches of the affected nerve are distributed, in other cases little or no 
suffering is experienced. Occasionally reflex spasms, contractures, tremors, 
and paralysis of the muscles are observed. 
Extirpation, to be of value in the above tumors, must be performed early. 
Gummata are common formations in syphilitic constitutions. They appear 
in the nerves,—especially the cranial,—but oftener in the brain or its mem- 
branes. Vertigo, a staggering gait, headache, convulsions, and paralysis are 
symptoms which announce the existence of such formations. 
Large doses of iodide of potassium constitute the most potent remedy with 
which to combat the disease. CHAPTER XXXIV. 
SURGICAL AFFECTIONS OF THE LYMPHATIC SYSTEM, SKIN, 
AND SUBCUTANEOUS CONNECTIVE TISSUE. 
The lymphatic system consists of a vast number of vessels—superficial and 
deep—which accompany the veins, have a free communication with the lymph- 
spaces of connective tissue and with serous sacs, and the contents of which 
reach the venous system, at the junction of the internal jugular and sub- 
clavian veins, by means of the right and left lymph-ducts. Like the veins, 
the lymph-vessels are supplied with valves, and they have the same number 
of coats as the veins have. Lymph-follicles are composed of a rete, in the 
meshes of which lie numerous lymph-corpuscles, and they are covered by tut 
exceedingly fine net-work of capillary blood-vessels. The ductless glands in 
the upper part of the respiratory and alimentary passages, beneath the tongue, 
and in portions of the intestines, along the routes of the lymphatics, are 
lymphatic glands,—single or in clusters.—and they vary in size from the 
bigness of a grain of mustard-seed to that of an almond. 
The lymph-glands consist of an external cortical and an internal medullary 
portion. The whole body is surrounded or encapsulated in a sheath of con- 
nective tissue. The interior frame-work or trabecula of the gland is made 
up of interior prolongations of fibres from the sheath, containing also smooth 
muscular fibres, and forming by their numerous interlacings a large number 
of spaces—“ lymph-spaces”—like those which exist elsewhere in the connec- 
tive tissue of the body, and which are occupied by lymph-corpuscles. Though 
all the contents of the lymph-vessels pass through these glands, there is 
no continuity between the afferent and efferent trunks. The former, after 
reaching the gland, divide into a large number of small vessels, which pene- 
trate the capsule or sheath and pour their contents into the interior lymph- 
spaces. The fluid contained in the lymphatic vessels differs in appearance at 
different times. In the intestinal trunks—sometimes called lacteals—during 
digestion it somewhat resembles milk, but at other times it is colorless or 
lymph-like. 
The lymphatic system of vessels is evidently concerned in two great func- 
tions,—that of receiving, elaborating, and emptying into the venous system 
the products of intestinal digestion, and the more menial but not less im- 
portant one of conveying to a similar destination the effete material or sewage 
resulting from the tissue-waste of the body. 
The glands in which the lymph-vessels terminate and begin serve to 
arrest and separate the more crude constituents of the lymph, at the same 
time giving to it a higher distillation before allowing it to enter the efferent 
vessels. 
This brief review of the anatomy and physiology of the lymphatic system 
will aid us in understanding its diseases and the phenomena which they 
present. 
Congenital Absence and Irregularities of Formation of the thoracic duct 
have been observed in a number of instances, the anomalous conditions con- 
sisting in multiple division of the duct, and its emptying into the azygous vein, 
instead‘of at the junction of the internal jugular and subclavian veins. LYMPHANGITIS. 
445 
Lymphangitis—Angeioleucitis.—Inflammation may attack either the mi- 
nute branches or plexuses, or the larger trunks of the lymphatics. 
The causes concerned in developing lymphangitis are said to be idiopathic, 
traumatic, and septic. I do not think any violence would be done to nosology 
by rejecting entirely the term idiopathic, believing as I do that all cases of 
the disease so designated are septic in their origin, being produced by some 
peculiarity in the products of tissue metamorphosis or waste. To this source, 
therefore, would I refer those low grades of inflammation affecting the skin 
and subcutaneous tissues, which so often tend to suppuration and necrosis 
of cellular tissue, such as erysipelas, simple or phlegmonous. In many cases 
the disease is both traumatic and septic; the instrument—say a needle, a 
hook, or the point of a knife, used at the dissecting- or post-mortem table 
—conveying, at the time the puncture is made, some animal poison into the 
body. 
Symptoms.—The local signs which indicate an attack of lymphangitis may 
appear primarily on the surface of the skin, or they may commence in the 
deeper or subcutaneous lymph-vessels. 
When superficial, and arising from a traumatic or septic cause, such as the 
prick of a needle charged with some animal virus, a slight degree (or some- 
times an intense one) of itching is often experienced at the seat of the injury, 
followed by red or scarlet lines, which, commencing at the wound, radiate 
upward, multiplying as the inflammation ascends, and forming hard, beaded, 
or knotted cords in the line of the veins, and quite tender to pressure. The 
hardness is caused by the coagulation of the contents of the vessels and by 
inflammatory infiltration of their walls, and the knotted condition by the 
constriction of the valves between the isolated masses of coagula. When 
the lymph-ducts or capillaries are first affected, the color of the skin becomes a 
diffused or erythematous blush. The inflammation of the lymph-vessels soon 
extends to the glands into which they enter, and the latter become swollen 
and tender. If the arm, as so often happens, is the part affected, the supra- 
condyloid and axillary glands are the ones which participate in the inflam- 
mation; not so much, I think, from the latter being propagated to these 
bodies by continuity of tissue, as from infectious irritation, derived either 
from the changed quality of the lymph or from the detention of a portion 
of the original poison. From the power which the lymph-glands possess of 
arresting and holding obnoxious material, it is not uncommon to meet cases 
in which the first notification received by the patient of the intrusion into 
the lymphatic system of some irritant is announced by swelling and tender- 
ness of one or more lymphatic glands, the afferent vessels communicating 
with the latter having floated the poison, to the gland without producing 
any injury whatever. 
In the more aggravated degrees of lymphangitis the inflammation extends 
to the finer radicles of the lymphatic system, giving a diffused instead of a 
linear redness to the part, in the midst of which, notwithstanding the accom- 
panying and equally extensive induration and swelling of the limb, the hard, 
knotted lines of the larger vessels can still be felt,—a fact which will serve, 
when the surgeon is called in some time after the attack, to distinguish the 
disease from ordinary erysipelas. 
When the inflammation begins in the deeper lymphatics, the external red- 
ness, either linear or diffused, will be preceded by swelling, induration, and 
oedema of the subcutaneous connective tissue. 
In bad cases of lymphangitis, arising from septic causes, the inflammation, 
instead of being confined to the lymph-vessels, extends to the connective 
tissue, and will often be followed by suppuration, exceedingly dangerous, by 
its diffusion, to the life of the affected and adjacent tissues. 
The constitutional symptoms which sometimes introduce, and which in bad 
cases always accompany, the inflammation, are not materially unlike those 
which presage an ordinary febrile attack or belong to low forms of adynamic 
or typhoid disease. A short period, seldom extending beyond a few hours, of 446 
SURGICAL AFFECTIONS OF TIIE LYMPHATIC SYSTEM. 
general indisposition, manifested by flushes of heat alternating with rigors, 
stretching, headache, thirst, and loss of appetite, indicates the mischief which 
is about to supervene. After the onset, should the disease appear grave, and 
should the vascular excitement become pronounced, there will often be a 
high temperature, rapid, feeble pulse, parched skin, dry, dark tongue, torpid 
followed by loose bowels, low muttering delirium, and the other phenomena 
which so commonly mark septic fever. 
Diagnosis.—Assuming erysipelas not to be an inflammation of the lymph- 
vessels, lymphangitis is liable to be confounded with it, and also with phlebitis. 
In erysipelas as it usually appears there is absence of linear inflammation, 
the redness being diffused and accompanied by early oedema, with a disposi- 
tion to spread in all directions, but with no tendency to concentrate towards 
the Emphatic glands, though they may become enlarged,—phenomena which 
differ from the more common signs of lymphangitis. 
Phlebitis has several characteristics in common with inflammation of the 
lymphatics. In both there are divergent lines of color, corresponding to 
which are hard, knotted cords; but it will be found in phlebitis that in con- 
sequence of the much greater size of the veins as compared with the lym- 
phatics, and the dark blood carried by the former, the cords are larger and 
darker, and the color, instead of having a scarlet hue, is darker or more of a 
purple-red. Nor are the glands so likely to become enlarged as in lymphan- 
gitis. 
Prognosis.—While it cannot be denied that lymphatic inflammation, es- 
pecially when induced by septic causes, is a very grave disease, yet, on the 
whole, the prognosis is rather favorable than otherwise, unless complicated 
by pre-existing kidney disease, in which case the gravest results may be an- 
ticipated. Even when the patient escapes with his life, the health is often 
so lowered that the system is left in a most vulnerable condition, and may 
become the prey to any weakness which may be Avaiting for a favorable op- 
portunity for attack. 
Treatment.—On the earliest manifestation of the local inflammation a 
blister should be applied so as to encircle the part at some distance above 
and beyond the inflamed vessels, at the same time enveloping the affected 
surface in cloths well soaked with a hot lotion consisting of muriate of am- 
monia, laudanum, tincture of belladonna, carbolic acid, and Avater. To pre- 
vent evaporation of the liquid and to retain its heat, the cloths must be cov- 
ered Avith Avaxed paper or oiled silk. The lotion Avill require to be removed 
once in six or eight hours. If the inflammation extends into the subcuta- 
neous tissue, and there follows great tension, threatening suppuration, or if 
evidences of pus exist, free incisions into the infiltrated parts avi 11 become 
necessary. 
The induration which frequently remains along the course of the lymphatic 
trunks after the inflammation has subsided Avill disappear under the use of 
a mixture consisting of equal parts of mercurial, iodine, and belladonna oint- 
ments, well rubbed into the parts every evening. 
In mild cases of lymphangitis in a patient otherwise health}', little con- 
stitutional treatment will be required. The boAvels should be opened by a 
gentle cathartic, a febrifuge administered during the stage of febrile excite- 
ment, and the diet regulated Avith reference to the capacity of the individual 
to receive and appropriate food. When the disease bogins to draw on the 
vital resources of the system, the latter must be sustained by full doses of 
quinine and iron, and by a nutritious diet of milk, animal broths, and 
stimulants. When sleep cannot be otherwise obtained, opiates in moderate 
quantities must be given. 
Wounds and Rupture of the Thoracic Duct and of the Lymph-Vessels.— 
Wounds of the thoracic duct are very uncommon. A number of the cases of 
the accident which are found scattered through surgical and medical writings 
will scarcely bear criticism. The great trunk of this vessel is hidden away in WOUNDS OF THE LYMPH-VESSELS. 
447 
front of the spinal column, its abdominal portion lying between the aorta 
and ascending vena cava, and in the thorax between the former vessel and 
the azygous vein and behind the oesophagus, and, finally, behind the arch of 
the aorta, so that nature has given the duct a local security commensurate 
with the prominence of its otfice in the animal economy. There are, how- 
ever, a few cases of wound of this vessel: one, that of Quincke, verified by 
an autopsy, and those of Monro and Guitfort, in which the signs were so 
decisive that it would be unfair not to admit their genuineness. 
The evidences of an injury of this nature would be a stab or shot wound 
reaching the position of the duct and followed by the discharge of a milk- 
like fluid, either externally or into the cavity of the abdomen or the thorax, 
answering in appearance to that of chyle during digestion, and in the interval 
of digestion to that of lymph. 
Dilatation and Rupture of the Thoracic Duct is also a recognized accident, 
being produced by obstructive causes, such as pressure from enlarged glands, 
from carcinomatous and sarcomatous tumors, or from cretaceous, bony, and 
cheesy concretions in the lumen of the duct. The part of the vessel which 
appears to dilate or to give way first is the expanded portion, or recep- 
taculum chyli. When the duct does not yield, some of the adjacent lymph- 
vessels may rupture. 
The only hope fora patient suffering from interruption of the thoracic duct 
will lie in the possible existence of a collateral branch, which might serve to 
establish another communication between the lymphatic and venous systems. 
Injections on the cadaver have shown that such communicating trunks do 
exceptionally exist. 
In cases of rupture or wound of the great lymph-trunk, which may be 
suspected if with the escape of the characteristic fluid there are increasing 
emaciation and weakness, nothing surgically can be done. Instead of feeding 
the patient, no food should be given, the only hope being that the walls of 
the duct may remain as much as possible in a state of collapse, and thus 
favor any attempt which nature may make towards closing the opening. 
Wounds of the Lymph-Vessels must be veiy common. Such lesions are pro- 
duced every time an incision is made into any part of the body. Since no 
evil usually follows having the nature of fistula or lymphorrhagia, the 
presumption is that lesions of these vessels either heal quickly, or are ob- 
literated by inflammation. Examples, however, of both of the conditions 
named are recorded, particularly when the wounds have been made at the 
bend of the arm in the once common operation of venesection. The lymph- 
vessels at the flexures of the joints are numerous and large, and, being 
necessarily affected by the movements of the articulations, when wounded 
may fail to heal promptly. Nothing could better conduce to lymphorrhagia 
or to the formation of a lymph-fistula than those operations for mammary 
cancer in which the axillary region, a space exceptionally rich in lymphatic 
vessels, is cleared of diseased glands ; but I am not aware that any one has 
seen sequels of the kind alluded to after such extirpations. For the above 
reasons I am led to doubt the accuracy of the diagnosis in at least some 
of the cases which are asserted to have been instances of lymph-bleeding and 
lymph-fistula from wounds. Why should the remarkable and phenomenal 
cases of the latter be confined to the days of Van Swieten, Schraeger, 
Monro, and other distinguished physicians of the same period, and not occur 
at the present time, when keen-eyed observers are ever on the alert to 
discover some new thing? 
The treatment, were a case of the kind to occur, would be the application 
of nitrate of silver to the opening, followed by a compress and bandage. 
As a result of obstructive causes, several different affections belonging 
to the lymphatic system are met. They are lymph-oedema, lymph-varices, 
chyloderma, or lymph-scrotum, lymphangiectasis, and chylocele. 448 
SURGICAL AFFECTIONS OF THE LYMPHATIC SYSTEM. 
(Edema.—The transudation of the more liquid portion of the lymph into 
the subcutaneous connective tissue, or lymph-spaces, of the lymphatic sys- 
tem, constitutes lymph-oedema (Fig. 202C), and is symptomatic of some 
obstruction to the flow of the lymph located in the thoracic duct, in the 
larger lymphatic vessels, or in the venous system. It is also attributed to 
the presence in the blood of the filaria sanguinis hominis. In the case of a 
woman in the Pennsylvania Hospital, under the care of I)r. Morton, with 
lymph-oedema of the right leg, the blood was carefully examined by Drs. 
Hunt and Fricke without discovering anything more abnormal in the fluid 
than an unusual proportion of the white corpuscles. When the oedema is 
the result of obstruction either in the thoracic duct or in the venous system, 
the swelling will be on both sides; but when it is situated at a point where a 
large number of lymphatic trunks concentrate, as in the saphenous opening, 
or above the internal crural ring, it will bo confined to the limb of the cor- 
responding side. 
The extent to which the cure of the oedema is possible will depend on the 
removability of the cause. Unfortunately, this is too often of a permanent 
nature and beyond the resources of surgical art. 
Fig. 2026. 
Lymph-oedema—From one of the author’s hospital patients. 
There is in the lymphatic system, as in that of the blood-vessels, a capacity 
on the part of one set of vessels to enlarge, compensating for the failure of 
others to carry on the circulation; and by this provision considerable relief 
may ultimately be obtained in cases where the blockade is quite local. 
Superficial Varicose Enlargement of the lymph-vessels is observed chiefly 
in those parts, as the thigh, penis, and hypogastrium, from which the radi- 
cles or plexuses concentrate in the inguinal glands. These varices appear 
either as hard, uniform cylinders, containing a limpid, milky, or whey-like 
liquid, or in the form of knotted or constricted cords, sometimes straight, 
at other times tortuous. In the former the dilatation of the vessels has be- 
come uniform in consequence of the valves having been broken down, while 
in the latter the valves hold out against the obstructing force, and as each 
intervalvular section of the vessels becomes distended in turn, the knotted- 
like appearance is assumed, the line at length resembling a string of beads. 
Whatever tends to obstruct the passage of the lymph into the lymph- 
glands will favor the formation of varices, in the same manner as impedi- 
ments to the flow in the venous system will cause varicose veins. Hence the 
affection is most frequently seen on the penis, in consequence of coagulation 
of the lymph in the great dorsal lymph-trunk, resulting from the inflamma- 
tion of gonorrhoea, chancre, or adenitis. The disease will be particularly 
well marked about the fhenum, where the lymph-vessels are very numerous, 
and also on the prepuce. Mechanical pressure from femoral hernia and from LYMPHANGIECTASIS. 
449 
tumors located in the groin have also caused these lymph-varices. Excessive 
venery may likewise give rise to a similar condition. 
Treatment.—As the cause of the lymph-obstruction is often of a tempo- 
rary character, and the varices slight, they will subside with the disappear- 
ance of the cause: hence remedies addressed to the urethritis, the chancre, 
or the bubo, or to the inflammation of the periglandular connective tissue, 
which precedes the varices, will often remove both. When the swelling per- 
manently remains, and the resulting inconvenience is of a character to jus- 
tify a resort to opei’ativo measures, a portion of the enlarged cord, with the 
overlying structures, may be excised, and the wound closed by sutures. 
Deep Varices.—A dilated and tortuous condition of the abdominal and 
pelvic lymphatics which run along the cava and the iliac vessels has been ob- 
served. As these lymph-trunks enter the body in the course of the hernial 
passages, the enlargements resulting from their obstruction ultimately occupy 
the same regions as hernia, so that in every recorded case of the disease 
the swellings have been mistaken for the latter affection. Nelaton, although 
pre-eminent as a diagnostician, fell into the same error. This error is more 
likely to be made from the fact that the tumor does not materially differ in 
shape, in compressibility, or to the touch, from a case of hernia. It is also 
similarly affected by position, slowly increasing in the upright and diminish- 
ing in the recumbent posture. 
Taking into consideration the bilateral character of the tumor,—a feature 
not common in femoral hernia,—its compressibility, its incomplete reducibility, 
and the absence, or at least the indistinctness, of any impulse communicated 
to the hand on coughing, which symptoms, according to the descriptions 
given of the recorded cases, appear to have characterized lymphatic varices, 
it would seem that some progress towards an accurate diagnosis could have 
been made. The differential solution of the problem, however, would be 
most satisfactorily worked out by the grooved needle. Both forms of swell- 
ing, viz., lymph-varices and hernia, have been met with in the same person. 
The cases of pelvic lymphatic varices forming external tumors which have 
been recorded—twelve in number—occurred for the most part in young 
subjects, males with a single exception, and all proved fatal. 
Chyloderma, or lymph-scrotum, has been considered under the head of 
surgical affections of the genito-urinary organs. (See vol. ii. page 524.) 
Lymphangiectasis.—This name is given to a condition in which the super- 
ficial lymph-vessels are sometimes dilated, twisted, and contorted, admitting 
of the more or less continuous transudation of lymph, known also as lymphor- 
rhagia. (Fig. 2027.) At other times the lymphatics are dilated into pouches, 
or into rows of knotted enlargements, and accompanied by hemispherical 
enlargements of the lymph-radicles, which appear on the surface as vesicles 
and are filled with lymph. The limb becomes enlarged and elastic to the 
touch. 
The affection is either congenital or acquired. When acquired, the dis- 
ease arises from obstructive causes, inflammatory, non-inflammatory, or me- 
chanical, by reason of which portions of the lymph-channels are occluded. 
The fluid which is present in the tissues in cases of ectasia, rupture, or 
transudation from the lymph-vessels is complex in its composition, not only 
representing the usual succulent material which normally fills the lymph- 
spaces of connective tissue, but also containing various tissue-elements, 
both constructive and destructive; and the accompanying enlargement may 
often in part be considered a real hypertrophy as well as an oedema. The 
loss of strength from rupture of the over-distended lymph-sacs, with fre- 
quent attacks of erysipelas, gradually reduces the patient, until, as a rule, 
death occurs either from exhaustion or from some intercurrent internal 
inflammation. 450 
SURGICAL AFFECTIONS OF THE LYMPHATIC SYSTEM. 
The lymph-leakage must be opposed by cauterizing the point where it 
escapes with the solid nitrate of silver, by compresses and bandages, and by 
Fig. 2027. 
Lymphangiectasia. 
elevation of the limb, while the general strength must be supported by tonics 
and nutrients. 
The loss of lymph is followed by impoverishment of the blood and by other 
signs of defective nutrition, and the mischief must be combated by the use 
of iron and other tonics. 
Chylocele is a term used to designate a collection of chylous fluid in the 
tunica vaginalis. It has an obstructive cause. Some of the lymphatics of 
the serous membrane of the testicle, becoming ovei’-distended, give way and 
allow the chyle and lymph to escape into the cavity of the sac. The accident 
has occurred after a sharp attack of gonorrhoea, during which the inguinal 
glands were inflamed and some of the lymph-channels no doubt were blocked 
up by eoagula. 
The signs of chylocele, as to the size, form, and location of the swelling, 
are the same as those of hydrocele. In the former the enlargement would 
not be translucent. The grooved needle would aid in the diagnosis. The 
fluid would have the physical and chemical characteristics of chyle. 
Treatment.—The treatment is the same as that of hydrocele,—namely, 
tapping with a trocar and canula, and, after the removal of the fluid, injecting 
the sac of the tunica vaginalis with tincture of iodine. 
Lymphangioma.—This singular growth, which may be either congenital 
or acquired, consists of dilated lymph-spaces and lymphatic vessels, the re- 
sulting structure resembling cavernous tissue. This growth will be studied 
under the head of tumors. 
The lymphatic glands are subject to inflammation, to hypertrophy, to neo- 
plastic growths, and to degenerations of a tuberculous and cretaceous nature. 
Lymph-Glands. INFLAMMATION OF LYMPH-GLANDS. 
451 
The glands which ordinarily demand the attention of the surgeon are the 
inguinal, the supra-condyloid of the arm, the axillary, and the cervical. These 
bodies are lenticular or almond-shaped, and are usually found in clusters 
or strung together in lines. They are encapsulated by a wall of connective 
tissue, and are connected by the same material. 
Adenitis, or inflammation of the lymphatic glands, is the result of a variety of 
causes,—idiopathic, traumatic, diathetic, specific, or infective. The idiopathic 
causes are cold, fatigue, and over-exercise. The traumatic causes, which are 
most probably infected wounds, are punctured wounds and abrasions, espe- 
cially at the extremities of the limbs. A very slight prick of a finger or of a 
toe will often be followed by inflammation of the axillary or inguinal glands. 
Paring a corn too closely not unfrequently gives rise to an inguinal adenitis. 
A boil on the wrist or arm will cause swelling of the axillary glands, most 
probably infective in character. Instances of specific adenitis are seen in the 
bubo which follows gonorrhoea and chancrous sores. Inflammations arising 
from diathetic causes are seen in scrofula and carcinoma. Inflammatory 
enlargement of the lymph-glands, particularly those of the neck, is very 
common in children. The exciting cause may be diseased teeth or caries of 
the jaw. 
There is a symptomatic enlargement of lymph-glands which is ascribed to 
distant irritation,—that, for example, which in the inguinal glands often fol- 
lows an inflamed corn, a contusion of the toe, or excessive venereal indul- 
gence. The enlargement and tenderness w’hich follow under these circum- 
stances are the result of congestion, rather than examples of inflammation, 
and are induced through the medium of the nerves. 
Adenitis exists either in an acute or a chronic form, attacking one gland 
or several glands simultaneously. Not unfrequently the inflammation ex- 
tends to the periglandular connective tissue, or the latter alone may be the 
seat of inflammation ; and in this case the disease, in many instances, might 
readily be mistaken for true adenitis. 
Symptoms.—Acute adenitis, which usually follows some precedent inflam- 
mation, commences with swelling, induration, and tenderness of the gland, 
and sometimes is accompanied by redness of the superincumbent integument. 
The entire limb is often rendered stiff and sore from the local disease. The 
increase in size of the gland when acutely inflamed is rapid, the inflamed 
part often attaining in a few hours the bulk of a shell-bark or a pullet’s egg, 
and changing from its normal almond shape to a more spherical form. When 
the inflammation extends to the periglandular tissue, as is always the case in 
sharp attacks, there will be increased tumefaction, with oedema. Through 
the connective tissue the inflammation may extend from one gland to another 
until the entire group is overtaken by the disease. When adenitis is ac- 
companied by redness of the overlying skin, that symptom is an evidence of 
periadenitis. 
Unless the constitution is one of a highly impressible nature, easily dis- 
turbed by local irritations, very little general indisposition may be antici- 
pated in cases of adenitis: at most a little elevation of temperature, with 
some increased frequency of pulse, dry skin, and slight thirst, will accom- 
pany the local affection. 
Acute adenitis tends to suppuration, though when promptly combated by 
judicious treatment, resolution may be expected to follow. The purulent 
matter is often external to the inflamed gland in the periglandular connective 
tissue. 
Chronic adenitis, though sometimes the result of the acute form of the 
disease, has its causation much more frequently in some defect in nutrition 
or other fault of the general system. The class of patients who suffer most 
from this variety of glandular enlargement are strumous children. Such 
enlargements are often associated with suppuration of the ear and with 
tarsal ophthalmia. 452 
SURGICAL AFFECTIONS OF THE LYMPHATIC SYSTEM. 
The cervical glands are the ones most generally affected, though none 
perhaps are exempt. Chronically-enlarged glands can often be felt under 
the jaw, beneath the chin, above the clavicle, and along the borders of 
tbe sterno-cleido-mastoid muscles. The enlargement of the gland ordinarily 
takes place in a gradual manner, although the development may be sudden, 
several glands being affected at the same time; and the attack is in most 
cases attended with little or no soreness or other sign of inflammation. 
When several glands are involved at once, the mass often assumes a lobulated 
form, and may attain an enormous bulk, equaling in size the foetal head, 
and, by encroaching upon the trachea, the great blood-vessels, and the nerves 
of the neck, it may interfere materially with respiration, circulation, and 
the nerve-supply of the thorax. The swelling of the arm, which so often 
contributes to the suffering of the patient in the last stages of mammary 
cancer, is due to infective inflammation and enlargement of the axillary 
glands. Similar evils follow enlargements of the deep glands belonging to 
the lymphatic system. In one instance I was called to see a young patient 
whose pelvis was so completely occupied by a glandular enlargement as to 
compress and displace the bladder to a degree which necessitated the use of 
the catheter in order to empty the viscus. 
Chronic adenitis is often associated with a peculiar suppurative burrowing 
in the cellular tissue of the neck, the sinuses extending in long, narrow 
branches, covered with discolored skin, and lined by unhealthy granulation- 
tissue. . . 
The morbid changes found in the lymphatic glands in acute and chronic 
adenitis are quite dissimilar. In the former, the gland is filled with a sero- 
fibrinous ti’ansudation, giving to its parenchyma a dark-red or reddish-brown 
color. The soft contents of the gland under the microscope exhibit many' 
lymph-corpuscles and large multinucleated endothelial cells. Purulent foci 
and hemorrhagic infarctions are also seen scattered through the gland. The 
pus which is discharged from a suppurating gland is generally thin and 
mixed with flakes of a cheese-like matter. In the cavernous portion of the 
gland the fibres, instead of retaining their normal homogeneous or structure- 
less appearance, are swollen, fibrillated, and granular. Similar changes take 
place in the fibres of the follicular part of the gland, but to a much less 
degree than in the cavernous portion. The vessels also of the follicles are 
greatly dilated and crowded with blood-corpuscles, many of which are free 
and mingled with the lymph-cells. 
In chronic adenitis the trabecula? of the cavernous part of the gland are 
hypertrophied from increased connective-tissue formation, the encroachment 
of which upon the follicular system is followed by more or less atrophy of 
its reticulated fibres of connective tissue and of its blood-vessels. The 
morbid change is essentially one in which, with great increase in the fibrous 
stroma of the gland, there is a corresponding disappearance of its lymphoid 
elements. But the morbid alterations consequent on chronic inflammation 
do not stop here ; others, such as the caseous, waxy, calcareous, amyloid, and 
colloid degenerations, are observed. 
Treatment.—In acute adenitis the application of a few leeches around 
the base of the swelling, followed by lotions of muriate of ammonia, lauda- 
num, and tincture of belladonna in water, with general and local rest, will 
usually secure the resolution of the inflammation in the course of three or 
four days. Should no impression be made on the disease within that time, 
it will be in vain to persevere longer with antiphlogistics. Suppuration 
will be inevitable, and it should be favored by the use of hot poultices, the 
pus being liberated by a free incision as soon as fluctuation is discovered. 
The possibility of a gland, when acutely inflamed and undergoing suppu- 
ration, contracting an attachment to an adjacent blood-vessel over which 
it may be located, will suggest the necessity for an early' evacuation of the 
pus in order to prevent any' ulcerative damage to the coats of the artery 
or vein. ADENITIS. 
453 
Chronic adenitis generally demands both local and constitutional remedies. 
Whenever any obvious local cause for the swelling can be discovered, its 
removal, if possible, will be indicated. When the adenitis, as is usually the 
case, is a symptom of a diathesis, constitutional remedies must be given. 
The medicines which experience has shown to possess unequivocal merit 
are cod-liver oil, iodide of iron, Lugol’s solution of iodine, bichloride of 
mercury, iodide of potassium, iodoform, and carefully-prepared decoctions 
of sarsaparilla and Chimaphila umbellata. Alteratives require to be con- 
tinued for a long time, and should bo given in moderate doses. Whenever one 
remedy becomes distasteful to the patient, it should be exchanged for another, 
so that the system shall be continually under the modifying influence of some 
one of this class of drugs. Medicines, however, are of little value, if pure 
fresh air, exercise, and food abounding in the elements of nutrition are 
withheld. 
The local remedies most to be relied on for effecting the resorption of the 
debased products of chronic inflammation, which occupy tho parenchyma 
of the gland, are ointments of iodoform, iodine, iodide of lead, and mercury. 
None of these yield better results than iodoform. Whatever ointment is 
selected, it should be well rubbed into the parts. Much of the benefit to be 
derived from the remedy will depend on the faithful manner in which this 
is done. Not less than half an hour should be occupied in the inunction. 
Friction with the oleaginous ingredients of the ointment is capable of doing 
much good, probably the chief good, by breaking down the inflammatory 
products in the gland and imparting a new stimulus to its circulation,—con- 
ditions which conduce to the removal of degenerated products. Pressure, 
which differs from friction only in degree and continuance, can also be em- 
ployed with advantage in certain localities, as over the groin. A compress 
and spica roller, or a bag of shot, will serve this purpose well. Electro-gal- 
vanism has been used with advantage; so, also, has electrolysis. Injection of 
iodine into the centre of tho hypertrophied gland, blistering, and subcutaneous 
clipping of its interior with a delicate bistoury, have been advocated. In many 
cases the glands, in defiance of all these measures, general and local, will con- 
tinue to increase in size by new formations of fibrous tissue or accumulations 
of caseous material, until the question of excision must be considered. The 
prejudice entertained against the knife too often prevents the patient from 
submitting to operation until the magnitude of the growth, its depth, and 
its adhesions render the procedure both difficult of execution and dangerous 
to life. When excision is undertaken, the secret of success in this operation 
consists, as it does in all other operations for the removal of growths, in 
keeping the knife in close contact writh tho tumor, and in breaking up ad- 
hesions and bands of fascia with the fingers. Great care is necessary when 
the glands are being separated from large* arteries and veins. The latter, 
especially, are liable to be torn when too much traction is made on the con- 
nective tissue or the diseased mass, for which reason I make it a rule when 
detaching tumors in the region of the neck, if seated over blood-vessels, to 
use the fingers of both hands, one set being placed towards the vessels and 
the other against the tumor, and to make pressure or disrupting force in 
opposite directions. 
Amyloid Degeneration of lymph-glands is not often an isolated affection. 
It is associated with a similar condition of other organs, such as the liver and 
the spleen. Protracted suppuration predisposes to amyloid disease. Thus, it 
is associated occasionally with old cases of necrosis of the thigh, or coxalgia. 
The disease causes an enlargement of the glands. The existence of the de- 
generation can be demonstrated by applying a solution of iodine to any of 
the numerous transparent points which appear over the cut surface of the 
gland, and which, when touched with the solution, are changed from their 
peculiar gray color to a dark brown. 454 
SURGICAL AFFECTIONS OF THE SKIN. 
SURGICAL AFFECTIONS OF THE SKIN AND SUBCUTANEOUS TISSUE. 
Erysipelas (from kpodpo-:, red, and x£Ao<;, skin) may be defined to be a dif- 
fused inflammation of the cutaneous and subcutaneous connective tissue, 
preceded and accompanied by constitutional disturbance, depending on the 
presence of some poison in the blood or other circulating fluids of the body. 
By some writers (as Cazenave and Boyer) erysipelas is regarded as an acute 
exanthema. 
Varieties.—Two degrees of the disease are recognized, not differing in 
their essential nature, but only in depth,—namely, the superficial or cutane- 
ous, and the deep or cutaneo-subcutaneous. The fii*st variety may exist with- 
out the second, but the latter almost invariably includes the former. The 
deep or cutaneo-subcutaneous variety is often called phlegmonous erysipelas, 
presenting, as it does, phenomena in several respects corresponding to 
phlegmon. Surgical nomenclature includes also an cedematous form of ery- 
sipelas, so designated from oedema being a prominent characteristic of the 
disease. This feature belongs also to deep or phlegmonous erysipelas; but 
there can be no good reason for burdening the nosology of the disease with 
unnecessary names. 
The deep form of erysipelas answers to the cellulitis of Duncan of Edin- 
burgh.* 
Another division of erysipelas is into idiopathic and traumatic, the former 
arising from internal and the latter from external causes. If the disease 
ever does arise idiopathically, strictly considered, that is, independently of a 
break in the continuity of tissue, such an occurrence must, in my judgment, 
be extremely rare. 
Erysipelas is not confined to the skin and subcutaneous tissue alone, but 
attacks mucous membranes, and the submucous connective tissue, sometimes 
primarily, at other times secondarily, or by extension from the skin through 
structural continuity of the two at the outlets of the body. Thus, facial 
erysipelas will pass into the mouth, fauces, and larynx, and also fasten upon 
the conjunctiva?. In the same manner an inflammation of this character 
commencing on the buttock will enter the rectum. The faucial inflammation 
of scarlatina, if not identical in its anatomical features, is very clearly allied 
to that of erysipelas; and the disease which at one time was so prevalent in 
the West, called the “black tongue,” was no doubt of the same nature. 
Serous membranes are not exempt from erysipelatous inflammation, but 
it never appears on them as a primary affection. The arachnoid and, indeed, 
all the other membranes of the brain are prone to suffer from inflammatory at- 
tacks of this nature, the disease being propagated from the scalp through the 
vascular connections which exist between the latter and the meninges of the 
brain. In like manner the peritoneum and the pleura may suffer secondarihr, 
the inflammation passing by a similar route—the communicating vessels— 
from the external parietes to the membranes within. 
Synovial membranes also participate in the disease, examples being seen 
after traumatic injury of the joints, in which erysipelas, after attacking the 
external structures, has passed into the articulation. There is also an ery- 
sipelatous thecitis and bursitis,—the inflammation primarily in the skin 
or subcutaneous tissue extending into these synovial sacs,—an occurrence 
which sometimes seriously complicates lacerated and punctured wounds of 
the hand. 
Though no part of the surface of the body can claim exemption from an 
attack of erysipelas, yet certain portions are more liable than others. Gen- 
erally it will be found that in those regions where the integument is dense, or 
where its components are firmly bound together, the anatomical conditions 
exist which are favorable for the appearance of the inflammation when 
Erysipelas. 
*• Edinburgh Medico-Chirurgical Transactions, vol. i. ERYSIPELAS. 
455 
the proper excitant is applied. These localities are the face, the ears, the 
scalp, the front of the breast, and the posterior part of the trunk. 
Causes.—These are divided into predetermining and determining. 
Predetermining.—Many causes are enumerated calculated to favor an erup- 
tion of erysipelas, among which may be mentioned the following : 
Sex.—It is said that females suffer from erysipelas more frequently than 
males. According to my own observation, the sexes are nearly alike liable 
to the disease. On examining the mortuary returns in the city of Philadel- 
phia for the three years 1879-1882, furnished me by Dr. Ford, a member 
of the Board of Health, I find that the deaths from erysipelas were 308, of 
which number 153 were males and 155 females. In 260 cases recorded by 
Bird, 147 occurred in males and 113 in females. 
If there is any greater predisposition of the female sex, I do not suppose 
it depends essentially upon anything connected with the difference of sex, 
exclusive of puerperal causes. Women are much less exposed than men 
to those casualties or traumatic injuries which open the door to the invasion 
of the disease. There can be no doubt, however, that women overtaken by 
accidents during menstruation are peculiarly susceptible to inflammations 
of the kind under consideration. It is a knowledge of this fact which, unless 
in cases of emergency, induces the surgeon to decline all important opera- 
tions on the female while she is in this state. 
Age.—The period of life which furnishes the largest number of cases of 
erysipelas is that between fifteen and forty-five }rears, notably the latter half 
of this period. In England, according to Zuelzer, the percentage of deaths 
in 12,556 fatal cases of erysipelas between the fifteenth and twenty-fifth years 
was 12.04, and between twenty-five and forty-five years 20.09. Here, again, 
it will be seen that the liability to the disease bears a conspicuous relation to 
the most active periods of life, when persons are most exposed to injury. 
Habits.—Bad habits of personal life have much to do not only in disposing 
to attacks of erysipelas, but also in increasing the mortality of the disease. 
This statement receives corroboration from the number of cases occurring 
among intemperate and dissolute persons. 
Seasons.—Erysipelas occurs at all seasons of the year. Haller found that 
during a single decade the largest number of cases in the General Hospital, 
Vienna, occurred during April, May, October, and November. In the Middle 
States of this country, January, February, and March, provided the weather 
is damp and changeable, are the months of the year when most cases of ery- 
sipelas are seen. As the weather during these months is characteristically 
variable, the transitions from cold to heat and from wet to dry being sudden 
and often extreme, the presence of the disease during the period named may 
be legitimately referred to atmospheric conditions. 
Countries.—Erysipelas is but little if at all affected by geographical con- 
siderations, for it is seen in all parts of the earth. If there is any exception 
to this universality, it is in the regions under the equator, where it is alleged 
by some writers never to appear. 
Organic and functional diseases.—Under the head of organic and functional 
predisposing causes may be enumerated diseases of the kidneys, diseases of 
the liver, disorders of the digestive organs, derangements of the uterus, and 
mental emotions of a depressing nature, any one of which may play a part 
in the sphere of causation. 
Local conditions exert an unquestioned power in disposing to outbreaks of 
erysipelas. These conditions can generally be detected by instituting a rigid 
sanitary inspection, when the origin of the evil will often be discovered to 
be some plague-spot in drainage or the violation of hygienic laws. It is not 
only in military camps and hospitals, but also in private residences, that, 
either from carelessness or from ignorance, these pest-centres are allowed to 
form. There is scarcely a hospital of any magnitude in this country or 
abroad in which erysipelas lias not at some time prevailed, and from causes 
which were wholly preventable. 456 
SURGICAL AFFECTIONS OF THE SKIN. 
In 1828 the disease prevailed to a great extent in the hospitals of Paris. 
Trousseau mentions a serious epidemic of the kind in the Maternite in 1858, 
and Cfintrac speaks of a similar epidemic at the Hospital St.-Andre, Bor- 
deaux, in 1844 and 1845 ; so also, according to Schonbein, the disease in 
1836 broke out in the hospitals at Zurich. At St. Bartholomew’s and at St. 
George’s Hospital, and indeed in all the great hospitals of London, the dis- 
ease at different times has prevailed to an extent which has made all opera- 
tions unsafe. At these periods any break in the of the skin, such 
as the slightest abrasion, would be followed by erysipelatous inflammation. 
Ulcers did not escape, and even the application of a blister was not without 
danger: indeed, in some instances all operations save those of urgent neces- 
sity had to be declined. 
These violent eruptions of the malady were regarded in the light of epi- 
demics, but were no doubt in almost every instance endemic. Since, however, 
the laws of sanitary science have been recognized and enforced in the con- 
struction, ventilation, and internal administration of eleemosynary institu- 
tions, and since improved methods of dressing have been introduced into 
surgical practice, the scourge has practically disappeared, and anything like 
what is designated as an outbreak of the disease at the present time in the 
wards of a hospital would be justly charged to defective administration. In 
proof of the unfrequency of erysipelas in hospitals in recent times the state- 
ment of Bryant may be quoted, that of 9253 patients in Guy’s Hospital 
during the five years preceding 1857 there were only 172 cases of erysipelas. 
The disease rarely originates in the hospitals of Philadelphia, the patients 
who suffer from the malady being affected before their admission. I)r. Hunt 
has shown that of 65 patients treated in the Pennsylvania Hospital for 
erysipelas, 62 had the disease when admitted. 
Exciting causes.—Contagion and infection.—There has been a large store of 
facts accumulated which tend to show that micrococci enter into the causation 
of this disease, and that it is both contagious and infectious,—that is, can be 
developed through the air and also by personal contact. The first opinion 
receives support from the almost simultaneous appearance of the affection 
in all parts of the surgical wards, when it prevailed at the Hotel-Dieu, at 
La Pitie, and in the Military Hospital at Breslau. Gibson says that at Mon- 
trose, in 1822, the Infirmary had to be abandoned from inability to prevent 
the disease. 
The malady has been known to pass regularly from bed to bed along one 
side of a ward, returning with similar regularity on the opposite side, only 
a single inmate escaping. Volkmann gives an instance of this kind. When 
prevailing at St. Bartholomew’s, the disease, according to Savory, behaved 
somewhat after the same manner. 
There are numerous facts on record which show that erysipelas can be 
communicated by sponges, instruments, dressings, nurses, and the clothing of 
the surgeon. Konig states that at Bostock’s clinic, erysipelas, which had be- 
come quite common, was communicated by the soiled pillows and mat tress of 
the operating-table, and that this was the true source of infection was proved 
by the disappearance of the disease with the removal of the suspected bed- 
ding. In further confirmation of the contagious nature of erysipelas the 
experiments of Orth may be cited, in which the disease was communicated 
by inoculation from man to animals. Besides the above examples, there are 
a large number of isolated or individual cases given by writers, all attesting 
the communicability of the affection by a specific poison. 
Epidemic influences must also be recognized among the predisposing causes. 
There have been periods when, from some subtile and inappreciable atmos- 
pheric condition, erysipelas has passed through a city and over extensive 
country districts, rendering it dangerous to perform the most insignificant 
operation. Professor Gross the elder states that at one time, during an 
epidemic of erysipelas at Louisville, so common was the malady that not 
only was it necessary in many instances to avoid operations, except where ERYSIPELAS. 
457 
they were imperatively demanded, but that even blistering, leeching, bleed- 
ing, and the introduction of setons had to be abandoned, on account of the 
liability of all broken surfaces to become affected with the inflammation. 
Nor was the epidemic of this period (1842 to 1846) local in its ravages. It 
swept over several States of the Union, and in the West passed under the 
name of the “ black tongue.” So convinced am I of the portability of ery- 
sipelas that when I am attending a case of the kind I avoid as much as pos- 
sible the use of the knife. I am sure that in two instances in which the 
mammary gland was removed I was, in spite of precautions, the medium of 
communicating the disease. 
Another feature connected with epidemic erysipelas is the tendency to 
impress almost all other diseases with some of its own characteristics. Thus, 
the scratch of a pin, a leech-bite, the vesicated surface of a blister, or the 
edges of a simple bed-sore which may have almost entirely closed, are all 
liable to be fixed upon by the malady. An ordinary attack of fever will be 
accompanied by erythematous spots over the body, whilst exanthemata 
occurring during the period of epidemic activity will be unusually severe. 
Wounds, especially punctured and lacerated, together with contusions, and 
exposure to cold, damp currents of air, all come under the head of exciting 
causes. 
There are some reasons for believing that the materies morbi of erysipelas, 
whatever it may be, is different from that which is concerned in the pro- 
duction of hospital gangrene, pytemia, or low forms of fever. During the 
prevalence of hospital gangrene at the Chestnut Hill Military Hospital I 
cannot recall a single case of erysipelas, either on the side of the house 
where the former disease originated or in any other part of the building; 
nor have I seen erysipelas in any of our civil hospitals the origin of which, 
by the most strained construction, could be traced to the presence of pysemic 
patients. On the contrary, the periods during which cases of pyaemia have 
existed in my wards have been rather notable for the absence of erysipelas. 
On this point the records of surgery are not silent. During the Crimean 
War, in which hospital gangrene and pyaemia prevailed to a fearful degree 
among the English soldiers, cases of erysipelas were comparatively rare; and 
in the military hospital at Trautenau, Yolkmann mentions the existence of 
pyaemia, but no erysipelas. Indeed, facts are not wanting to show that 
there is a certain incompatibility in the simultaneous presence of the two 
maladies in the ward of a hospital. Take, for example, the statement of 
Pugos, given by Zuelzer, that in an epidemic of erysipelas which occurred at 
Bordeaux, and in which thirty-four per cent, of the sick died, there was not seen 
a single case of pyaemia. These facts militate against the pyaemic miasm 
theory of Boser, and against the relationship of the two affections assumed 
by Pirogoif. Nor does the disease appear to arise from tho aggregation of a 
large number of persons in close quarters. In the Philadelphia Hospital 
and Almshouse, where during the winter from three to four thousand paupers 
and pauper patients are of necessity closely crowded, erysipelas, except in 
sporadic cases, I never saw during a service of twelve years. The same 
observation, I believe, may be made in regard to the inmates of the Phila- 
delphia county jail and the Eastern Penitentiary. But, while atmospheric 
impregnation by exhalations from the body does not appear to constitute a 
material factor in the causation of erysipelas, this cannot be asserted of 
contamination of the air from the toxic, emanations of human dejections. 
On two occasions, with an interval of ten years, as recorded by Yolkmann, 
the disease broke out in the Middlesex Hospital. In both endemics the cause 
was found to have originated in a defective pipe which lay in the wall of the 
ward and communicated with the privy. The disease each time promptly 
disappeared when the broken pipe was mended. At the Berlin Charite the 
same thing occurred, and from the same cause, a broken pipe leading to the 
water-closets, the repair of which put an end at once to the erysipelas. 
Symptoms.—The symptoms of erysipelas are both local and constitutional. 458 
SURGICAL AFFECTIONS OF THE SKIN. 
The disease appears at variable periods after the reception of a wound, but 
rarely earlier than eight or ten days, unless at times when the malady pre- 
vails in an epidemic form, when the attack may be much sooner. The ap- 
proach is generally announced by languor, loss of appetite, and a rigor or 
chill; or a sudden rigor alone may precede the local appearance of the in- 
flammation. The chill is followed by considerable arterial excitement and 
an unusually high temperature, i-anging from 103° to 105°; the tongue be- 
comes loaded with white, pasty secretions ; the complexion grows sallow and 
sometimes icterode; the bowels are constipated, occasionally relaxed ; the 
pulse, at first full, but compressible, becomes less resistant and more frequent 
as the disease advances; and the urine exhibits an increase of urates, with 
a diminished amount of chlorides, the secretion frequently containing albu- 
men. When the face and scalp are the seat of the disease, it may be accom- 
panied by quiet delirium with some degree of heaviness or stupor. 
Local Signs.—When the affection commences in the cutaneous or super- 
ficial form, the inflammation is of a brownish red, diffused and spreading over 
the surface unequally in different directions, sending out long processes in 
one direction, which may coalesce, and in other directions moving in an un- 
broken wave of color. The inflamed surface is tender to the touch, hot and 
burning, and not unfrequently is surrounded with a few vesicles filled with a 
straw-colored serum. On pressure, the vessels are emptied and the redness 
disappears; but on removing the finger the color immediately reappears with 
the instantaneous return of the blood. 
In the deeper or phlegmonous variety of erysipelas, a much graver form 
of the disease, the color is dusky red, frequently livid or purple; the swelling 
is hard, brawny, and oedematous. The oedema and hardness depend on ana- 
tomical peculiarities of structure,—the former, when the disease is localized 
on the face and eyelids, being usually so great as to render the features 
often unrecognizable; the hardness is always most marked where the differ- 
ent portions of the skin and subcutaneous tissues are most closely interwoven. 
When the serous element of the transudation predominates, the skin presents 
a shining, stretched appearance, with vesicles, blebs, or phlyctamse over its 
surface. 
Knotted or beaded indurations are sometimes felt under the skin of the 
inflamed part, running in the directions of lymph-glands, which reveal the 
implication of the lymph-vessels in the disease. According to Franck, Cho- 
mel, and other writers, erysipelas of the head and face is heralded by a 
painful and swollen state of the cervical lymph-glands. There must be 
many exceptions to this rule, for it does not accord with what I have 
observed. 
In phlegmonous or deep erysipelas the inflammation either begins pri- 
marily in the subcutaneous connective tissue, or extends into it from the sur- 
face, and may be attended with very little pain. The of this form 
of the disease is to suppuration and necrosis of the areolar tissue : indeed, 
the devastation sometimes reaches deeper than the latter, laying bare the 
muscles, or possibly ending in their destruction, and exposing the bones. 
Notwithstanding the advent of suppimition, it does not follow that fluctua- 
tion, one of its characteristic signs, will be present. There is often a soft or 
quaggy condition which reveals what is beneath the skin. The pus, mingled 
with serum and fibrin, spreads through the connective tissue, not being cir- 
cumscribed by a defensive wall of lymph, as in ordinary abscess. When the 
parts are laid open so as to allow of the escape of inflammatory products, 
they are found to consist of unhealthy pus, mingled with flakes of depraved 
lymph and shreds of dead connective tissue. 
The general symptoms which accompany phlegmonous erysipelas are of an 
adynamic type, the pulse becoming feeble and frequent, the tongue dry and 
dark, the urine scanty, often albuminous, the respirations quickened; often, 
particularly when the inflammation is located in the scalp, there are mut- 
tering delirium and stupor. As the disease is prone to extend to mucous ERYSIPELAS. 
459 
membranes, it may in facial erysipelas enter the nose or mouth and by con- 
tinuity of structure attack the fauces, larynx, and bronchia, giving rise to 
laryngitis, bronchitis, and pneumonia. 
The effect of an erysipelatous attack on recent wounds or on ulcerated 
surfaces is entirely inimical to repair. Not only is the work of reconstruction 
arrested, but often the bond of union in the one and the cicatrization of the 
other will break down, the wound or sore reopening under the destructive 
action of the poisoned blood. 
Erysipelas is rarely general, so as to involve the entire body. In a very 
obese woman from whom I removed a carcinomatous mamma, the inflamma- 
tion, which commenced in the neighborhood of the wound, rapidly spread 
over the whole body ; and in another case the disease followed the excision of 
a small cyst of the scalp, beginning around the incision and traveling slowly 
down over the face, neck, trunk, and upper and lower extremities, finally 
terminating at the ends of the toes, occupying in the passage six weeks, and 
never attacking a new installment of skin until the blush had faded in a 
large degree from that previously affected. 
A form of erysipelas is described by some authors as erratic, the inflam- 
mation leaving one spot and breaking out in another,—a division of no 
practical import. 
Course and duration.—In the superficial or dermoid variety of erysipelas, 
the severity of the disease will be over in three or four days. The color 
gradually fades away, changing from the scarlet to a dull pale-red or a light- 
yellow color, and is accompanied with desquamation of the cuticle and wrink- 
ling of the skin. With the decrease in color there follows a corresponding 
subsidence of fever, the two disappearing at the same time. When the dis- 
ease has been in the scalp, the hairs are apt to drop out after the disappear- 
ance of the inflammation, but, the hair-follicles remaining, they will again 
grow. Subcutaneous or phlegmonous erysipelas rarely reaches its culmi- 
nating stage earlier than the fifth or sixth day. It is followed by desquama- 
tion of tbe cuticle, and terminates in from twelve to fourteen days. In other 
instances the inflammatory stuffing of the skin and subcutaneous tissue may 
result in suppuration, with extensive sloughing. 
Diagnosis.—Erysipelas is often confounded with certain cutaneous affec- 
tions, as erythema, urticaria, and carbuncle. 
In erythema there is no precedent chill, usually no febrile disturbance, and 
no marked rise in the temperature. The efflorescence in erythema often ap- 
pears in parts of the body not particularly predisposed to erysipelas, as over 
the front of the chest, or on the upper and lower extremities, and the patches 
of colored skin are small, painless, without any burning sensation, circum- 
scribed, with little tendency to spread or to coalesce, without swelling, and 
free from desquamation,—the disease being in all these respects unlike ery- 
sipelas. 
In urticaria the stinging and itching sensations of the eruption, its wheal- 
like shape, and its disposition to spread over widely-separated portions of the 
body at the same time, together with its usual dependence upon some dietetic 
indiscretion, are characteristics which will serve to prevent the disease from 
being mistaken for erysipelas. 
Carbuncle, which in its forming stage is sometimes mistaken for erysipelas, 
exhibits certain peculiarities which should prevent the commission of any 
error of diagnosis. In carbuncle prominent and early symptoms are great 
induration and marked stiffness in both the inflamed and the adjoining parts. 
When located on the back of the neck, a very frequent site, the patient avoids 
moving the head ; there is little oedema, and the disease is not announced by 
antecedent chill. 
Morbid appearances.—The structural alterations caused by erysipelatous 
inflammation are generally limited by the deep fascia, and therefore confined 
to the skin and underlying connective tissue. In the early or congestive 
stage of the inflammation, the derm and all its layers are infiltrated by serum, 460 
SURGICAL AFFECTIONS OF THE SKIN. 
fibrin, and granular leucocytes, mingled with connective-tissue cells and a 
few red blood-corpuscles. It is this infiltrate which causes the indurated con- 
dition of the inflamed part. At the marginal line of the part and in the 
lymph-spaces of the connective tissue the white corpuscles are seen in con- 
siderable numbers. The endothelia of the lymph-spaces are also in an active 
state, and in the lymphatic vessels belonging to the superficial layer of the 
derm, as well as around them, are seen numerous granulated cells, which do 
not materially differ in appearance from those which constitute a portion of 
the infiltrate in the derm. The desquamation which is one of the features 
belonging to erysipelas is caused by the cells of the rete mucosum, 
the result of pressure, in consequence of which their secretory function is 
destroyed and they are rejected as dead matter. The blood-vessels are filled 
with corpuscles, their walls remaining unchanged, unless suppuration occurs, 
in which event their outline is lost, the traces of their former course being 
indicated by the debris of disorganized blood-corpuscles. That a local tym- 
phangitis exists in every case of erysipelas within the inflamed area there 
can be no doubt; and when contiguous to a lymph-gland the erysipelas may 
be accompanied by adenitis and a leucocytosis corresponding to the extent 
to which these glands are involved. The massing of cells in the meshes of 
the connective tissue, both in and beneath the derm, unless prevented by 
early resolution, soon causes the fibrillae to soften, swell, and finally dis- 
appear, leaving in their stead a structureless-looking substance, with here 
and there fibres which have escaped destruction in the process of suppura- 
tion. 
It is the fibrinous element of the infiltrate which in cases of phlegmonous 
erysipelas gives to the affected part the stiff, doughy feel which masks the 
fluctuation in cases of suppuration, and modifies also the pitting produced by 
pressure, the depressions being shallow and not persistent. 
What part is played by the bacteria seen in the erysipelatous portion, and 
first discovered by Hiiter, is still an unsettled question. These low organ- 
isms are not at all peculiar to this particular variety of inflammation, and 
to assert that upon their presence the disease depends, would be to adopt 
the post hoc ergo propter hoc method of argument. The experiments of Lu- 
lcomsky would seem to show that they are not altogether passive intruders, 
as, according to this writer, their presence was observed only during the 
active stage of the inflammation. Orth also found that the infectious quality 
of the cedematous material seemed to bear a certain relation to the number 
of these organisms which it contained. 
So far, therefore, as the anatomical changes which are present in erysipelas 
can be interpreted, they do not materially differ from those observed in non- 
specific dermatitis or subdermatitis. 
Is there any anatomical explanation for the peculiar manner in which the 
inflammatory blush of erysipelas spreads, moving in truncated processes, 
which are followed up by broad waves of color, filling up the intermediate 
spaces, and making abrupt detours around certain points, as though con- 
fronted by some insurmountable obstacle? There is every reason to believe 
that the answer to this inquiry will be found in the arrangement of the an- 
atomical components of the integument. The intersections of the connective- 
tissue bundles in the main take place in directions which give to the meshes 
of the fascia a rhombic form: as the fibres of the areolar tissue support the 
capillaries and lymphatics, the same form will be assumed by the net-work 
of these vessels. Whatever, therefore, increases the tension of these parts, 
as does the exudation in erysipelas, must elongate these rhomb-shaped inter- 
fascicular meshes into slit-like crevices, through which, the longitudinal re- 
sistance being less than the transverse, the blood-flow will be invited in the 
direction of least opposition. The connection between the skin and the sub- 
cutaneous fascia or other parts also strongly influences the facility with 
which erysipelas extends. Wherever this connection is close and firm, the in- 
flammation is always retarded, and sometimes is arrested. From this cause ERYSIPELAS. 
461 
erysipelas of the thigh, in traveling upward towards the abdomen, will sud- 
denly halt at the abdomino-femoral fold, over Poupart’s ligament, and in some 
cases it will reach a higher point only by outflanking the groin. For the same 
reason the depressions of the skin caused by the linear arrangement of the 
cutaneous papillae and the wrinkles will resist the extension of the inflamma- 
tion. The chin, for a similar reason, enjoys a conspicuous immunity from 
erysipelas when the malady attacks the face. 
The morbid conditions found in the internal organs in fatal cases of ery- 
sipelas consist in an enlarged and softened state of the spleen and intense 
congestion or inflammation of the parenchyma of the kidneys, with pneumo- 
nia and occasionally with ulcerative duodenitis. Bastian has called attention 
to embolism in the small arteries in a case of fatal erysipelas, the obstruction 
being made up almost entirely of white corpuscles massed together. This 
may have been wholly accidental, and a consequence of the inflammation 
having been propagated to lymph-glands, with resulting leucocytosis, and 
not necessarily connected with the primary malady. Besides these organic 
lesions, others, such as pleuritis, peritonitis, and meningitis, have occasionally 
been seen. 
Prognosis.—Several considerations are to be taken into account in forming 
a prognosis as to the probable termination of a case of erysipelas: for ex- 
ample, the character of the prevailing epidemic, the danger being in propor- 
tion to its severity. Age also is not without its influence, the very young 
and the aged having the least capacity for resisting the adynamic tendencies 
of the disease. Habits must not be overlooked. The intemperate and disso- 
lute make a bad fight with erysipelas. Hygienic surroundings, if of an un- 
favorable character, will convert what would have been a mild attack of the 
disease, under more favorable conditions, into one of tbe gravest kind. The 
portion of the body affected is also no inconsiderable factor in the prognostic 
problem. Erysipelas of the face and head must always be regarded with 
more anxiety than an attack which is seated upon the body or a limb. When 
erysipelas is engrafted upon another disease, the danger is seriously en- 
hanced, as is the case during an attack of typhoid fever or after severe inju- 
ries. According to Nunneley and Bird, a rise in the frequency of the pulse 
occurring after the sixth day is a very unfavorable symptom. This symptom, 
I cannot help thinking, has been greatly overestimated as a danger-signal. 
Looking at the subject from a general point of view, erysipelas in America 
cannot be regarded as a very fatal malady, the death-rate not exceeding 
seven or eight per cent. In the city of Philadelphia, with a population of 
900,000, the deaths from erysipelas for three.years—1879 to 1881, inclusive— 
amounted to only 308. 
The symptoms which forebode a fatal termination in erysipelas are an in- 
creasing rise of temperature after the disease has been fully established, or 
following the third day of the efflorescence, increasing frequency and feeble- 
ness of the pulse, with a clammy perspiration, an icterode hue of the skin, a 
scanty secretion of urine, a distended belly, and increasing stupor. 
Treatment.—When erysipelas appears, whether in the wards of a hospital 
or elsewhere, isolation of the patient should be imperative. All soiled dress- 
ings, sponges, and instruments used about the affected person should be 
removed, so as to leave no possible medium for conveying infection. Even 
the nurses who have been in attendance upon erysipelas patients are unclean 
and unfitted to attend to the wounds of others unless, by repeated ablutions, 
a complete change of garments, and a short absence from duty, they have 
undergone a process of cleansing. 
Two plans of treatment have been practiced. In one, the lancet, purga- 
tion, and nauseating antimonials, with a low diet, were the chief elements. 
In the other, iron, quinine, a generous diet, and a moderate amount of stim- 
ulus were equally prominent. The two methods are directly antagonistic, 
and are based on opposite theories of the nature of the disease. The ad- 
vocates of the first regard erysipelas as a sthenic disease, while those who 462 
SURGICAL AFFECTIONS OF THE SKIN. 
adopt the latter contend for its asthenic tendencies. While I have no 
hesitation in giving, in the main, an unqualified adhesion to the last-named 
doctrine, and in most respects also to the supporting plan of treatment, which 
must necessarily be indicated by an asthenic state of the constitution, I can- 
not avoid thinking that an error may be committed by too emphatically 
dwelling upon the ever-present phantom of debility. I have seen, among 
vigorous persons in the country attacked by erysipelas, the disease cut short 
and convalescence follow in a brief period under the use of blood-letting, a 
mercurial purge, and small doses of antimony, with a diet of toast-water. 
I shall not soon forget the impression which was made upon my mind by a 
case of relapsing erysipelas which attacked the stump, following amputa- 
tion, in one of my patients in the Pennsylvania Hospital. The inflammation 
in this case was peculiarly obstinate, having reluctantly faded away and 
again suddenly revived. The man, who was not at all remarkable for con- 
stitutional vigor, had been plied with the conventional drugs, such as iron 
and quinine, with milk-punch and the essence of beef, yet without much 
impression upon the disease, which still lingered about the arm. Suddenly 
in the night the patient had a secondary hemorrhage, losing a considerable 
amount of blood before the nurse came to his assistance. From that hour 
the erysipelas disappeared, the healing advanced, and the man made a rapid 
recovery. While it would be illogical to attempt to build up a peculiar 
phlogistic theory and a Sangrado use of the lancet on isolated instances like 
the foregoing, yet they constitute a sufficient ground for not dogmatically 
ignoring the abstraction of blood in those cases of the disease which are 
characterized by a high grade of vascular tension. When facial erysipelas 
attacks a person otherwise of a sound, vigorous constitution, and is attended 
with headache, a full, bounding pulse, and tendency to stupor, the abstrac- 
tion of blood, either from the arm or by wet-cupping over the back of the 
neck, will afford relief and may be unhesitatingly practiced. 
The bowels should, in all cases of commencing erysipelas, be opened by a 
saline aperient, preceded by two or three grains of calomel or its equivalent 
of blue mass. This may be followed by a refrigerant mixture, such as the liquor 
ammonite acetatis. After the second day of the attack the patient should 
be placed on a preparation which, at the same time that it exei’ts a modi- 
fying influence on the blood, stimulates the action of the kidneys, which 
are most effective organs for eliminating morbific agents from the body. 
Iron, which was introduced into practice by Bell in 1851 in the treatment of 
erysipelas, has enjoyed and continues to hold a high reputation in the disease. 
I prefer to administer it in the form of Basham’s mixture, giving with each 
dose an additional ten drops of the tincture of the sesquichloride of iron 
every three hours. If the temperature continues to rise, quinine may be 
given in doses of five grains, repeated at intervals of two hours until three 
or four doses have been taken. 
The diet should consist of milk, light gruels, beef-tea, and other animal 
broths. Free ventilation and scrupulous cleanliness of the bedding and linen 
of the patient are also subjects which must receive the personal attention of 
the surgeon. 
Local Treatment.—Opinions as to the value of local treatment in ery- 
sipelas are singularly incongruous, some physicians approving, others disap- 
proving, and a third class regarding all such applications as matters of in- 
difference, not capable of doing either good or evil. The local agents which 
have been used at different times are very numerous. Among them are the 
bichloride of mercury, recommended by Pitcher; chloi-oform, by Ilolston ; 
creasote, by the late Dr. Gilbert, of Philadelphia; mercurial ointment, by 
Dean, Little, and Kicord; lard, by Solin; cold water, by Hebra; warm appli- 
cations, by Bust; and lime-water and sweet oil, by Meigs. Velpeau was par- 
tial to the use of sulphate of iron, which he applied either in solution or in 
the form of an ointment. The tincture of iodine has been extolled as a top- 
ical application in erysipelas, and is to be applied with a camel’s-hair brush RHUS DERMATITIS. 
463 
over and beyond the inflamed surface, either in its officinal strength or diluted 
with alcohol. Nitrate of silver, recommended by Higginbottom, is a favorite 
application with many physicians. A strong solution (grs. xl, distilled water 
fgi) or the solid stick is to be applied to the affected surface and a short dis- 
tance beyond on the sound skin, the parts having been previously cleansed 
from all unctuous matters by an alkaline wash of potash. A fifty per cent, solu- 
tion of ichthyol in alcohol, smeared over the affected surface, seems to have a 
decidedly good effect. Neudorffer and Peterson recommend hypodermic in- 
jections around the inflamed part, the former of carbolic acid (two per cent, 
solution), the latter of salicylic acid (a stx-ong solution). 
Blistering in erysipelas was commended by Physick ; and there is no doubt 
that it does good in some cases by depleting the vessels and thus relieving 
the dermatitis and cellulitis. The blister should be applied directly over the 
diseased surface and allowed to remain until vesication is produced. This 
will require from six to eight hours, after which the blister should be re- 
moved, the blebs punctured, and the serum allowed to escape. 
Pressure by a neatly-applied compress and bandage, an old plan revived 
by Velpeau in 1826, has also been advocated, particularly in the early stage 
of phlegmonous erysipelas, as an inflammatory resolvent, and no doubt it is 
capable of doing good in many eases, by the support furnished to the blood- 
vessels and the muscular rest which is obtained. A mixture of lead-water 
and laudanum is frequently employed. While I am not enthusiastic over 
local applications, some benefit appears to have followed the employment of 
a two per cent, solution of bromine, or of the solution of ichthyol, frequently 
brushed over the diseased skin. Freely dusting over the part fine rye-meal, 
powdered starch, arrowroot, or rice-flour does good in cutaneous erysipelas, 
by excluding the air, absorbing the cutaneous secretions, and thus allaying 
local irritation. 
When the affected part becomes greatly swollen, tense, and throbbing, and 
the disease threatens destruction to the inflamed tissues, free incisions should 
be made at once. The surgeon should cut boldly down into the subcuta- 
neous tissue, or until the infiltrate is reached,—a practice introduced into sur- 
gery by Dr. Hutchinson as early as 1814, though said to have originated in 
Eussia at an earlier date. It is better in these cases to make three or four 
small incisions, each one inch and a half in length, rather than a single long 
one, at the same time planning these cuts so as not to inflict injury on im- 
portant vessels or nei*ves. 
At times the surgeon does not see the patient until the swollen, tense con- 
dition has given way to one in which the parts have a boggy, sometimes 
crepitating feel. The necessity for division xinder such circumstances is 
even more imperative, as suppuration and gangrene of the connective tis- 
sue have occurred, and a way must be opened for the escape of the liquid 
accumulations and structural debris ; or, where the serous element predom- 
inates, a number of punctures with the point of a bistoury should be sub- 
stituted for free incisions. The relief experienced from giving vent to the 
inflammatory products pent up in the tissues is immediate, and will be fol- 
lowed by an abatement of all the symptoms. The dressing to be applied 
after dividing the parts will be either a light flaxseed-meal poultice or a 
piece of lint saturated with warm water containing a few drops of carbolic 
acid and a little laudanum, and covered in either with waxed paper or with 
oiled silk. 
Rhus Dermatitis.—This form of inflammation of the skin is the result of 
poisoning produced by the poison-oak and other species of sumach. There is 
a singular susceptibility on the part of many persons to the action of these 
poisons. A medical friend in this city cannot pass close to the windward of 
the Rhus toxicodendron and expose his body without suffering severely from 
the characteristic inflammation. Other persons, and among them the writer, 
can handle these poison-bushes with impunity. Different members of the 464 
SURGICAL AFFECTIONS OF THE SKIN. 
same family may not be alike vulnerable to the poison. A prominent mem- 
ber of the profession in Philadelphia informs mo that in his generation the 
sisters suffer, but the brothers are exempt. Of nine children of his own, the 
boys, four in number, poison, while the girls escape. 
The inflammation makes its appearance shortly after exposure, the latent 
stage rarely exceeding eight or ten hours. The inflammation appears on the 
hands, face, and genital organs. The hands are generally instrumental in 
carrying the contagion to other portions of the body. The efflorescence is 
sometimes, in the mildest degrees of the poisoning, of an erythematous 
appearance, but more frequently is vesicular in its character. It is ac- 
companied by great heat, itching, and swelling. The oedema is greatest in 
those parts in which the skin is thin and loosely connected to the subjacent 
parts. Hence the eyelids when attacked become greatly swollen and are 
closed ; in like manner the scrotum and prepuce become filled with serum. 
The vesicles soon rupture, their places remaining marked for some time by 
dried crusts of inspissated serum and sero-pus. There does not appear to 
be any definite period in which this form of dermatitis runs its course. With 
some persons the inflammation will have passed away in six or eight days, 
while in others it will extend over as many weeks. 
Treatment.—External applications are all that will be required in the 
treatment of this inflammation. I have rarely employed an}' other remedies 
than lotions of acetate of lead or of sulphate of zinc. Cloths wet with these 
solutions, of the strength of one drachm and a half of the salt to one pint 
of water, and kept constantly laid over the affected parts during the acute 
stage of the inflammation, will meet the requirements of the case. When 
the itching is very severe, some relief will be obtained by sponging the sur- 
face with a dilute solution of carbolic acid (f 3ss to water Oi). Dr. James C. 
White, of Boston, who is the author of an excellent article on rhus-poisoning, 
speaks favorably of black-wash frequently applied. The fluid extract of 
Grindelia robusta (f‘5’j to water Oi) is also a favorite application with many 
physicians. Professor Both rock speaks highly of the fresh juice and the 
tincture of Sanguinaria canadensis, applied freely over the affected parts. 
In the wards of the Pennsylvania Hospital, where this remedy has been in 
use for some time, its value is fully recognized. 
When the oedema is great and antecedent to the eruption of vesicles, 
small punctures made in the distended skin with a flat-pointed needle will 
ease the tension and give considerable relief. 
The nervous irritation attending rhus-poisoning is frequently so great as 
to demand the use of some sedative, the best being bromide of potassium 
with deodorized tincture of opium. 
Dermoid and Subdermoid Connective-Tissue Hypertrophies. 
Callosities are patches of thickened skin which are frequently seen over 
the fleshy pad covering the metatarsal bones along the outer border and 
upon the heel of the foot. They occur also on the palmar surface of the 
hand at points over the metacarpo-phalangeal articulations. These callosi- 
ties have a yellowish color, consist of an increased production of the epi- 
dermic layers, and are in almost all cases the result of irritation caused by 
friction. When the accumulation of epidermic scales occurs to a very un- 
usual degree, these callosities, by pressure on the subjacent nerves of the 
cutaneous papillae, often become painful and require treatment. 
Treatment.—So entirely dependent are callosities on pressure for their 
existence, that whenever this excitant is withdrawn for a considerable length 
of time they spontaneously disappear ; but, as the urgency of occupation will 
frequently not allow of the removal of the cause, palliative treatment will 
be required, the best being prolonged bathing of the parts in hot water 
containing a small quantity of bicarbonate of soda, or in a weak solution 
of liquor potassse (half the officinal strength). After the hardened patches CORNS. 
465 
in this way have been well soaked and softened, they can easily be scraped 
off with the curette extremity of a director, or pared away with a knife. 
The surface from which they have been removed should then be painted 
with dilute tincture of iodine. Persons who have been unaccustomed to toil, 
and are by force of circumstances compelled to handle tools of any kind, 
may, by way of preventing these callous formations, wear buckskin gloves 
when working. 
Clavus—Corns. 
Corns are flat, circumscribed callosities, situated usually on the interme- 
diary articulations of the dorsal surface of the toes, sometimes on the meta- 
tarsal fleshy pad of the sole of the foot. The outer surface of the little toe 
is particularly liable to clavus. When situated between the toes, these for- 
mations have a soft consistence, in consequence of being constantly macer- 
ated by moisture, and are called soft corns. 
The anatomical structure of a corn consists of 
hypertrophy of the papillae with an unusual accu- 
mulation of the epidermic layers of the skin. 
The papillae, pressed upon by the hard epiderm, 
assume the form of an inverted cone, the base of 
which can always be recognized by its white 
appearance and solid consistence in the centre of 
the surface of the corn. The apex of the cone 
is buried in the derm, making for itself a little 
cavity by causing the absorption of the sur- 
rounding parts. (Fig. 2028.) As the papillary 
eminences of the corium contain the loops of 
nerves and blood-vessels, the pain and inflam- 
mation experienced when undue pressure is made 
upon the corn will be readily understood. 
The cause of clavus is always pressure, either 
as a result of badly-fitting shoes, or arising from deformity of the foot. 
Treatment.—First in importance in the treatment of clavus is the re- 
moval of all pressure. This may be effected by exchanging the usually badly- 
fitting shoes for others which have at least some resemblance to the shape of 
the human foot. In many instances nothing more will be required, the 
growth disappearing in the absence of the old pressure. When this does 
not follow, the corn should be removed. This can sometimes most satisfac- 
torily be accomplished in the dry state of the growth by the finger-nail, 
which, being insinuated between the margin of the corn and the sound 
skin, gently pries the former away from the latter, fix-st at one point and then 
at another, until the central axis or core of the callous body has been l'eached, 
and this core, after being bent in different directions, can be di*awn out en- 
tire from its deep connections with comparatively little pain, leaving a de- 
pression, which should be immediately filled with a little morphia cerate. 
In other cases it is better to subject the corn to a pi’eliminaiy softening. 
A flaxseed-meal poultice should be laid over the part during the night, and 
on the following morning, after removing the dressing and washing the pai’t 
in warm wrater, the thickened epidermis can be easily pai’ed away with a sharp 
knife, taking care not to go too deep or too near the skin. Carelessness on 
this point not unfrequently creates a violent inflammation at the base of the 
corn. After shaving the coni to the requisite extent, th,e solid niti’ate of 
silver can often be advantageously applied to the exposed surface. To pro- 
tect from further pressure, a shield should be worn over the part. Appli- 
ances of the kind are generally made of circular pieces of felt having a 
central perforation corresponding to the base of the corn, one sui’face being 
covered with some adhesive matei-ial to hold the plaster in place. A pro- 
tection equally satisfactoxy can be made by placing together a number of 
Fig. 2028. 
Section of a corn. 466 
SURGICAL AFFECTIONS OF THE SKIN. 
square pieces of adhesive plaster, cutting a hole in the centre, and then 
turning the little shield into the proper shape. 
Corns are liable to become inflamed, and in this condition arc exceedingly 
painful. The proper plan of treatment is to apply hot poultices of flaxseed- 
meal wet with lead-water and a few drops of laudanum. 
Soft corns require that the toes should be kept apart and the moisture 
absorbed. These indications are best fulfilled by the interposition of little 
pledgets of absorbent cotton dusted with gallic acid and renewed twice a 
day. Should these measures not prove successful, these growths should be 
subjected to a treatment similar to that directed for the hard corn. 
As a moist soil favors the production of interdigital corns, even when there 
is no undue pressure to account for their presence, persons whose feet habit- 
ually sweat should be instructed to bathe the parts in a solution composed 
of alum and alcohol, its use to be followed by dry frictions. 
Verruca—Warts. 
Warts are excrescences, single or multiple, which may appear upon the 
surface of different parts of the body. The localities where they are most 
common are the hands, the face, and about the genitalia of both sexes. 
They are more common in young than in middle-aged and old persons. 
Warts differ considerably in form and appearance. The most common 
variety is a prominent, fissured, sometimes slightly-pedunculated growth, 
having a brown or yellow color, and consisting of closely-aggregated rods 
with terminal clavate extremities ; or they be short, conical outgrowths, 
made up of more or less closely packed filaments with pointed extremities, 
and having a brown, red, or purple color. In other cases the growths are 
flat, sessile, but little elevated, and with no marked surface-cleavage, all the 
papillary rods being covered with an unbroken layer 
of epidermic cells. 
Warts are hypertrophied elongations or vegeta- 
tions of the cutaneous papillae, covered by thickened 
epidermis. (Fig. 2029.) The connective tissue and 
vascular components of the vegetations diminish in 
amount from below upward. 
When occurring on the genitalia of the male, the 
favorite seat of these growths is on the glans penis 
and the prepuce; in the female, on the inner or 
mucous surface of the vulva and vagina. In these 
localities they are frequently seen in great numbers, 
in some instances completely covering the head of 
the male organ or filling up the vagina of the female. 
These vegetations, when situated on the genitals and 
in groups, are usually bathed in moisture, the exha- 
lations from which are extremely offensive. 
Except in those situated on the genital organs, of the gonorrhoeal origin 
of which there can in many cases be no doubt, we know very little of the 
causes concerned in developing warts. In most cases they are probably due 
to local irritation. The period of life at which they most prevail—that is, 
adolescence—is one in which the hands, obedient to an ever-prying curiosity, 
are everywhere. The multiple outbreaks of these growths which are some- 
times witnessed would seem to imply the occasional opei'ation of a general 
cause, or a diathesis, in their production. 
Another curious circumstance connected with warts is the mysterious, 
sudden manner in which they sometimes disappear, altogether independently 
of any local medication. 
Treatment.—The most simple plan of removing a wart is to clip it off on 
a level with the skin and touch the bleeding surface with nitric, chromic, or 
glacial acetic acid. When cutting is declined, the same result can be attained 
Fig. 2029. 
Section of a wart. HORNS. 
467 
by repeated cauterizations with any one of the above-named acids, or by a 
paste of chloride of zinc, in apptying which the surrounding skin should be 
protected by a little wall of wax, putty, or diachylon plaster. A favorite 
domestic remedy for removing warts, and one often successful, is turpentine 
rubbed on the excrescence morning and evening. Touching the warts with 
the hand of a dead man was one of the practices formerly common among 
simple-minded and superstitiously-inelined people. 
Yerrucous vegetations on the genitals should be treated by first thoroughly 
cleansing the growths with chlorinated soda, and then filling up the inter- 
stices and covering the surface of the warts with tannic acid, subsulphate 
of iron, or calomel, at the same time being careful to keep the adjoining 
mucous surfaces apart by interposing soft lint or absorbent cotton. When 
this method fails, the growths should be clipped off with the scissors or 
scraped away with a curette, and the surfaces touched with nitric acid. The 
hemorrhage following these operations is frequently profuse, but can be 
controlled by freely sprinkling over the bleeding points the subsulphate of 
iron, with the addition of a compress and bandage. 
Cornua—Horns. 
Horns differ from warts chiefly in the density of the epidermal cells and 
in their closely laminated or superimposed association. They do not mate- 
rially differ from the nails or the horns of animals in their structure. These 
dermoid excrescences are hard, twisted, distorted outgrowths, rounded or 
conical at their extremities, their surfaces rough and wrinkled, having a dull 
yellow or brown color, and in many respects resembling in appearance the 
horns of the ram ; or they may be flat, with transverse ridges and inverted 
edges, resembling a thickened and deformed nail. The circular rings which 
appear on the surface of these outgrowths have very much the same im- 
port as those seen on the horns of animals, marking the periods of growth. 
Horns may be single or multiple, and they vary in size from mere points, 
scarcely rising above the surface of the skin, to excrescences two or three 
inches in length. Several examples are recorded of these growths having 
attained colossal dimensions. The most remarkable of these was reported 
Fig. 2030. 
Fig. 2031. 
Horns growing from the nose and face. 
Section of a horn, showing its laminse. 
by Prof. Cevallos, in which the horn had three distinct branches and measured 
at its base fourteen inches in circumference.* 
These excrescences exhibit a notable preference for the face (Fig. 2030) 
* Remarkable cases of corneous growths are also reported by Aldrovandus, De Thou, Bartholin, 
Planque, and others. See Medical Repository, 1820. 468 
SURGICAL AFFECTIONS OF THE SKIN. 
and scalp, regions which are rich in sebaceous follicles; but other parts of the 
body are not exempt. 
A section of one of these horns (Fig. 2031) exhibits the laminated or strati- 
fied arrangement of its layers, the laminae consisting of flattened, closely 
impacted and joined epithelial cells. 
These laminae never desquamate: hence, though at first soft, pliable, and 
translucent, they eventually become hard, unyielding, and opaque. When 
the horns drop off, as occasionally happens, a depression is left, lined with a 
delicate fibrous membrane and sheath, in direct relation with the subjacent 
papillae of the corium, the two constituting the true reproductive matrix, 
from which another born soon grows. 
Horns form in both sexes alike, and at all ages, but are most frequently 
met with in elderly persons, and are to be regarded as an evidence of struc- 
tural degeneration occurring where the architectural force which determines 
the orderly disposition of parts has been weakened, and. having lost its 
governing influence, allows these exhibitions of unlicensed activity. 
Treatment.—There are two methods of dealing with corneous growths. 
In one, the born is twisted or wrenched from its bed and the matrix de- 
stroyed by caustic potash ; in the other, the base of the horn and its matrix 
are to be included between two elliptical cuts and the whole growth excised, 
the edges of the wound being afterwards approximated by interrupted 
sutures. The latter plan, being both expeditious and efficient, should have 
the preference. 
Moles. 
Moles are round, oval, or oblong discolored spots or patches of skin, vary- 
ing in size from the head of a pin to several inches in extent, and frequently 
surmounted with either soft down-like or stiff bristling hairs. These for- 
mations are generall}r congenital, sometimes acquired, have a brown, gray, 
or chocolate color, and may occupy any portion of the surface. Frequently 
they are met with in such numbers as to suggest the idea of a genei’al con- 
stitutional causation. 
I was consulted a short time since by a lady on account of a mole which 
occupied the entire right side of the face, and which was covered with a heavy 
growth of long, dark hair. 
These spots consist in an hypertrophy of the derm with its papillae and 
hair-glands, with a deposition of pigment in the deep epidermic cells. 
Moles remain during life without causing any inconvenience, unless situ- 
ated at places where they are exposed to friction from the clothing, when 
they may become inflamed and ulcerate, leaving an obstinate and unhealthy 
sore. 
Treatment.—When causing no inconvenience, such a growth should be 
allowed to remain undisturbed, but when occupying a region where friction 
is unavoidable, or when commencing to grow, it is better to remove it writh 
the knife, including it between two elliptical incisions. The necessity for 
surgical interference in such cases arises from the known tendency of these 
growths to become the seat of carcinoma, especially of the melanoid form. 
Frequently the services of the surgeon will be solicited from motives of 
personal vanity; and when the discolored patch is covered with thick hair, 
and is conspicuous from its position, there can be no objection to an opera- 
tion, though, as a rule, operations of complaisance should not be encouraged. 
In one instance 1 removed, at one sitting, from the face of a lady, four moles, 
each of which had its crown of hairs; and in another case, of a young girl, 
a similar operation was performed, the mole extending from the zygoma 
nearly down to the base of the jaw, and measui’ing fully one inch in its 
transverse diameter. Its surface was covered with a strong growth of hair. 
When the removal of a mole is determined upon, excision is the proper 
procedure. Caustics, such as chloride of zinc, Vienna paste, and London 
paste, are capable of doing harm by the irritation which they produce. KELGID. 
469 
Large, redundant, pendulous folds of integument are sometimes seen, as 
a congenital affection, hanging from the neck, nates, and other parts of the 
body. They present nothing unusual or different 
in their anatomical composition from the healthy 
integument, and are inconvenient only from their 
bulk. There is another tumor, composed wholly 
of tegumentary elements, which is occasionally 
observed. This growth may exist singly or in 
numbers. It is generally pedunculated, the attach- 
ment being long and slender, and the body of the 
tumor lobulated (Fig. 2032), or the growth may 
be cylindrical and only slightly constricted near 
the base. At the University Hospital, in 1881, I 
removed a growth of this nature, nearly three 
inches in length, and as thick as the little finger, 
from the pubic region of a woman: she believed 
it to have been congenital. It grew with her 
growth, and became irritated by contact with her 
clothing, so as to induce her to seek relief by 
operation. 
Cutaneous Redundancy. 
Fig. 2032. 
Dermoid fibroma—From a case of 
Dr. Claudius Mastin. 
Keloid. 
Keloid is a bard, smooth, slightly elastic, cicatricial-looking outgrowth, 
of a pale-red or lilac color. The irregular, root-like prolongations or ex- 
tensions of the disease into adjacent parts, presenting some resemblance to 
the crab, have secured for it the name of keloid. The first intelligent de- 
scription of keloid was 
given by Alibert. The dis- 
ease commences ordinarily 
in a small dense nodule, 
extending its branches in 
different directions, the 
edges of which, however 
irregular, are always 
sharply defined. The sur- 
face of the growth, some- 
times smooth, and at other 
times wrinkled, is sensibly 
elevated above the level of 
the skin, and is somewhat 
rounded in its contour. It 
is not confined to any par- 
ticular part of the body, 
but the skin over the ster- 
num is possibly the favor- 
ite seat of the disease. 
There may be several 
patches of keloid, over the 
chest, arms, neck, and be- 
hind the scapulae. In a re- 
markable case which I saw 
in this city, occurring in 
a negro, a patient of Pro- 
fessor Gross the elder (Fig. 
2033), the growths occu- 
pied the front of the chest, the outer portions of the shoulders and arms, 
and the neck. They were of different shapes, some distinct, others running 
Fig. 2033. 
Gross’s case of keloid. 470 
SURGICAL AFFECTIONS OF THE SKIN. 
together, and all more or less elevated above the adjoining sound skin. On 
the neck the growths were particularly large, and surrounded this region like 
great ruffs or links of sausage. The man, at the time of observation, was 
over fifty years old, the disease having commenced when lie was quite young. 
Keloid is met with at all periods of life, and in both sexes. Negroes are 
believed to be more predisposed to the disease than other persons. 
The elements of the growth consist chiefly of connective tissue developed 
in the minute vessels of the corium, the fibres of which are massed into dense 
white bundles, which, instead of interlacing, run for the most part in parallel 
lines. 
Keloid, though sometimes arising spontaneously, generally follows some 
injury, such as a cut or a puncture, and is found also in the cicatrices following 
burns, scalds, and operations. I have seen it begin after excision of the 
female mamma, in the small cicatrices left by the sutures employed to retain 
in position the flaps of integument. The disease often commences in the 
perforation made in the lobe of the ear for ear-rings. 
The disease partly described by Dr. Thomas Addison in 1854, and styled 
Addison’s keloid, or morphcea, is altogether a different affection from the 
one under consideration, being an atrophic condition of the derm with cica- 
tricial hardening. 
When keloid is of traumatic origin, the duration of the period between the 
reception of the injury or wound and the appearanqe of the disease varies. 
I have seen it arise in the cicatrix of a wound a few weeks after healing had 
taken place; and in one case, after the removal of a growth from the pos- 
terior border of the scapula, the keloid characteristics appeared immediately 
after the union of the skin-flaps. On the other hand, months and even years 
may elapse before the disease develops. 
The progress of keloid is as variable as the time intervening between its 
appearance and the determining cause, the disease extending rapidly in one 
case and in another slowly ; or, after growing for a few years, it may remain 
stationary ever after. In the case of a little girl who was under my care for 
supposed spinal disease, and who had a keloid growth in the site of an old 
cicatrix behind the scapula, the disease appeared to be undergoing spon- 
taneous cure. 
Usually speaking, keloid is not inconsistent with the enjoyment of good 
general health. In only one instance, that of a medical student who had a 
keloid growth over the sternum, have I seen any tendency to degeneration 
or transformation into a tumor of difterent neoplastic elements. In this 
case the number of spindle-cells which were found after the excision of the 
diseased part appeared to ally the latter more closely to sarcoma than to 
keloid. 
Treatment.—I know of no treatment calculated to effect any benefit in 
cases of keloid. My experience in regard to operations does not differ from 
that of other surgeons. The growth has always recurred immediately after 
excision. Our duty will be best fulfilled by instructing the patient to guard 
against all local irritations, medicinal or otherwise. 
Two varieties of molluscum are described by writers,—namely, molluscum 
sebaceum and molluscum fibrosum. The sebaceous variety has its origin in 
an inflammation of the sebaceous glands, the cystic enlargement of which, 
acting as an irritant, provokes a circumscribed dermatitis or peri-folliculitis, 
which, being kept up for some time, results in the transformation of the 
surrounding embryonic cells into connective tissue, thus forming a hyper- 
trophic acne. Of this nature are the fleshy-looking masses covered with 
dilated tortuous vessels which often adorn the nose of the bon vivant. The 
other variety of molluscum, the one at present under consideration, is a dif- 
ferent growth, not deeply seated in the derm, and is made up of a succu- 
Molluseum Fibrosum. MOLLUSCUM FIBROSUM. 
471 
lent connective tissue whose materials are in different stages of develop- 
ment, ranging from the characteristic spindle-cell to the perfected fibre. 
Fig. 2034. 
Fig. 2035. 
Molluscum fibrosum. 
Molluscum fibrosum is often 
a transmitted affection. 
These growths occur both 
singly and in large crops, and 
they may be found upon any 
part of the surface of the 
body. The tumors differ in 
size, ranging from that of a 
small pea to that of a walnut. 
They vary as much in form 
as in size, being flat, round, 
and pyriform, and attached 
to the skin either by a sessile 
base or a narrow footstalk- 
like pedicle. (Fig. 2034.) To 
the feel the tumors are soft 
and unresisting, though occa- 
sionally a certain degree of 
elasticity can be discovered on 
pressure. The skin covering 
the molluscum remains un- 
changed in appearance, but is 
liable to undergo some thin- 
ning or atrophy from stretch- 
ing. The increase of the tumors is usually limited, the process of growth 
ceasing after the tumor has acquired a certain bulk. A remarkable example 
of molluscum fibrosum (Fig. 2035) was one removed by Professor Ford, of 
Augusta, Georgia, from a negro man. The growth was twenty-five inches in 
length, twenty-eight inches in circumference, and weighed eight pounds. A 
large number of small tumors were scattered over the body of the patient. 
Ford’s case of molluscum fibrosum. 472 
SURGICAL AFFECTIONS OF THE SKIN. 
The tumors are painless, and do not affect the general health; but when 
existing in great numbers, so as to assume the importance of a diathesis, 
they are likely seriously to disturb the nutrition and weaken the strength 
of the patient. 
Treatment.—Except when a molluscous tumor attains an unusual size (in 
which case it should be excised), such a growth may be allowed to remain 
undisturbed. If suspended by a narrow pedicle, or if it occurs on an exposed 
part of the body, the tumor may be clipped off with the scissors on a level 
with the skin, after which the stump should be touched with a crayon of 
nitrate of silver. If the patient is too timid to undergo this treatment, the 
pedicle may be strangulated with a thread. 
Neuroma Cutis. 
Dr. Dubring has described under tbe above bead an affection character- 
ized by tbe existence of numerous neuromatous neoplasms of different sizes, 
which have their primary origin in the true derm. At one place within the 
limits of the affected region these growths were solitary, and at another 
place grouped in large 
numbers (Fig. 2036), and 
not exceeding a small pea 
in size, having a smooth 
surface, and without any 
marked change of the 
overlying skin. The pain 
was paroxysmal and se- 
vere. During the attacks 
of pain the temperature 
of the affected side, which 
was always higher than 
that of the sound side, was 
increased two or three de- 
grees, and this rise was at- 
tended with a marked red- 
ness of the skin over the 
nodules. Mental worry or 
cold currents of air were 
sufficient, in the case given 
by Duhring, to provoke 
paroxysms of pain. Only 
two cases of this affection, 
up to the present lime, 
have been recorded,—one 
by Duhring and another 
by Kosinsld. In the for- 
mer the disease was seated 
over the arm and shoulder, and in the latter over the nates and thigh. The 
pain, which was one of the singular features of this variety of neuroma, did 
not come on until long after the appearance of the disease. 
The elements of the morbid growths in Duhring’s case consisted of non- 
medullated nerve-tissue imbedded in white and yellow connective tissue. 
The walls of the blood-vessels were thickened and surrounded with round 
bodies resembling lymph-corpuscles. (Fig. 2037.) 
This affection differs from the sensitive tumor we have already described 
both in position and in composition, for the sensitive tumor is a fibroma 
seated in the subcutaneous tissue, and is never observed in closely-aggregated 
groups. 
Treatment.—The treatment required in neuroma cutis is exposure and 
excision of a piece of the nerve-trunk the branches of which lie within the 
Fig. 2036. 
Neuroma cutis. ELEPHANTIASIS ARABUM. 
473 
affected region. This operation was done in Kosinski’s case with decided 
Pig. 2037. 
Microscopic appearance of neuroma cutis. 
relief from suffering, a portion of the sciatic being removed; but in Duhring’s 
patient neurotomy was less successful. 
Elephantiasis Arabum—Boucnemia Tropica—Barbadoes Leg. 
There are two diseases, quite unlike in their character, described under 
the name of elephantiasis,—namely, elephantiasis Graecorum and elephanti- 
asis Arabum. The first is what in the East is known as true leprosy, while 
the second is the disease called Barbadoes leg, or Cochin leg. 
Elephantiasis Graecorum is commonly a hypertrophic tuberculated affec- 
tion of the derm, generally appearing on the face and extending into the 
mouth, larynx, nose, and eyes. The disease causes great deformity of the 
features. When ulceration occurs, the destruction is not limited to the soft 
parts, but extends to the bones. The disease is incurable. 
The confusion which has existed in the description of several cutaneous 
affections common in Eastern countries no doubt originated to some extent 
in the assumption that the term leprosy was employed to designate a spe- 
cific disease. Under the Mosaic economy the word had a ceremonial as 
well as a medical signification, and in both was used in a generic sense to 
cover a number of skin affections. Similar confusion may also have arisen 
from the Arabian physicians confounding the terms elephantiasis and leprosy, 
when translating the Greek of Hippocrates. 
Elephantiasis Arabum, of which we propose more particularly to speak, 
has a certain geographical importance, being quite rare in this country, and 
also in Great Britain and on the Continent, but very common in many Eastern 
countries, as Egypt, Syria, India, China, and Japan, as also in Norway, the 
West India Islands, and South America. The disease exhibits a partiality 
for certain portions of the body, particularly the legs, scrotum, and foreskin 
of the male, and the genitalia of the female. Though occurring in both 474 
SURGICAL AFFECTIONS OF THE SKIN. 
sexes, males suffer more frequently than females from the disease. Of 945 
cases of elephantiasis seen at Travancore by Fayrer, 716, or 75.77 per cent., 
were males, and 24.23 per cent, were females. The growth often attains an 
enormous bulk, weighing in many instances from thirty to seventy-five pounds. 
Preceding the local enlargement there is often some febrile disturbance, 
followed by redness, tenderness, and cedematous swelling of the affected 
part. These 83Tmptoms subside and again return, and with each recurrence 
the parts are left increasingly thickened and hard, the induration extending 
into the subcutaneous connective tissue. The enlargement is generally uni- 
form; that is, if a lower extremity is attacked, the entire limb will be in- 
creased" in size. The hypertrophic changes which succeed the steady progress 
of the now chronic dermatitis and cellulitis produce different external ap- 
pearances. In some instances the surface of the affected part is thrown 
into folds, ridges, or wrinkles of hypertrophied skin, with deep intervening 
fissures or furrows. (Fig. 2038.) This condition answers to the glabrous 
form of the disease. Instead of 
ridges, and sometimes in addition to 
them, the cutaneous papillae become 
enormously enlarged, when the sur- 
face will be covered with wart-like 
elevations,—the elephantiasis verru- 
cosa of Virchow and other writers; 
while in a third variety these papil- 
lary eminences may attain such co- 
lossal magnitude as to merit the ap- 
pellation of tubers, — elephantiasis 
tuberosa. There is also a naivoid 
form of elephantiasis, congenital in 
its origin, which exhibits very much 
the same surface-peculiarity as is 
seen in the warty variety,—namely, 
a knotty, wrinkled appearance; but 
in this variety the subdermoid con- 
nective tissue is interpenetrated with 
large, thin-walled venous channels. 
This was very much the character of 
a large scrotal elephantiasis removed 
by the late Professor John Neill from 
a patient in the hospital of the Uni- 
versity of Pennsylvania. With the 
increase in size, weight, and rugose 
or nodulated character of the part, 
the skin generally grows darker, may bo covered with epidermic scales, 
and is deprived of sensibility. The tuberculated prominences may undergo 
ulceration resulting in unhealthy sores. The pain attending the disease is 
sometimes annoying, but in many cases merely a dragging sensation is com- 
plained of. In such cases the chief inconvenience experienced comes from 
the weight and bulk of the tumors, which may render walking, or even 
standing, a difficult task. 
In attempting to discover the mysterious etiology of elephantiasis, a subject 
on which little light has been thrown, some writers have located the cause 
in the veins (Wise), some in the arteries (Carnochan), and some in the lym- 
phatics ; some regard the disease as a form of and others as the 
result of malarial poisoning. Of the 51 cases reported by Osgood, of Foo- 
chow, only one was certainly known to have no malarial history. On the 
other hand, Heffenger states that the disease is very common in the Samoan 
Islands, which are high, rocky, and of volcanic formation, and on which 
periodical fevers are unknown. 
When the hypertrophied part is cut into, the derm is found to be extremely 
Fig. 2038. 
Elephantiasis Arabum of the leg. ELEPHANTIASIS ARABUM. 
475 
dense, white, shining like a fibroma, and greatly increased in thickness, with 
colossal papillary outgrowths surmounted by a rough and thickened epidermis. 
The subcutaneous connective tissue, in its normal state soft, fleece-like, and 
pliable, with open spaces and widely intersecting fibres, is wholly changed, 
being massed into a dense, unyielding substance, consisting of fibrous tissue 
in various stages of development, and differing from a fibroma in having 
a certain amount of yellow connective tissue in its composition. It is also 
traversed by large veins, the mouths of which remain patulous when divided, 
from the inelastic nature of the material to which their walls are adherent. 
The nerves which are seen in the midst of the new formation, except in 
being somewhat altered in form by compression, do not materially differ 
from the normal type. 
There can be little doubt that a diffuse chronic dermatitis, of an ery- 
sipelatous character, is an important factor in the hypertrophic alterations 
of structure which constitute so notable a feature of the malady. That 
oft-recurring or prolonged inflammations of the derm of a subacute type 
and hypertrophic thickening of the skin stand in relation to each other as 
cause and effect is an undisputed pathological fact, but in what the antece- 
dent factor which determines the inflammatory development consists is far 
from being disclosed. That the lymphatics cannot be excluded from some 
participation in the changes present in elephantiasis is evident, as in all cases 
of the disease there is great engorgement of the lymph-spaces and lymph- 
vessels, the latter being dilated and many of their trunks converted into 
fibrous cords. This condition of the connective-tissue lymph-spaces explains 
the accompanying oedema. In addition to the above changes, there is also 
marked increase in both the vascular and the connective-tissue elements of 
the diseased part. The most plausible theory which can be constructed from 
the morbid anatomy observed in elephantiasis is one which regards the pri- 
mary disease as having the nature of a lymphangitis. On this supposition 
we have a ready explanation for the lymph-stasis, the dilatation of the lymph- 
vessels and spaces, and the multiplication of tissue-elements from the result- 
ing inundation of cell forms. By some writers the inflammatory excitant is 
believed to be the presence in the lymphatic vessels of a pai'asitic worm, the 
filaria sanguinis hominis.* 
Diagnosis.—Many cases of enlarged limbs are regarded as instances of 
elephantiasis which, except in the fact of bulk and the presence, per- 
chance, of a few cutaneous wrinkles or perhaps warty eminences over the 
feet, are wanting in the true characteristics of the disease. These cases 
are examples of lymph-oedema or of papillary dermatitis, and, while in some 
measure allied to elephantiasis Arabum, are lacking in the general diffused 
hardness, the deep furrows, and the pigmentation which belong to the latter 
affection. 
Prognosis.—Elephantiasis rarely terminates fatally. The disease continues 
to increase without apparently affecting the general health, and the new 
growth attains a size which may ultimately disqualify the patient for loco- 
motion. It is not uncommon for the tumor to grow to a certain size and 
then remain stationary, giving no further annoyance for a long time. 
Treatment.—The treatment of elephantiasis is very unsatisfactory, con- 
sidered from either a medical or a surgical point of view. Benefit, no doubt, 
may be obtained, when the inflammation assumes a spasmodic activity (in- 
dicated by increased heat and pain in the part), by adopting an antiphlo- 
gistic course. This should comprise local blood-letting, irrigation, elevation 
of the part, and the free use of tincture of iodine and laudanum, with com- 
pression,—the pressure to be made either by an ordinary or an elastic roller. 
Internally, iodide of potassium has been recommended as an alterative and 
sorbefacient, but its use is attended with little benefit. 
Among the surgical measures useful in the treatment of elephantiasis are 
* Dr. Heffenger considers the habits of the natives of Samoa, of sitting and sleeping upon a damp 
gravel floor, as a factor in the causation of the disease. 476 
SURGICAL AFFECTIONS OF THE SKIN. 
excision, amputation, ligation of the main arterial trunk supplying the hyper- 
trophied portion, compression, and nerve-section. 
The first two operations are necessarily attended with profuse hemorrhage, 
and therefore more than ordinary preparations should be made for its con- 
trol. (See Elephantiasis Scroti, vol. ii. p. 521.) Of 51 operations for elephan- 
tiasis in China, analyzed by Osgood, all are said to have recovered. Fayrer 
reports 193 cases operated on in Calcutta, at the College Hospital, from 1859 
to 1871, with a death-rate of 18 per cent. 
Ligation.—Dr. Carnochan, of New York, believing the disease to depend 
on too large a supply of blood, introduced the practice of ligation. In accord- 
ance with this theory, this surgeon tied the femoral artery in three cases of 
elephantiasis of the leg, the first in January, 1851. The success which followed 
these operations had the effect of inducing other surgeons to repeat the pro- 
cedure. Since that time the vessel has been ligated a large number of times 
by different surgeons, among whom may be mentioned Bryant, of London; 
Campbell, of Philadelphia; Butcher, Buchanan, and Alcock, of Scotland; 
Fayrer, of India; Fischer, of Hanover; and McGaw, of Detroit. 
I have seen two cases treated by ligation, but both were unsuccessful.. 
Compression.—A number of cases successfully treated by arterial compres- 
sion have been reported.- By this measure the same end is obtained as by 
ligation, the immediate object aimed at being the diminishing of the supply 
of blood to the hypertrophied tissues. 
Nerve-section.—In the case of a negro man, aged fifty years, admitted to the 
Pennsylvania Hospital for elephantiasis of the right lower extremity,—the 
left subsequently becoming affected (the patient having previously under- 
gone a ligation of the femoral artery without success),—Dr. Morton excised 
a portion of the right sciatic nerve. (Fig. 2039.) The operation was fol- 
lowed by a rapid diminution in size of the limb, the enlargement around the 
Fig. 2039. 
Morton’s case of elephantiasis. 
calf in seven weeks being reduced from twenty-three to eleven inches in cir- 
cumference. The effect of the operation was very striking, independent of 
the rapid decline in the size of the limb, as it was followed by an extensive 
epidermic desquamation, the skin, previously rough and wrinkled, becoming 
as smooth as that of a child. This patient some time after the operation 
was attacked by pleuro-pneumonia, and later by deep-seated suppuration in 
the opposite limb. The chest-trouble terminated in catarrhal phthisis, from 
which he died about five months after the section of the nerve. There was 
no reason for supposing that the nerve-section had any connection with the 
pulmonary disease. 
After a careful summary of the different plans of treatment, only excision 
or amputation appears entitled to confidence; though the entire safety of corn- SCLERODERMA. 
477 
pression should secure for it, in cases of elephantiasis of the lower extremity, 
a trial before resorting to the removal of the limb. 
The fatality attending operations would seem to be insignificant. Out 
of 60 cases operated on in China for scrotal elephantiasis during the fifteen 
years immediately preceding 1876, all recovered. Dr. Osgood, of Foochow', 
reports 51 similar operations, all without a single death; and Dr. George A. 
Turner, of the Samoan Islands, records 138 operations for scrotal elephan- 
tiasis Arabum, all the cases recovering save two, one of which died of diar- 
rhoea and one of fever. 
Scleroderma. 
This affection, so designated from the hardened state of the skin, is a form 
of dermoid atrophy of inflammatory origin, in which the connective and 
elastic tissue-elements alone of the skin are increased and condensed. The 
skin, for some extent, gradually becomes rigid, inelastic, immovable, and hard, 
and were it not for the gradual manner in the local evidence of disease 
fades away into the adjacent parts, the affected skin might be likened to 
some foreign substance which had been set into the surrounding parts, like 
a piece of mosaic. The inflammatory changes are of a chronic nature, and ex- 
tend to the subcutaneous, connective, and adipose tissues, the latter of which 
is finally absorbed. The atrophy extends to the blood-vessels, nerves, skin,— 
papillae and epidermis,—and in time to the bones. The disease, most com- 
monly, is seated on the face, neck, shoulders, or breast. The deeper changes 
are often succeeded by bullae and ulcers upon the diseased surface. 
The etiology of the disease is involved in obscurity. In some respects it 
presents characteristics which point to a nervous origin. 
The progress of scleroderma is not uniform. The disease sometimes stops 
spontaneously, and at other times continues throughout the life of the indi- 
vidual ; and in a few instances it has ended fatally.j 
The treatment which has been found useful is one calculated to modify 
both general and local nutrition. Cod-liver oil is often employed to advan- 
tage, as also arsenic. Oleaginous applications may be used, together with 
massage and electricity. 
Eiloid. 
Dr. John C. Warren, of Boston, has described a tumor w'hich, from its 
form resembling the coils of an intestine, has been named eiloid. Its exact 
nature has not been determined. It occurred on the neck of a young colored 
woman, appearing at the commencement as a small elevation, which finally 
enlarged until it formed three large rolls each four inches in length. The 
tumor resembled in appearance a portion of inflated intestine, and was un- 
attended by redness, heat, or pain. The growth, which was probably sarcoma, 
was removed, but shortly after returned. 
Framboesia—Yaws. 
Framboesia, or yaws, is a contagious affection of the skin peculiar to tropi- 
cal climates. It is quite common in the West Indies, and commences in the 
form of tubercles, papules, or tumors or small yellow or white spots, which 
gradually enlarge, projecting from the skin in the form of red, spherical, 
translucent bodies, resembling red currants. The tubercles have a regular 
surface, are covered with epidermic scales, and undergo ulceration. The 
disease exhibits a marked predilection for some parts of the face, for the 
genital organs, and for the extremities. 
The treatment consists in a rigid attention to cleanliness and ventilation, 
the use of nutritious food with chalybeates, and the local employment of 
carbolic acid washes and ammoniated mercury ointment. 478 
SURGICAL AFFECTIONS OF THE SKIN. 
The morbid growths which are met in the skin are both malignant and 
benign. The malignant neoplasms are epithelioma, sarcoma, melanosis, 
scirrhus, and encephaloma. The benign growths are cystoma and myoma. 
TUMOItS OF THE SKIN. 
Malignant Neoplasms. 
The epitheliomatous form of carcinoma will be treated of under the head 
of tumors in general. 
Sarcoma.—Sarcoma of the skin commences as a small nodule or shot-like 
body imbedded in the derm, having a smooth surface, is elastic, somewhat 
sensitive and even painful to the touch, the superincumbent skin being dull 
red, purple, or violet-colored. The tumors may be single or multiple. Some 
contain considerable pigment. Multiple sarcoma of the pigment variety, when 
present, is said to occur with singular uniformity on the feet. The disease, 
like sarcoma in other regions of the body, exhibits little tendency to infect 
the lymph-glands, but becomes generalized through the blood-vessels, and, 
unless removed before such diffusion takes place, will destroy life. The 
tumors sometimes undergo ulceration, and discharge a very unhealthy and 
offensive sero-sanguinolent fluid. 
Immediate extirpation offers the only chance of life to the patient. 
Melanosis.—Melanosis of the skin may easily be confounded with pig- 
mented sarcoma. Many of the cases which are recorded as melanotic are 
probably sarcomatous. The disease often appears simultaneously at different 
points of the body, the skin over the abdomen being a favorite seat for these 
tumors. In a patient whom I saw with Dr. Markley, of Montgomery 
County, in addition to numerous masses of the disease over the above-named 
region, a similar growth existed within the abdomen. These tumors, when 
developed in the skin, have a firm feel, are slightly movable, quite painful 
to pressure, and present a deep-blue or black color. 
When the disease appears in the multiple form, operations are not to be 
thought of; nor should they be recommended under any circumstances when 
there is not a reasonable prospect that the incisions can be carried into sound 
tissue. Even when removal is practiced early, and the neoplasm appears to 
be circumscribed, recurrence is the rule, and death the final result. 
Scirrhus.—Scirrhus of the skin is much more common as a secondary than 
as a primary affection. The latter form commences as a pale spot, having a 
firm, unyielding consistence, somewhat rough on the exterior, and crossed by 
one or many straggling vessels. With the usual invasive tendency of other 
malignant growths, the disease pushes its way in all directions. The invasion 
of the subdermoid connective tissue renders the growth, at first movable, more 
fixed, and at length destroys the derm and forms a foul, irregular, walled 
ulcer with everted edges, having no tendency to heal, but rather inclining to 
enlarge its boundaries. The discharges from the sore are thin, ichorous, and 
offensive, and the pain shooting or lancinating. When scirrhus of the skin 
is secondary to the disease elsewhere, as frequently occurs in carcinoma of 
the mammary gland, it may be seen and felt in the skin in the form of 
small, hard, round nodules. Their presence is an indication highly unfavor- 
able to operation, since they give evidence of a generally poisoned state of 
the fluids and solids of the body. Not only is the tendency in cutaneous 
scirrhus to destruction of the parts adjacent to the ulcer, but there is a dis- 
position to the establishment of new foci of disease in the lungs, liver, and 
other internal organs, and as a result the general health fails, the patient 
becomes sallow and loses flesh and strength, and finally dies from irritation 
and exhaustion. CUTANEOUS PARASITES. 
Little more can be done than to alleviate pain by administering anodynes, 
at the same time sustaining the system with food and resisting the destruc- 
tive action of the disease on the blood by the use of iron and arsenic. 
479 
Encephaloma.—Encephaloid carcinoma, like scirrhus, is rarely seen as a 
primary affection. Its first appeai’ance is not distinguishable from cutaneous 
scirrhus, the nodules being hard. In a short time, however, the distinction 
is revealed by the softening which takes place in the tubercles, and by their 
ulceration and the granulations which shoot up and furnish an unhealthy 
blood-stained discharge. 
In secondary encephaloma the local neoplasms appear as in primary 
cancer, and follow the same destructive course. 
When primary, extirpation by the knife may afford a respite from the 
disease, though its return will be more than probable; but when secondary, 
no benefit whatever can be expected from excision. 
Benign Neoplasms. 
Cystoma.—The sebaceous tumors so frequently met with in the skin must 
be regarded as retention cysts rather than as neoplasms. They are formed 
from the sebaceous glands of the skin; and wherever these simple follicles 
abound, tumors—wens, as they are often called—of this nature are common. 
For this reason the scalp is a favorite site for sebaceous cysts. 
Their formation is readily understood. The excretory duct of the gland 
becomes obstructed, either from an inspissated condition of its contents or 
from inflammatory causes. The function of the gland continuing, its walls 
become distended by the accumulated secretion, which finds no way of escape. 
To withstand the internal pressure, a slow inflammatory addition of new ele- 
ments, similar to those already present, is made to the wall of the gland, 
and in this way the follicle gradually assumes the importance of a tumor. 
For a more detailed account of the anatomy of sebaceous cysts, see the 
chapter on Tumors. 
Excision is the only satisfactory method of treating sebaceous cysts, the 
operator taking care to remove the cyst-wall, as otherwise the tumor would 
in all probability be reformed. 
Myoma.—Small, moderately firm myomatous growths, not exceeding a pea 
in size, and sensitive only on pressure, are occasionally seen imbedded in the 
derm. The skin covering these neoplasms has a purple or lilac appearance. 
These tumors are often regarded as sensitive fibromata, but when exam- 
ined microscopically are found to consist wholly of smooth muscular tissue, 
or both muscular and fibrous tissue, the former preponderating to an extent 
which would ally the neoplasm with myomata rather than with fibromata, 
the former component being developed from the muscles of the skin. 
Excision constitutes the remedy. 
The skin frequently offers a habitat for both vegetable and animal para- 
sites, the presence of which gives rise to great irritation. 
The parasitic affections which the surgeon is often called to treat, and 
which I will speak of in this connection, are the tinea circinata, or ring- 
worm, the chigoe, and the Guinea-worm. 
CUTANEOUS PARASITES. 
Tinea Circinata—Ringworm.—Tinea circinata is one of three forms of dis- 
ease produced by the same vegetable fungus, the trichophyton. This fungus, 
under the microscope, is seen to have a mycelium of finely-jointed threads 
and spores, which, coming in contact with the skin, penetrates between the 
epidermic cells, and grows in different directions, creating irritation and 480 
SURGICAL AFFECTIONS OF THE SKIN. 
producing an inflammatory patch of skin, which often has a circular or gyrate 
figure. This patch is very itchy, and is surmounted with minute vesicles 
or papules, and the rupture of these and the desiccation of the contends form 
scales, which collect on the surface of the diseased spot. 
Any part of the body may be the seat of ringworm, but the face, neck, 
and hands, being most exposed, are the portions which commonly suffer. 
The treatment of tinea circinata involves a thorough change of clothing, 
or at least the cleansing of that worn by boiling and afterwards drying 
under a high temperature. The inflamed patches of the skin must next 
be thoroughly cleansed with hot water and scrubbed with resin soap, after 
which an ointment of ammoniated mercury should be rubbed into the part. 
The hyposulphate of soda in solution, or a lotion of the acetate of copper, 
is frequently used in this disease, also an ointment composed of bicarbonate 
of potash, lac sulphur, and ci*easote. 
Chigoe—Sand-Flea.—This insect, chiefly seen in the West Indies and South 
America, is a small flea, not larger than a millet-seed, and armed with a pro- 
boscis, with which it bores its way into the skin between the toes or fingers, 
or less frequently on other parts of the body. Having once secured a iodg- 
ment in its burrow, the animal, which is always a fecundated female, deposits 
its ova in large numbers, which give rise to much local irritation, inflamma- 
tion, and swelling, ending often in ulceration. On exploring the burrow, a 
spherical bladder or cyst the size of a pea will be discovered. This cyst 
contains the ova of the animal. 
The plan of treatment adopted by the natives, who suffer from the para- 
site, is to enlarge with a pointed instrument the orifice through which the 
animal enters, and to extract the vesicle without rupture. 
Guinea-Worm.—The Guinea-worm, Dracunculus, or Filaria Medinensis, is 
another of the plagues which infest the human body. This entozoon is a 
native mainly of Africa and Central Asia, but has spread to other countries 
through commercial intercourse. This worm, when fully grown, is of a 
white color, cylindrical in form, and somewhat thicker than a stout thread 
of silk, its tissues being strong and elastic. It measures from throe to six 
feet in length. The interior structure of the animal is quite simple, and it 
may be said to consist of a very small intestinal canal and a large uterus. 
The body of the parasite has only a single opening, and that is placed at one 
end. The young brood are spindle-shaped, and do not exceed in length one- 
fortieth of an inch. 
There is a difference of opinion in regard to the manner in which the 
Guinea-worm succeeds in securing a lodgment in the human body. Some 
authors suppose that, inasmuch as the animal in many instances is devoid of 
a special apparatus for boring, the entrance is made through a sebaceous 
follicle or a hair-follicle, while others, with at least equal plausibility, believe 
that the worm gains admission through the medium of drinking-water. 
After the entrance has been effected, the worm remains quiescent in the 
tissues for a number of months, during which time little inconvenience is ex- 
perienced by the patient. As soon as the embryos have matured they are 
discharged into the surrounding soft parts, and the animal, on completing 
this act of parturition, at once seeks to escape from its burrow. It is now 
that the local symptoms develop. The skin of the hand, face, neck, scalp, 
scrotum, or other parts lying over the parasite, becomes inflamed and 
swollen. The attack is attended with intense itching, and will end in sup- 
puration unless the latter is prevented by an early operation. The approach 
of the worm to the surface is disclosed by the formation of a circumscribed 
induration, which after a time undergoes suppuration and ulceration, and 
through the opening thus formed the head of the animal may be descried, 
the body being either coiled up into a little roll or lying straight in the 
tissues. BALDNESS. 
The treatment must be conducted with caution, so that the worm shall 
•not be broken during the process of extraction. The latter is effected in 
two ways,—either by seizing the head with forceps and gently drawing it out 
and turning it around a little roll of adhesive plaster, which can be used as a 
spool for winding the parasite out of its habitat (a process often requiring a 
long time to accomplish), or by the knife. The tough, elastic character of 
the worm will allow of its being stretched to some extent, but the utmost 
•care is necessary that it be not broken. Physicians residing in the worm- 
pest regions acquire, it is said, great dexterity in extracting these parasites, 
cutting directly down on the burrow and turning out its occupant entire at 
-once, when lying in a coil, or removing the worm by traction applied to the 
middle of the parasite when uncoiled. 
481 
AFFECTIONS OF THE HAIR. 
When the aid of the surgeon is solicited on account of hirsute abnormality, 
it is usually under circumstances in which there is a rank growth of hair on 
some portion of the face, as the upper lip or the cheeks, or where a piliferous 
tuft, conspicuous by its isolation, occupies an exposed part of the same 
region or surmounts a mole or nsovus. The surgeon is also often consulted 
in cases of alopecia, or of follicular disease. 
Redundancy of Hair.—When the growth is on parts not exposed to the 
-eye, or where it can be concealed from observation by the dress, it will be 
best to discourage operation. When concealment is not possible, and the re- 
dundant hair becomes a source of mortification, four plans for its removal 
are presented: by depilatories, by avulsion, by galvano-cautery, and by ex- 
cision. 
Depilatories have no other effect than to destroy the hair down to the 
level of the skin. Their caustic action does not extend to or destroy the 
hair-follicle, and consequently the growth reappears. These agents, how- 
ever, are useful, since their employment can be repeated from time to time 
and with entire safety. The depilatory which I am in the habit of using 
•consists of hydrosulphite of calcium one drachm, and prepared chalk two 
drachms. The powder is made into a thin paste with water and spread over 
the obnoxious hair. After allowing the material to remain about half an hour, 
the hair will be destroyed, when the paste may be removed by washing. 
When the hair-shaft is large and stiff, the depilatories, unless possessed of 
very active caustic properties, will fail to effect the purpose, and in using the 
more potent applications the skin may be injured. 
Avulsion consists in seizing the shaft of the hair close to the skin with flat- 
bladed forceps and wrenching it out, along with its matrix, by the root. As 
the follicle will generally remain after the operation, the plan has no advan- 
tage over depilatories, and has the disadvantage of being very painful. 
Galvano-cautery, or electrolysis, when judiciously managed, will insure the 
destruction of the hair, root and branch. A platinum needle, connected 
with one pole of a battery, is to be introduced along the shaft of the hair 
down to its bulb or papilla, when a moment’s completion of the circle will 
be sufficient to do the work. The plan is well suited to cases where the 
hairs to bo destroyed are not too numerous. 
Excision in many cases has an advantage over other plans of treatment. 
It is, in general, quickly executed, and when the incisions are carried down 
into the subcutaneous adipose tissue it is always successful in preventing a 
reformation of the hair. 
Alopecia, or Baldness.—Atrophic changes in the hair may occur either 
from wasting of the dermoid elements, from trophic and other disturbances 
of the nerves, from advancing age, or from various alterations of the blood 482 
SURGICAL AFFECTIONS OF THE HAIR. 
consequent upon syphilis, or erysipelas, or the exanthemata or other fevers. 
Occasionally the absence of hair is congenital. 
Baldness ordinarily begins on the superior or vertical portion of the head, 
a region where atrophy of the fatty and other anatomical components of the 
scalp first takes place. When the pilous papillae are lost, as in senile baldness, 
the reproduction of the hair is impossible. To entertain a different opinion 
would be as unreasonable as to expect a crop of grain where no seed has 
been planted: hence the folly of applying, under such circumstances, the 
poisonous nostrums which are so extensively used for baldness. Baldness is 
more common in males than in females. 
Baldness which comes after febrile attacks, erysipelas, and syphilis, is 
anatomically different from senile alopecia. In the former the falling of the 
hair is the effect of disturbed nutrition, without seriously implicating the 
organic mechanism from which the hair grows. Accordingly, after the 
elimination from the bod}7 of the morbific poison, the glands resume their 
function, and a new growth of hair follows. 
Premature baldness is exceedingly common in America. Though doubt- 
less due chiefly to constitutional rather than to local causes, yet I am dis- 
posed to believe that the stiff hair-brush so generally in use is in some degree 
responsible for the defect. 
Localized Baldness, Alopecia Areata, is another example of atrophic hair 
disease. It may occur on any portion of the body normally supplied with 
hairs, though the affection is usually confined to the scalp. The diseased 
condition may affect one or several portions of the scalp simultaneously or 
consecutively. It is both a congenital and an acquired affection. 
The disease appears as a patch of baldness varjdng in size from a ten-cent 
piece to a dollar, or even the palm of the hand. The surface of the skin is 
perfectly smooth, polished, and devoid of hairs, unless it may be a few soft, 
downy ones, which also in time disappear. 
The cause of alopecia areata is involved in obscurity, but it is difficult to 
conceive of an affection so entirely circumscribed, appearing in the midst of 
a thick crop of hair, without attributing to the nerves of the spot some 
agency in causing the disease. 
Vitiligo.—Under this name there is an affection of the cutis which may 
or may not be accompanied by change in the color of the hair. By this 
term both Hippocrates and Celsus described three different varieties of 
leprosy. It would appear not improbable that it was an affection of this 
nature to which Moses referred in Leviticus, chapter xiii. 
The chief characteristic of the disease is the appearance on the scalp or 
other parts of the body of one or more milk-white spots or patches of skin, 
completely decolorized, and sharply defined by a dark border of multi- 
plied pigment-cells. Vitiligo, though sometimes disappearing in the same 
mysterious manner in which it appeared, generally continues as a chronic 
affection, and is unattended by any other appreciable local or constitutional 
symptoms. In some cases a connection between vitiligo and Addison’s 
disease is supposed to exist. 
The treatment of alopecia will be determined by the nature of the causes 
concerned in its production. Much may be done both in premature and in 
senile baldness to preserve the hair, or at least to delay its falling, by prophy- 
lactic measures. Stiff brushes should be discarded, and coarse combs with 
blunt-pointed teeth substituted. To prevent accumulations of epithelial 
debris about the roots of the hair, the scalp should be cleansed two or three 
limes a week with a ver}?- weak alkaline solution (sodae bicarbonatis, gr. x, 
aquae Oss), followed by a stimulating wash of bay rum or alcohol, containing 
a very minute amount of bichloride of mercury, not exceeding one grain of 
the salt to one pint of the liquid, or a little carbolic acid may be added to 
the alcohol. Both of the preceding articles are excellent parasiticides, and AFFECTIONS OF THE NAILS. 
483 
therefore effectual in removing any source of hair-degeneration which may 
be due to the very common presence of low organisms, animal or vegetable. 
The diet ought to be plain, substantial, and nutritious; a sufficient number 
of hours must be allotted to rest, and due attention must be given to exercise 
in the open air. The head-dress should be light and well ventilated. 
Alopecia resulting from erysipelas or from exanthematous and other fevers 
requires onty time and the restoration of the general strength by food and 
tonics. The hair again grows in, often in undiminished luxuriance. 
Syphilitic baldness will in a great measure disappear under the use of con- 
stitutional remedies adapted to the disease, such as mercury and the alkaline 
iodides. 
Alopecia areata is not, in our present state of knowledge, much influenced 
by medication. Any local or constitutional defects which on careful inquiry 
can be discovered, and which might be supposed to have a causal connec- 
tion with the disease, should be, as far as possible, corrected. The remedies 
which have been employed most are tonics and alteratives, such as quinine, 
iron, arsenic, and strychnia. 
What is true of medicinal agents in the treatment of alopecia areata is 
equally true in vitiligo. No remedies can be said to exert any curative power 
whatever, although arsenic is often given empirically in this affection. 
Pityriasis Capitis is another disorder of the scalp, affecting in time the 
vitality of the hair-follicles, and causing the loss of the hair. It is character- 
ized by an accumulation of epithelial scales, commonly known as dandruff, 
which often falls in showers over the clothing. There is also some attendant 
itching of the scalp. 
Pityriasis is a parasitic affection, depending on the presence of a vegetable 
organism, discovered in 1847 by Malassez. The spores of the fungus pene- 
trate into the superficial epidermic layers, and enter a little distance into the 
hair-follicles, not beyond their communications with the sebaceous glands. 
The rapid proliferation and desquamation of the cells constituting the dif- 
ferent epithelial layers, which form so prominent a feature of the disease, are 
ascribed to mechanical irritation from the presence of the parasite. 
The remedies employed in the treatment of pityriasis are first cleansing 
the scalp with an alkaline wash, and afterwards rubbing into the skin an 
ointment composed of ammoniated mercury with a little carbolic acid. 
Plica Polonica, or Polish plait, is the nama given to a tangled, matted, un- 
kempt condition of the hair, for the most part endemic and confined to the 
filthy inhabitants of Poland and Tartary. The secretion which glues to- 
gether the hair is dark and viscid, emitting an offensive odor, and is the 
product of inflamed and hypertrophied hair-follicles and sebaceous follicles. 
The treatment consists in first clipping and then shaving the hair from the 
head, softening and cleansing the surface of the scalp with hot carbolated 
water-dressings, and afterwards rubbing into the parts an ointment consisting 
of carbolic acid in mercurial and sulphur ointments. 
AFFECTIONS OF THE NAILS. 
The nails are the subject of various alterations in structure and appear- 
ance, the result of mechanical, chemical, and constitutional causes. 
Wounds.—Sharp-pointed bodies, as splinters, fragments of broken glass, 
and other substances, are frequently forced beneath the nails of the fingers 
and toes, and, coming in contact with the extremely sensitive matrix, produce 
great pain and suffering. The position of these foreign bodies is usually 
marked by a dark spot or line, visible through the nail, caused by the sur- 
rounding extravasation of blood. 484 
SURGICAL AFFECTIONS OF THE NAILS. 
The extraction of these bodies is accomplished without difficulty, after 
pressing the integument away from the nail, by seizing them with a pair 
of forceps the blades of which are somewhat flattened, and using a little 
tractive force. When the body is too deeply buried to be reached in 
this way, it should be exposed by an incision and removed through the 
opening, the patient being under the influence of an anaesthetic. After 
the extraction the parts may be covered with a lotion of lead-water and 
laudanum. 
Wounds of the nails never unite. The injured structure is removed by 
growth from the matrix, and the mutilation disappears. This is not the 
case, however, in longitudinal divisions. Where the separation extends up 
into the matrix, or entirely through the nail, a rough longitudinal groove 
will continue corresponding to the original injury. 
Avulsion of the nails.—The forcible tearing away, in its enth’ety, of a 
nail, is not an uncommon accident. Should the matrix escape unharmed, 
the ungual appendage will be reformed, although the new structure is liable 
to be less perfect than its predecessor, being often rough, wrinkled, or 
stubby. 
Constitutional conditions frequently determine alterations in the growth, 
appearance, and structure of the nails. An arrest of growth in these cu- 
taneous appendages of paralyzed limbs is among the ordinary phenomena 
observed in such lesions. Persons suffering from, or predisposed to, phthisis 
pulmonalis present an opposite condition, one in which the nails, in common 
with the phalanges, are strikingly hypertrophied. Individuals who, with- 
out any special organic imperfection, suffer from a general lack of life-force, 
often have, among other external marks of feeble health, brittle nails. The 
same condition may arise during any severe or protracted illness and again 
disappear with returning health and strength. The white cicatricial maculae* 
which are often seen through the nails in the ungual matrix are said to be 
pathognomonic of advanced constitutional syphilis. Favus and other para- 
sitic diseases tend to cause irregularity, thickening, and discoloration of the 
nails. 
Operatives engaged in various manufacturing industries, such as dyeing 
and the preparation of drugs, furnish numerous examples of nails deeply 
stained with pigments, or deformed from the action of irritants on the 
matrix. 
There is reason to believe that the dirt which so easily collects beneath 
the free extremity of nails often contains organic matters capable of com- 
municating infection, so that it may be said that a surgeon who is indif- 
ferent to cleanliness in this particular carries at the ends of his fingers 
something vastly more dangerous to the life of his patient than the keen 
edge of a bistoury. 
Matrixitis—Onychia—Inflammation of the Ungual Matrix. 
Matrixitis usually selects one of the fingers, the thumb, or the great toe. 
It is introduced by redness and swelling, commencing at the root of the nail 
and extending upward for a short distance. It is accompanied by pain. 
In a short time a little crack, fissure, or ulcer appears at the cutaneous bor- 
der of the matrix, through which is discharged a thin, ichorous pus. The 
inflammation, lingering for some time at the root of the nail, at length 
travels forward along the lateral and subungual portions of the matrix, the 
infiltration of the latter with that of the adjoining skin forming a circular in- 
duration from which is derived the popular name of the disease, “ run-round." 
The ulcei’ated surface enlarges in the same dh’ections, has an unhealthy ap- 
pearance, and discharges an irritating watery fluid. The nail becomes dis- 
colored and deformed, and often loosens and drops off. The skin, which at 
the commencement of the inflammation was red, becomes purple or livid, and 
the swelling and induration enlarge their boundaries. The affected finger CORNEOUS GROWTHS. 
485 
or toe becomes bulbous in form and much larger than the natural member. 
(Fig. 2040.) Matrixitis may be caused by a slight scratch, bruise, or pinch 
of the skin at the root of the nail; sometimes 
by a dissecting wound in the same locality. 
Some writers ascribe to it, in almost all cases, 
a general or constitutional origin, the out- 
come of scrofulosis or inherited syphilis. When 
occurring under puberty, as is often the case, 
a causation of the above nature in many in- 
stances is more than probable; but that the 
disease is in any sense peculiar to the young, 
or that a general diathesis is necessary for its 
existence, does not accord with my observa- 
tion, for I have seen the affection with equal 
frequency among children and adults, among the weak and sickly and in 
strong, robust servant-girls. The last case of onychia which I saw was 
in the person of an aged gentleman of this city remarkable for his health 
and vigor. 
Treatment.—In the very commencement of matrixitis the application of 
a couple of leeches immediately above the nail will have a good effect in 
lessening the inflammatory symptoms. The finger should be buried in hot 
poultices of flaxseed-meal for three or four days, the parts being thoroughly 
washed before each renewal of the poultice with a mixture consisting of 
equal parts of tincture of iodine, tincture of belladonna, and tincture of 
opium, or with a two per cent, solution of bi’omine, or with chlorinated soda. 
After the inflammation has been measurably controlled by the preliminary 
treatment detailed, the ulcerated surface may be dressed by sprinkling over 
it a little powdered iodoform, covering it with a piece of absorbent cotton or 
lint, and encasing the end of the member in a shield of muslin, or surround- 
ing it with two or three adhesive strips. The nitrate of lead, first recom- 
mended, I believe, by Dr. Edward Hartshorne, of this city, I have used with 
decided benefit, the powder being sprinkled thickly over the ulcer. Mer- 
curial ointment, citrine ointment, and a mixture composed of arsenious acid 
and glycerole of starch (acidi arseniosi, gr. i, glycerol, amyli, 50 have all 
been recommended, and in obstinate cases should be tried. Touching the 
ulcerated surface with dilute nitric acid will sometimes prove a valuable al- 
terative, causing the sepai’ation of the necrosed cellular tissue from its base 
and sides and inducing healthy granulations.. When the nail is entirely ne- 
crosed, and is loosely adherent to the matrix, it often acts as foreign matter, 
keeping up inflammation and progressive infiltration of the adjacent parts. 
In this condition it should be removed. 
When there is sufficient reason for believing that matrixitis is symptomatic 
of a general cause, constitutional remedies must not be withheld. Cod-liver 
oil, iodide of iron, and, in cases of syphilitic origin, iodide of potassium and 
mercury, are the most reliable remedies. 
Fig. 2040. 
Ulcerative matrixitis of the finger. 
Fig. 2041. 
Fig. 2042. 
Corneous Growths, having a rough, irregular surface, frequently spring 
Corneous growth from the matrix. 
Exostosis of the last phalanx of the great toe. 486 
SURGICAL AFFECTIONS OF THE NAILS. 
from the anterior part of the matrix and protrude beyond the nail. (Fig. 
2041.) These horny productions are caused by some injury to the matrix, 
and are met with on the toes and beneath the nail of the thumb. 
When continuing to grow, they should be excised. 
Exostosis.—An outgrowth of bone is sometimes seen cropping out from 
beneath the nail of the last phalanx of one of the toes (Fig. 2042) or fingers. 
This sometimes succeeds cases of chronic matrixitis, though occasionally 
arising from causes entirely undetermined. 
The treatment of phalangeal exostosis consists in the excision of the bony 
mass. When the attachment of the growth is broad, it may be necessary to 
remove with it the entire phalanx. 
The great toe is often the seat of a troublesome ulceration due to in- 
curvation of its nail, the edges of which, pressing against the flesh, cause 
inflammation, swelling, and, finally, ulceration. Fungous granulations spring 
up, overlapping the sides of the nail, the discharges from which are un- 
healthy and fetid. The inflammatory swelling of the toe frequently ex- 
tends beyond the limits of the ulceration. The soreness attending the 
disease often renders it impossible to bear 
tbe pressure of a shoe. (Fig. 2043.) 
The inversion may aifect both toes simul- 
taneously, or one only may suffer. Yery 
young children are sometimes the subjects 
of the affection, though the greatest number 
of cases are observed among adults, and the 
disease occurs in women more often than in 
men. 
The causes of incurvated nail are three- 
fold,—namely, narrow and tightly-fitting 
shoes, paring the corners of the nails too 
closely, and the accumulation of desquamated 
epidermis under their edges. 
Treatment.—To prevent ingrowing deformities of the nails, some atten- 
tion ought to be given to the manner in which they are pared, observing not 
to round the corners, but to cut away the redundant part by a transverse 
straight cut. The outer edges should also be kept free from collections of 
epithelial debris. 
In order to correct the incurvation and thereby relieve the integument 
from pressure, various methods have been devised, as follows: 
1. Scraping a longitudinal gi-oove a short distance from the inverted margin 
of the nail, with a view to weaken its structure, and then with a blunt, chisel- 
shaped insti’ument carefully inserting some absoi’bent cotton beneath the in- 
curvated edge, so as to l’aise the latter, at the same time pressing the flesh 
or granulation-tissue away from the nail. A little patience and some deft- 
ness of manipulation will often succeed in effecting a cure. When intro- 
ducing the cotton, it is not to be expected that at the first attempt the dossil 
will in all cases be placed beneath the edge of the nail its entii'e length; but 
this l'esult will follow at a second or third di’essing, during which additional 
small pieces of cotton will be made to follow the first. Previous to each 
application the feet should be soaked in hot water. 
2. Pi-essing the flesh away from the nail and pouring into the space be- 
tween the two tissues a little melted tallow. 
3. Cutting away the redundant flesh at the border of the nail and sur- 
rounding the toe with a strip of adhesive plastei*, in order to repress the 
subsequent gi*anulations. 
4. Removing by excision the incuiwated boi*dei-s of tbe nails, after ether- 
Incurvated Toe-Nail. 
Fig. 2043. 
Toe-nail ulcer. WHITLO W. 
487 
izing the patient. This is best done by first separating the matrix from 
the root of the nail, either with the handle of the scalpel or a curette, at a 
point corresponding to the portion to be removed, and then with a pair of 
sharp scissors, one blade being thrust under the nail, cutting the latter to its 
root. By seizing the inverted portion with the dressing forceps, it can be 
easily wrenched from its bed. The subsequent dressing will consist of a strip 
of lint moistened with carbolated oil wrapped around the toe and secured by 
a narrow roller. Two days after the operation the dressing will require to 
be removed, and, as it will adhere very tightly to the parts, considerable pain 
will be saved the patient by covering the toe, six or eight hours previously, 
with a flaxseed poultice. This will have the effect of softening the lint, and 
after a little soaking in warm water its detachment can be accomplished 
without the least difficulty. The original dressing can be repeated daily until 
the toe is well. 
5. The plan which I prefer, and which answers in most instances of in- 
verted toe-nail, is a very simple one. A 
piece of cork is cut into the shape repre- 
sented in Fig. 2044. The sharp, hook-like 
edge is passed into the groove between 
the nail and the flesh, and made fast to 
the part by carrying a piece of adhesive 
plaster around both the cork and the toe. 
(Fig. 2045.) A few renewals of the dress- 
ing will soon reduce the redundant gran- 
ulations, or flesh, to their proper level, 
and remove the painful pressure of the 
nail. The addition of a plate of tin metal 
to the convex surface of the cork will 
render it still more efficient. 
When all the usual measures fail to 
correct the vicious incurvation, it will be 
best to remove the entire nail and pre- 
vent its reformation, since in all proba- 
bility a new nail would be as deformed as its predecessor. The matrix should 
be destroyed either by caustic potash or by being dissected away with the 
knife. The evils said to follow this radical procedure I have never witnessed 
in a single case. 
Fig. 2045. 
Fig. 2044. 
Cork for inverted 
toe-nail. 
Cork applied. 
Whitlow—Paronychia—Felon, 
Few affections are more painful than whitlow. The inflammation is 
almost invariably seated in the thumb or one of the fingers, and may be 
limited to the skin and subcutaneous tissues, or may extend to the tendons, 
periosteum, and bone. 
Whitlow occurs in women more frequently than in men: it is a disease of 
adult and advanced life, being rarely seen in persons under puberty. 
Though the cause is sometimes traumatic, as when a digit is bruised by 
pressing against the head of a blunt-pointed pin, yet, the subjects of the in- 
flammation being persons who from their occupation are obliged to have 
their hands much in hot and in cold water, such as washerwomen and house- 
servants generally, it is quite probable that an influential factor in causa- 
tion is the maceration of the skin, together with sudden and frequently- 
repeated alternations of heat and cold. There are seasons also in wdiich 
paronychia assumes the importance of an epidemic. Boils and carbuncles 
often prevail with a like frequency, and between these affections and felons 
there is in some respects a similarity. 
The inflammation of whitlow is at first attended with tenderness of the 
part, a dark-red, leaden, or mottled color of the skin, swelling and tension, 
and, finally, extreme throbbing or pulsating pain. The last-named symptom 
is particularly severe when the hand is allowed to remain pendent. The 488 
WHITLOW. 
reason for the pulsatile character of the pain is found in a peculiarity of the 
terminal vessels of the fingers, the arteries retaining their original size, in a 
great measure, to the extreme ends of the digits, and hence at each contrac- 
tion of the left ventricle of the heart the blood is driven with unbroken 
force into these vessels. When the inflammation is seated in the skin and sub- 
cutaneous adipose and connective tissue, the swelling is usually diffused, in- 
volving the entire circumference of the finger, and the pain is not of a severe 
character. This of paronychia is most common about the sides of 
the nail, and when suppuration occurs the pus finds its way readily to the 
surface. When the inflammation is deep-seated,—that is, involving the ten- 
don, its sheath, and the periosteum,—the swelling and extreme sensibility to 
pressure will be chiefly confined to the palmar aspect of the finger by the 
limitations of the theca. The pain will be extremely severe and throbbing, 
and unless it receive timely relief the disease will destroy the bone; or it 
may travel back along the sheath of the tendons and invade the deep struc- 
tures of the hand, as the resistance of the overlying tissues prevents the 
products of the inflammation from finding their way to the surface. When- 
whitlow attacks the extremity of a finger, however superficial the disease 
may be at its commencement, there is a marked tendency for it to become 
deep and ultimately to destroy the phalanx. This is readily understood 
when it is remembered that there is no stratification of tissues over the 
ungual phalanges. 
The pain and swelling which attend whitlow may extend to the hand, 
often rendering the entiro arm helpless and causing tenderness of the axillary 
glands. 
In aggravated cases of the disease there are generally some symptoms of 
constitutional disturbance. The patient is hot and restless, has a full pulse, 
and complains of headache and pain or soreness in the back and in the limbs. 
Destruction of the tendons, necrosis of the phalanges, palmar abscess, and 
deformed, withered fingers are among the common results of neglected 
whitlow. 
Treatment.—While no affection can be more painful, or is attended with 
greater danger to the welfare of the fingers, none is more quickly or more 
effectually relieved when brought early to the attention of the surgeon. 
Yai’ious measures are frequently emplojmd with a view to abort the inflam- 
mation, such as painting the affected finger with tinctiu-o of iodine, or envel- 
oping it in strong mercurial ointment or in laudanum and lead-water. A 
popular domestic practice in cases of felon is either to pound the diseased 
finger or to subject it to parboiling. All such procedures are for the most 
part useless, and not without danger from the delay imposed by their employ- 
ment. The knife affords the only safe and reliable cure, and it must be used 
with promptness and boldness, laying the parts freely open by a long and 
deep incision down through the integument, sheath, tendon, and periosteum to 
the bone. Simple as is this operation, I frequently see patients who continue 
to suffer because the incision had not been properly planned,—that is, it had 
been made on the side or the back of the finger, and therefore external to the 
tendon and its sheath, when it should have been made exactly in the middle 
of the palmar surface of the digit. The knife should never be withheld 
under the impression that suppuration has not occurred. The incision should 
be made as soon as the nature of the disease is recognized, or whenever the 
dusky-red swelling and throbbing pain are present. 
After opening the whitlow, the finger should be enveloped for twenty-four 
or thirty-six hours in a hot flaxseed-meal poultice, after which the only 
dressing required will be a piece of linen wet with laudanum and water and 
covered with oiled silk. 
When the inflammation has been neglected until the bone has become ne- 
crosed, there remains only amputation or excision. When the last phalanx 
is the one involved, the latter operation should by all means be adopted, as 
by leaving the soft parts the length of the finger will in a great measure be MYCETOMA OF INDIA. 
489 
preserved, and the deformity prove trifling. When the proximal or inter- 
mediary phalanges have been destroyed in their entirety, amputation will 
be required. The surgeon must not, however, be premature in advising this 
operation, as it sometimes happens that only a small portion of the bone is 
damaged, and this injured part, after undergoing exfoliation, can be readily 
removed. It is better, therefore, before proceeding to radical measures, to 
wait until nature has defined the extent of the necrosis and has made some 
progress in the separation of the dead piece. The practice of enucleating 
the bone, under the impression that a new phalanx will be formed, will meet 
with little success, since the periosteum is often destroyed, sharing the same 
fate as the other deep structures of the finger. Should, therefore, the first 
or second phalanx be the diseased bone removed, and no new osseous granu- 
lations follow, the finger would prove both a deformity and an inconvenience. 
Unless, then, the periosteum is found to be sound, it is in vain to shell out the 
dead phalanx and allow the finger to remain, under the impression that 
another bone will be formed. 
Frequently after the cure of a whitlow, where the inflammatory infiltration 
has been great, there will remain a certain amount of thickening, with a 
leaden color of the skin and more or less stiffness of the finger. This con- 
dition will be relieved and the usefulness of the digit be restored by macer- 
ation in hot water, and subsequent kneadings, frictions, and motion. 
Delhi Boil of India. 
Delhi or Aleppo boil is described by Fayrer as a spreading soi’e, which, 
commencing as a papule, and followed by infiltration and induration of the 
skin, terminates in ulceration with fungous granulations. It is peculiarly 
intractable to treatment. 
The disease is thought to be infectious and capable of being communicated 
to man and the lower animals by inoculation with the specific cell-matter, but 
not with the pus from the surface of the sore.* The ulcerations are fre- 
quently multiple. While regarded by some medical officers of the Indian 
army as a parasitic disease, others, being unable to discover the parasite with 
the microscope,f refer it to the use of well-water highly charged with th3 
carbonate of lime, and to the effects of climate, it being most frequent during 
the most exhausting seasons; still others claim lor it a constitutional 
Why persons in other places drinking water containing a large amount of 
the same foreign matters should not suffer from the disease is not explained. 
The evidence which leads some writers to regard the affection as a variety 
of lupus is not sufficient. 
The treatment employed is both local and general. The first embraces 
thorough ablutions, the use of the hot iron to destroy the sore and establish 
a new and healthy action in the surrounding tissues, and (after the sloughs 
drop out) treating the remaining ulcers by stimulating and astringent appli- 
cations. 
Mycetoma is a disease which prevails endemically in many parts of India, 
particularly in the Bombay and Madras presidencies, where it was formerly 
known as hypertrophy of the foot, with diseased metatarsal bones.§ The 
earliest notice of this affection was by Dr. Colebrook|| and by Dr. 
though very little was known of its pathology until the appearance of a 
Mycetoma of India. 
* Practitioner, vol. xv. p. 264, and Lancet, April 28, 1877, p. 610. 
f Lancet, April 7, 1877, p. 487. 
j Lancet, June 2, 1877, p. 823. 
| Records of the Jamsetjee Jejeebhoy Hospital, February, 1846. 
| Madura Dispensary Report, 1848. 
f India Annals, No. xii., July, 1859, pp. 513, 514. 490 
SURGICAL AFFECTIONS OF THE GLANDS. 
paper by Dr. H. Vandyke Cai’ter, of London.* The foot is in almost every 
instance the part affected, although a disease of the hand, believed by some 
observers to be of a similar nature, has been noticed among fishermen and 
their families residing on the northeast coast of Scotland. 
Mycetoma is in a great measure confined to males. In Fletcher’s list of 26 
oases only 1 female appears, and in 114 cases collected from different sources 
there are but 4 females. 
All classes of the natives are alike liable to be attacked by this singular 
affection, but European residents are said to be exempt. 
Symptoms.—The foot is swollen to two or three times the normal size, the 
toes are widely separated, and the enlargement is limited by a sharply-defined 
line to the foot. The color of the skin remains unchanged, but it is studded 
over with tubercle-like prominences. Some of these remain unbroken, while 
others undergo ulceration, the ulcers having raised edges, and leading into 
sinuses which pass deeply into the structures of the foot. The discharge 
from the sores has a sanious appearance. The enlargement and swelling 
often do not extend farther back than the tarso-metatarsal articulations. 
The disease at length is followed by diarrhoea, probably from septic causes, 
which eventually wears the patient out unless operative measures are adopted. 
Pathology.—Mycetoma is regarded by Dr. Carter as a fungoid or parasitic 
disease. Berkley*}* describes the fungus as resembling a true o'idium, and 
names it Chiomyphi Carteri. The particles or masses which are always 
present in the diseased structures ax*e believed to be these fungi. The micro- 
scopic examinations made by Dr. G. R. Ballingallj; reveal lai’ge cells of differ- 
ent forms,—round, oval, and irregular. In some the cell-walls seem to consist 
of sevei’al layei’s, and are suiTounded by fungi consisting of long, irregular 
spicul®, some of which are detached, while othex*s are collected into tufts. 
In some cases all the earthy matter disappears from the bones, so that the 
knife cuts through these structures, meeting with little resistance. Some- 
times a few of the metatarsal bones are found extremely bax-d, while others 
are soft, and in other instances both the soft parts and the bones ai*e converted 
alike into a homogeneous, gelatinifornx substance. The muscles in some of 
the dissections made presented in appearance nothing unusual, though the 
bones were completely honeycombed. In all cases thei’e were present numer- 
ous minute tubercles resembling fish-i-oe l}*ing between the muscles, and 
extending from the bones to the skin. Nodules of the same material, often 
black in color, were also observed lying in the cavities of the carious 
bones. 
Treatment.—The only remedy is amputation, which proves uniformly 
successful if the operation is not too long delayed. Of 34 amputations done 
in Bellaxy, 30 wei*e successful and 4 died. At Guntoor 26 amputations 
wei’e made, all of the patients recovering, and at Cuddapah, of 4 similar 
operations, all succeeded. One hundi-ed and fourteen amputations for myce- 
toma of the foot, collected from diffei’ent sources, furnish 96 i*ecovei*ies, 12 
deaths, and 6 result unknown. That the disease is wholly a local one, and not 
likely to return in the l’emaining foot or to appear elsewhei*e, will appear 
from the statement of Godfrey, who followed the history of 22 individuals 
who had been opei'ated on,—8 of them from six to twelve years and 14 from 
two to five years,—and in none was thei’e any reappearance of the disease. 
Fletcher mentions the case of a man whom he saw twelve jTears after ampu- 
tation, and who was unusually sti’ong and vigoi'ous. 
Bronchocele—Goitre. 
The thyroid gland, an appendage to the vascular system, the function of 
which in the economy is very imperfectly understood, consists of two lateral 
* Transactions of the Medical and Physiological Society of Bombay, 1861, p. 104. 
f Intellec. Obser., 1863, p. 249. 
j Transactions of the Medical and Physiological Society of Bombay, New Series, vol. ii. ABSCESS OF THE THYROID. 
491 
lobes placed one on each side of the trachea, and connected across the latter 
by an isthmus, which lies in front of the two or 
three upper tracheal rings. (Fig. 2046.) 
The gland is enveloped in a strong fascia, and 
covered by the sterno-hyoid, sterno-thyroid, omo- 
hyoid, and sterno-cleido-mastoid muscles. The 
lobes by their outer borders are in close relation 
with the primitive carotid blood-vessels, and are 
supplied with blood from the superior, the in- 
ferior, and frequently the middle thyroid arteries. 
Congenital absence of the thyroid body was 
noticed in two cases by Curling,* a deposit of fat 
occupying the place of the gland. Beachf men- 
tions a case in which, at the age of twelve months, 
no gland could be found on dissection. Hyrtl 
has seen several instances of congenital absence 
of the isthmus of the thyroid. 
The thyroid body is frequently the subject of 
disease, becoming the seat of abscess, or of vas- 
cular, cystic, fibrous, calcareous, and carcinomatous hypertrophy. 
Fig. 2046. 
Enlarged fibroid goitre. 
Abscess.—Abscess of the thyroid is very rare. The only case of the kind 
which I have seen followed the introduction of a seton. Discon| mentions 
one instance in which chronic abscesses recurred three times, and ultimately 
so completely destroyed the cellular connections of the body that it finally 
protruded through one of the openings made to evacuate the pus and dropped 
out. Cowles§ furnishes a case of abscess following an acute attack of in- 
flammation in the gland. 
The symptoms of suppurative thyroiditis are swelling and fluctuation, 
preceded by tenderness and rigors. When the suppuration is deeply seated, 
it will be very difficult to discover the presence of pus, which can be de- 
termined with certainty only by using the exploring needle. Abscess of the 
thyroid, from the anatomical peculiarities of the gland, will become diffused 
rather than circumscribed. In the case which came under my own notice 
this was the character of the suppuration, and on account of this fact the 
body was largely destroyed. Dr. Oulmont mentions a case of fatal pyaemia 
following an abscess of the thyroid body. 
Superficial abscess may occur externally to the capsule of the gland, in the 
cellulo-adipose tissue between the thyroid and the skin, and be mistaken for 
abscess of the thyroid. The swelling of the superficial abscess, however, will 
be very much more prominent than it will be likely to become in thyroid 
abscess. Besides, there will be little or no rising-and-falling movement of the 
tumor during deglutition, which always occurs with enlargement located 
in the gland, by virtue of its fascial connection with the trachea. 
Treatment.—When the evidences of acute thyroiditis are present, threat- 
ening suppuration, the inflammation must be attacked by leeches, followed 
by anodyne and saturnine lotions applied over the gland ; by purgatives ; and 
by cardiac sedatives, such as tincture of aconite or veratrum viride. The 
practitioner should at the same time enforce a restricted diet. 
Gascoyen|| gives a case in which the inflammation ran so high as to termi- 
nate in sphacelus of the entire gland, followed by recovery. Leybert re- 
ports seven cases of a similar kind. When suppuration follows, the treatment 
will not differ from that proper in abscess elsewhere,—namely, evacuation 
of the abscess-cavity by puncture or incision. 
* Lancet, 1850, vol. ii. p. 25. 
f Medical Times and Gazette, May 30, 1874, p. 603. 
| Boston Medical and Surgical Journal, vol. xxviii. p. 15. 
} Ibid. 
|j British Medical Journal, February 12, 1876, p. 192. 492 
SURGICAL AFFECTIONS OF THE GLANDS. 
Vascular Enlargement.—There are two varieties of vascular enlargement 
of the thyroid body. The first is that generally known as Graves’s or 
Basedow’s disease, or, technically, exophthalmic goitre ; the second is called 
aneurismal goitre. 
Graves’s or Basedow’s Disease is characterized by an accelerated action of 
the heart and arteries, enlargement of the gland, and protrusion of the eye- 
balls. The disease is rarely seen before puberty, and is more common in 
females than in males. 
The etiology of the affection continues to be a subject on which authorities 
differ, some regarding the disease as due to anrnmia, some as due to disturbance 
of the menstrual function, others attributing it to hereditary influence, while 
a fourth class regard it as a neurosis. The last view accords with my own 
clinical experience. The last three cases of exophthalmic goitre which have 
been under my care—two females and one male—developed suddenly under 
the following circumstances. 
In the first case, that of a young woman, the disease suddenly appeared 
after her father had forbidden the visits of a lover. I advised that the girl 
be allowed to see her suitor as an essential part of the treatment. To this 
the father reluctantly consented, and this consent proved of more value than 
drugs; for after the embargo was removed the symptoms rapidly subsided, 
and the girl recovered. In the second case the patient was a young and 
handsome married woman, the disease commencing after an unexpected 
reverse in worldty circumstances. The third case was that of an ambitious 
young man, who, to make up lost time, had been taxing his mental power 
to the utmost degree, night and day, in order to pass with honor a final 
examination, the consummation of which was followed by the disease. 
Exophthalmic goitre occurs in both an acute and a chronic form. In the 
first, the enlargement of the gland takes place rapidly, and may subside in 
an equalty short time, and the patient may entirely recover. In the chronic 
variety, the approach of the disease is more gradual and the structural 
changes are more likely to be permanent. 
Symptoms.—The usual history of exophthalmic goitre is. first, palpitation 
of the heart, followed by a frequent pulse, ranging from one hundred to even 
two hundred per minute, and seldom, even in the most quiet mood of the dis- 
ease, falling below eighty-five or ninety pulsations. Soon a soft swelling of 
the entire thyroid body appears, accompanied by loud blowing sounds, heard 
on applying the ear, and with a distinct fremitus communicated to the hand 
when laid over the tumor. Last in order follows the abnormal prominence 
of the eyes, the mobility of the balls being diminished in proportion to the 
ocular protrusion, and the eyelids not moving up and down with correspond- 
ing movements of the eyes. 
The general or constitutional symptoms are increase of temperature, 
headache, and slight vertigo, with hysterical, sometimes epileptic, seizures. 
Anatomical changes.—The anatomical characteristics of exophthalmic goitre 
are enlargement and dilatation of the arteries of the gland, hyperplasia of 
connective tissue, and not unfrequently the formation of cysts. Within the 
orbit and behind the globe of tbe eye there will be found a considerable in- 
crease in the fatty components of the region, with fatty degeneration of the 
muscles of the ball and also of the ophthalmic artery. Within the eyes, 
when examined with the ophthalmoscope, the retinal veins are often seen 
enlarged and tortuous. Ulceration of the cornea has occasionally been ob- 
served. The iris remains unchanged, and the pupil normal. There are no 
sounds discovered which indicate valvular or other structural disease of the 
heart. 
Morbid alterations in the cervical ganglia of the sympathetic have been 
described which are believed to point to the nervous origin of the disease, 
—an opinion which has received the support of Trousseau, Traube, Reckling- 
hausen, Yirchow, and others. HYPERTROPHY. 
493 
Treatment.—The remedies employed in the treatment of ordinary cases 
•of thyroid hypertrophy are altogether unsuited to cases of the disease under 
consideration. Every cause of a mental or emotional nature which can be 
discovered should, as far as possible, be removed. Quinine, iron, and digi- 
talis are the agents which experience has shown to exert the best effects. 
Yeratria is sometimes used to lessen the frequency of the heart’s action, and 
benefit has been derived from the use of the constant galvanic current em- 
ployed for the same object, the negative pole being applied over the sympa- 
thetic nerve in the neck. All nerve-stimulants must be avoided, as tea, coffee, 
tobacco, and alcohol in every form. The diet should be chiefly farinaceous, 
with a moderate supply of meat and eggs. Temporary change of place, of 
scenes, and of all other surroundings will often effect good results. 
Cystic Hypertrophy.—In cystic enlargement of the thyroid thero is a new 
formation of glandular elements. The follicles enlarge, the epithelial cells mul- 
tiply, and by outgrowths, or a process of budding, the original gland-elements 
produce others. The follicles become hypertrophied and distended, forming 
small cysts, which by repetition enlarge the gland and give to it a honey- 
combed appearance, or several of these smaller cysts, either by continued ex- 
pansion or by the disappearance of the intermediate walls, may form larger 
ones ; and this process at length converts the en- 
tire body into a number of cells or cavities (Fig. 
2047) filled with a glairy or colloid fluid. Many 
of these cysts contain from one to twelve ounces 
of material. Cystic goitre, from being pene- 
trated in all directions by cavities and contain- 
ing a considerable quantity of gelatinous fluid, 
has generally a soft and fluctuating feel. Fre- 
quently the cells of the tumor are filled with 
blood derived from rupture of the vascular tufts 
which project into the dilated follicles. This blood 
in time becomes absorbed, leaving only the traces 
of its former existence. Crystals of cholesterin with fatty and caseous 
materials may also be present in the cavities of the gland. 
Fig. 2047. 
Cystic goitre. 
Fibrous Hypertrophy.—In this variety of goitre there is a new formation 
of interlobular and interfollicular connective tissue, which 
by encroaching upon the vesicles ultimately causes their 
destruction from pressure of the glandular elements, and 
substitutes fibrous tissue. (Fig- 2048.) Goitres of this 
kind are recognized by their great firmness or hardness 
of texture. Sometimes there is such a combination of 
connective-tissue hyperplasia and cyst-formation in the 
tumor as to secure for it the name offtbro-cystic goitre. 
Fig. 2048. 
Calcareous Hypertrophy.—This variety of goitre is gen- 
erally a transformation, either from the cystic, fibrous, 
or fibro-cystic varieties, by calcification or a deposit of 
lime-salts. A cartilaginous form might also be recog- 
nized, were any practical advantage to result from such 
a division. The calcareous hypertrophy can be distin- 
guished, when the deposition is considerable, by the 
bony hardness of the tumor. Kebbel* reports a case of calcification so hard 
that a saw could with difficulty be passed through it. 
Fibrous hypertrophy of 
the thyroid. 
Aneurismal Hypertrophy is a condition in which the capillaries and small 
arteries of the gland become greatly dilated, while the vessels of larger size 
not only undergo similar dilatation, but also become exceedingly tortuous, 
* Lancet, 1877, vol. ii. p. 125. 494 
SURGICAL AFFECTIONS OF THE GLANDS. 
giving rise to strong pulsation and blowing bruits in the tumor. There is 
frequently a calcareous element mingled with the vascular constituents of 
aneurismal goitre. 
When the new elements which increase the magnitude of the thyroid are 
equally distributed through its substance, the enlargement will be general and 
the surface of the tumor uniform (Fig. 2049); if confined to one lobe, it will be 
partial or lateral; and when occurring 
in separate and distinct parts of the 
gland, the growth will be lobulated. 
Geographical considerations.—Goitre, 
though not at all uncommon in this 
country, has less geographical signifi- 
cance here than in many other parts of 
the world. The disease is more com- 
mon in the Northern States and in the 
mountainous districts of New England 
than in the South or West. In man}’’ 
places goitre prevails as an endemic. 
In England, Derbyshire, Surrey, and 
Nottingham are the localities which 
furnish the largest number of cases. 
In certain parts of Switzerland, Savoy, 
and the Tyrol there are villages in 
which almost all the inhabitants have 
goitre. It prevails in Piedmont, and is 
met with in all the deep valleys of the 
Alps, Apennines, and Pyrenees, about the foot-hills of the Cordilleras, at some 
points on the Rhine, as at Schlettstadt, and at St. Aubin, Rosieux, and other 
places in France. It is said that in France alone there are not less than 
500,000 persons suffering from goitre. The disease is frequently associated 
with cretinism. In Piedmont and Savoy, according to the official reports, the 
number of individuals so affected is 22,371. 
According to Dr. Hachine, in the government of Irkoutsk, which is drained 
by the Lena and its tributaries, there were, in 1870, 3400 subjects of goitre 
and 161 cretins. In some villages twenty-five per cent, of the people were 
goitrous. Goitre was not known in Siberia previous to the Russian conquest. 
Its introduction into the country is ascribed to the habit of the Russians of 
living in closely-heated and filthy rooms. The Siberians, who are much in 
the open air, do not suffer from the disease. 
Causes.—Various causes have been assigned for the production of goitre, 
such as the use of snow-water and lime-water, the absence of sunlight, the 
presence of malaria, etc. 
With regard to the use of snow-water, it may be stated, on the authority 
of Captain Gerard, that in certain parts of the Himalayas the inhabitants 
are compelled for several months of the year to drink snow-water, and yet 
goitre is less common among these people than among those who live on the 
damp foot-hills of the same region. In Sumatra, where snow is never seen, 
goitre prevails to a considerable extent. As to the injurious effect of lime- 
water, Humboldt noticed that at Maroquita, where the water flows from a 
granite formation, enlargements of the thyroid were unusually common; and 
I may add that in the Pequea and Conestoga Valleys of Pennsylvania, where 
the water is heavily impregnated with lime-salts, goitre is exceptionally rare. 
It cannot, however, be doubted that there does exist a connection between 
the disease and certain occult peculiarities of climate and soil. From the 
geographical study of goitre in England, made by Professor Labour, of New- 
castle, it would appear that calcareous soils alone have little to do with the 
causation of the disease, but that when such soils are impregnated with 
ferruginous and earthy salts the conditions are present which favor the 
formation of goitre. 
Pig. 2049. 
Symmetrical goitre. AFFECTIONS OF THE THYROID. 
495 
Goitre may be among the late productions of syphilis. In a patient of 
my own not only was the tumor to be referred to a cause of this kind, but 
on a number of occasions, during some new manifestation of the consti- 
tutional vice, the gland would undergo sudden and alarming enlargement, 
resuming its former bulk under the use of large doses of iodide of potassium. 
Several writers have noticed very marked disturbances in the nutrition 
of the thyroid body from causes connected with both menstrual irregulari- 
ties and utero-gestation. Cases of acute enlargement of the thyroid gland 
have been observed between which and pregnancy there seems to have been 
some connection. Roberts* has reported three cases of this nature, all of 
which were developed in primiparse and all terminated fatally from 
What connection exists between the uterus and the thyroid body to explain 
the sudden increase of the latter is not known. We know that between the 
parotid gland and the testis there is a sympathetic relation, through which 
testitis or epididymitis may arise as a sequel of mumps. Thyroid hyper- 
trophy as a result of utero-gestation is not more singular. The fatality 
attending the complication increases very much the surgical interest of the 
affection. 
All these phenomena are probably due to the communications which exist 
between the uterine, pneumogastric, and cervical sympathetic nerves. 
Diagnosis.—Enlargements of the thyroid can be distinguished from other 
cervical growths by the position of the swelling, situated as it is on both 
sides of the trachea, and especially by the tumor obeying the movements of 
the larynx and trachea in deglutition. 
Aneurism.—When the hypertrophy is great, the lateral lobes of the gland 
will often overlap the carotid vessels. The pulsation of the arteries commu- 
nicated to the enlarged mass might lead to the error of supposing the case 
to be one of aneurism, but the absence of bruit and of centrifugal expansion, 
and the rising and falling of the gland in deglutition, will enable the observer 
to eliminate the idea of aneurism. 
Malignant growths originating in the remains of the thymus gland or in 
the bronchial glands occasionally make their appearance on the front of the 
neck, above the steimum, encroaching on the thyroid region. The history 
of these neoplasms will be sufficient to prevent them from being confounded 
with goitre. The former, when first appearing as a cervical tumor, are seen 
emerging from behind the sternum at a point some distance below the thy- 
roid region, and very soon make their presence and serious nature known 
by distressing dyspnoea and impairment of the health from neoplastic gen- 
eralization. In one case, reported by Markham,f an enlarged thymus, weigh- 
ing two and a quarter ounces, had become blended with a bronehocele. 
Cysts 'occasionally are met with directly over the thyroid body. Their 
median position, their definition of outline, and at the same time the fact of 
their allowing a certain degree of movement without affecting the mass of 
the gland, are features calculated to lead to a correct diagnosis, though no 
decisive steps of an operative character should be undertaken without first 
using the grooved needle. 
A sacculated or varicose dilatation of some part of the venous system at the 
root of the neck, either the internal jugular and the subclavian or the trans- 
verse vein, has been seen projecting into the supra-sternal fossa; but it is very 
improbable that a soft, bluish swelling, partly concealed by the sternum, 
and rising and falling with the acts of inspiration and expiration, as would 
probably be the case, could be mistaken for goitre. 
Enlarged lymphatic glands may also form a tumor on the front of the neck, 
simulating bronehocele. In cases of this nature, careful inquiry will usually 
disclose a history showing that the tumor was on its first appearance lateral,— 
that is, entered the median cervical region from the inner edge of the sterno- 
cleido-mastoid, along which muscle a chain of lymph-glands are found. 
* American Journal of the Medical Sciences, October, 1876. 
f Medical Times and Gazette, May 1, 1858, p. 464. 496 
SURGICAL AFFECTIONS OF THE GLANDS. 
There will, in all probability, be other evidences of the character of the 
swelling in similar enlargements of contiguous glands belonging to the 
same class. Another differential sign will be the mobility of the tumor 
during deglutition, whether it be formed from a central or from a lateral 
lymph-gland. 
Prognosis.—With regard to the probability of a cure, we may say that 
the tumor in young subjects is generally very manageable, either disappear- 
ing under proper treatment or remaining stationary, with little tendency to 
increase. In adults, and more especially in old persons, goitre is much less 
under the control of drugs than in young persons. The structural altera- 
tions of the gland undergone in these cases are of a nature too fixed and 
stubborn to be greatly influenced by remedies. Seldom, however, are cases 
encountered where life is seriously imperiled by the disease. Only in a single 
instance, and that in a patient far advanced in life, have I seen death occur 
from causes fairly attributable to bronchocele; though a number of cases can 
be found scattered through surgical literature wThere a fatal termination took 
place from pressure of tho growth upon the trachea, causing suffocation. 
Dickinson* records a case of this kind, where death was occasioned by as- 
phyxia. Bryant gives a case of acute enlargement of the thyroid in a young 
man of nineteen years, which, notwithstanding tracheotomy was performed, 
proved fatal. Two fatal cases occurred in the Pennsylvania Hospital, one a 
man aged forty years, and the other one aged eighteen years. In both the 
disease assumed an acute form, death being attributed to the effects of press- 
ure, causing dyspnoea, and finally suffocation. 
Lennox Browne, in offering an explanation for dyspnoea, w'hich, without 
serious stenosis of the trachea, sometimes causes death, attributed the as- 
phyxia to the absence of the ordinary action of the tracheal muscles. A 
more rational solution of the problem, it appears to me, might be found 
in the pressure to which the pneumogastric and recurrent laryngeal nerves 
are exposed from a large growth like bronchocele. Professor Rose has shown 
that in many instances the pressure from an enlarged thyroid body induces 
fatty degeneration of the cartilaginous rings of the trachea, leaving only a 
membranous tube, the sides of which, from a sudden bend of the neck or 
from acute enlargement of the gland or from pressure of any kind, are easily 
forced together, causing suffocation. This condition would explain the sudden 
deaths which have sometimes occurred in goitrous subjects. 
The croaking or stridulous voice which often accompanies great enlarge- 
ment of the thyroid body is due to pressure on the recurrent laryngeal nerves, 
rather than to compression of the trachea. Paralysis of the vocal cords has 
been seen to arise from the same cause. 
Treatment.—The treatment of goitre is conducted on both medical and 
surgical principles. 
The medical management of a case must be determined by the age of the 
patient and the character of the growth. When the individual is young and the 
enlargement not far advanced, and before the new elements of the gland have 
reached a stable form of tissue, or before the follicles have become much en- 
larged, the disease can be attacked with the greatest confidence of success. 
Every cause, physical or emotional, which is calculated to excite the circula- 
tion, must be avoided. A moderate and rather restricted diet should be pre- 
scribed, and a gentle action kept up upon the bowels by tho daily adminis- 
tration of a small dose of some saline cathartic. Three or four days of a 
preparatory treatment of this kind will open the way for the use of iodine, 
the best preparation of which is the compound (or Lugol’s) solution. From 
eight to fifteen drops of the liquid, according to the age of the patient, may 
be given in a little sweetened water, three times a day, one hour after meals, 
and the remedy must be continued until signs of atrophy in the gland begin 
to appear, after which the same preparation should be continued in slightly- 
diminished doses. The use of the fiuid extract of ergot at the same time 
* Lancet, 1801, vol. ii. p. 12. GOITRE. 
497 
will prove a useful adjuvant to the iodine. When the disease shows some 
reluctance to yield under internal treatment, local inunctions should be em- 
ployed,—the best ointments for this purpose being the biniodide of mercury, 
the iodide of lead, and the iodide of ammonium. Monat, of Bengal, found 
the best results to follow the use of biniodide of mercury. The discutient 
should be rubbed into the enlarged gland for not less than twenty minutes 
«very day, or until the skin becomes irritated, when it should be suspended 
for a short time, or until the tendency subsides, and then resumed. The 
inunction should be done either before an open fire or in a good sunlight. 
When goitre in an adult has existed for some time, the most that can be 
promised from medical treatment is a temporary arrest in its growth, or 
possibly a cessation of growth, the tumor remaining in a state of unchanging 
hypertrophy. 
The physician is often deceived in the treatment of soft goitres, which may 
slowly grow less, at the same time assuming a greater degree of density. The 
attendant may interpret the change as due to the action of remedies, when it 
is really the result of a gradual transformation of the cystic into the fibrous 
form of the disease. 
Operative Measures.—The operative plans of treatment embrace injec- 
tions, the seton, ligation of the thyroid arteries, tapping and injecting, in- 
cisions, electro-galvanism, mixed methods, and extirpation. 
Injection.—By this plan, introduced by Stoerck, of Vienna, in 1872, differ- 
ent substances are introduced hypodermically into the interior of the hyper- 
trophied gland, such as tincture of iodine, perchloride of iron, concentrated 
preparations of ergot, and alcohol. The instrument employed for the pur- 
pose is the ordinary hypodermic syringe. The amount of the above-named 
substances to be injected at one time is, of tincture of iodine, eight or ten 
drops; of Squibb’s fluid extract of ergot, ten to twenty minims; of alcohol, 
five to eight drops; and of perchloride of iron, ten to twelve drops. The 
injections should be made into different parts of the tumor, and at intervals 
of three, four, or five days. This method of treatment succeeds best with 
soft or cystic goitre, though it has been used in hard or fibrous cases of the 
disease.* In a case of very large soft goitre for which I advised repeated 
injections of tincture of iodine, a complete cure was effected. Watsonj* 
reports a case of cystic goitre which at the time of writing was decreasing 
under the use of perchloride of iron by injection. The same surgeon suc- 
cessfully treated a second case, in which a blood-cyst of the gland was present, 
and which had existed twelve years and was attended with great dyspnoea. 
The perchloride of iron was injected in the fatter instance after the tumor 
had been tapped and the fluid drawn off.j; 
The object in employing injections is to induce a grade of inflammation 
which, instead of going on to suppuration, shall result in the obliteration of 
the cavities of the gland by a new formation of connective tissue both within 
and between the walls of the cysts. 
Seton.—The seton is an ancient means of treating goitre, dating back to 
the time of Celsus, but revived by Dr. Quadri, of Naples, in 1824. Of 7 
cases treated by Quadri§ with the seton, 1 was reported cured and 6 de- 
creasing. Hutchinson|| reported 2 cases cured by this plan. Kennedy*[[ cured 
1 after two years, and Spanton** reports a case in which the use of the seton 
was followed by hemorrhage, requiring its removal six days after introduc- 
tion and the application of the ligature to the left common carotid, the patient 
dying from septicaemia. Cheliusff gives another case treated by the seton, 
which at the time of the report was undergoing gradual decrease. Morton, 
* British Medical Journal, October 26, 1867, p. 375. 
f Ibid. 
j Medical Times and Gazette, September 29, 1866, p. 342. 
| Medico-Chirurgical Transactions, vol. x. p. 18. 
|| Chapman’s Journal, vol. iii. p. 421. 
f’ Dublin Quarterly Journal of Medicine, 1847, vol. iii. p. 271. 
** British Medical Journal, July 17, 1875, p. 88. 
ff Lancet, 1835-36, p. 253. 498 
SURGICAL AFFECTIONS OF THE GLANDS. 
in a case of thyroid hypertrophy admitted into the Pennsylvania Hospital,, 
introduced a seton, which was followed by cure. 
Of the above 13 cases, only 3 are certainly known to have been cured. In 
Hutchinson’s cases the lives of the patients were jeopardized by an attack 
of erysipelas, and in Spanton’s case death was the result. The operation,, 
therefore, is not one meriting pi’ofessional sanction. 
Ligation of the thyroid arteries.—This operation, executed by Mr. Blizzard,, 
consists in exposing and tying the superior and inferior thyroid arteries. It 
was supposed that by cutting off the supply of blood the size of the gland 
would be reduced from inanition. The names associated with this operation 
are those of Blizzard, its originator, Walther, Jameson, Brodie, and Chelius. 
The last-named surgeon* ligated the left superior thyroid artery in one 
case, and in another both vessels. The success attending these operations was 
not of a character to induce a repetition of it by any one at the present time. 
Tapping and injection.—Bryant,j* in a case of cystic goitre which had ex- 
isted six years, effected a cure by tapping and injections of tincture of 
iodine; and EdwardsJ has cured by a similar plan a case of sero-sanguineous 
cyst of the gland of twelve years’ standing, which had caused very trouble- 
some dysphagia, dyspnoea, and impaired voice. 
A modification of this method has been advised by Mackenzie,§ of Lon- 
don, with a view to bring on suppuration,—namely, by tapping the cysts, 
drawing off the contents, and injecting through the canula, which is allowed 
to remain, a solution of perchloride of iron, repeating the injection every two 
or three days until suppuration is established. Out of about fifty cases treated 
by this plan, only one is reported to have resulted fatally. 
Incision.—Free incisions have also been made into these tumors. A case 
treated in this way by Liston|| resulted in permanent cure. A goitre incised 
under the care of was reported as decreasing, and a third, operated 
on by Hewees,** died from hemorrhage. The risks attending this method are 
too great to warrant its repetition. 
Another plan was to make a small incision into the gland sufficiently large 
to admit a pair of dressing forceps, with which the interior of the body was 
crushed in various directions, so as to effect its thorough disorganization. 
Caustics have been employed in different ways for the cure of bronchocele. 
Turner,ff after making a slough in the integument over the l>37pertrophied 
gland with caustic, introduced a director and broke up its interior structure. 
Two cases treated in this manner resulted in cure. Ollier opened the cyst 
by incision and applied to its interior nitric acid and other cauterizing agents. 
Antiseptic dressings and free drainage were afterwards maintained. 
A third mode of using caustics is by means of caustic arrows prepared 
from the chloride of zinc, and thrust into the gland in order to produce 
sloughing and destruction of the substance of the tumor. 
Electrolysis has been applied to the treatment of goitre. As yet there are 
not a sufficient number of cases on record to determine the value of tliifr 
agent. Smithsucceeded in curing a case by galvano-puncture (constant 
current) after repeated tappings and injections with iodine had failed. A 
second case was treated by Pooley,§§ but the patient died shortly after, 
whether from the remedy or from the disease is not stated. 
In cases where, from sudden swelling of the thyroid body, a patient is 
threatened with suffocation, several courses are open to the choice of the sur- 
geon. If the symptoms are not urgent, the local abstraction of blood and 
the administration of a cardiac sedative, such as veratrum viride, will be suf- 
ficient to give the required relief. Should these measures fail and the dyspnoea 
* Lancet, 1835-36, pp. 252, 253. f Lancet, 1861, vol. i. p. 137. 
f Lancet, 1864, vol. i. p. 666. § Lancet, May, 1872. 
|| Lancet, 1844, vol. ii. p. 189. 
Medical Times and Gazette, February 23, 1867, p. 193. 
** British Medical Journal, January 18, 1879, p. 84. 
ff Medical Times and Gazette, January 20, 1855. 
jj Medical Record, vol. x. p. 534. §§ Medical Record, vol. iv. p. 498. become alarming, laryngotomy or tracheotomy may be demanded. It has 
also been advised under circumstances of obstructed breathing from sudden 
hypertrophy of the thyroid to divide freely the deep cervical fascia which 
covers in the gland, or, what is better, to perform the operation of Sir Dun- 
can Gibb, which consists in exposing the isthmus of the gland and dividing it 
after ligation on eaeh side. In a case where the surgeon deems it necessary 
to remove muscular resistance by operation, division of the sterno-hyoid and 
sterno-thyroid muscles will be equally important with division of the sterno- 
cleido-mastoid. 
In sudden enlargements of cystic or vascular bronchoceles threatening 
asphyxia, a trocar and canula should be thrust into the gland, the canula being 
allowed to remain for some time : the discharge of blood and other liquid con- 
tents will lessen its size and diminish tracheal or nerve pressure. A hare-lip 
suture will control the bleeding after the removal of the canula. 
When ti-acheotomy or laryngotomy is performed to relieve dyspnoea, a soft, 
flexible gum tube should be passed some distance into the trachea, in order 
to ascertain if there is any collapse of the walls of the air-tube, such as would 
follow fatty metamorphosis of the rings of the tube. 
Extirpation.—Extirpation of the thyroid gland should be undertaken only 
when other means of treatment have been exhausted, and only then when 
the dyspnoea is growing progressively worse and the danger to life becoming 
imminent. In removing the thyroid an incision should be made over the 
median line of the tumor, commencing below the chin and terminating at the 
top of the sternum. Should the tumor be very large, it may be necessary to 
make a second incision transversely or at right angles with the first. The flaps 
of integument being reflected, the superficial and deep cervical fasciae are 
next to be raised and divided in the median line, on a director, taking care to 
tie or to secure by serres-fines any vessels which may bleed freely. The cap- 
sule of the gland having now been exposed, the surgeon carefully separates it 
with the fingers from the deep fascia and the sterno-hyoid and sterno-thyroid 
muscles on each side, until the superior and inferior thyroid arteries are 
reached. These vessels are now to be separately ligated, after which the 
capsule of the thyroid may be opened, and the gland carefully enucleated 
from its bed, partly by the fingers and partly by clipping with the scissors 
any bands between the tumor and its capsule which may oppose their sepa- 
ration. As far as possible, all vessels should be tied before being divided, 
otherwise the progress of the operation will be delayed and obscured by the 
bleeding. At this stage of the procedure, if the hemorrhage is free and 
comes from many different points, it will be best not to stop in order to tie 
individual vessels, but to proceed with all possible expedition to get behind 
the tumor and raise its sides from the trachea, when a needle armed with a 
strong double ligature should be passed through the isthmus or pedicle, and 
each half of the included tissue tied separately. The hemorrhage being in 
this manner prevented, the growth can be leisurely cut away a sufficient 
distance from the ligatures not to endanger their hold of the pedicle. When 
there is no necessity for haste, it will be better to detach the gland from the 
rings of the trachea by the finger and the knife and remove it in its entirety. 
When the bleeding comes from different points of the tumor and is profuse, 
it can be controlled by twisted sutures. The hemorrhage being provided 
for, it only remains to cleanse the wound from all blood-clots, introduce a 
drainage-tube, and bring the edges together with sutures. 
Extirpation of the thyroid body, except under the most urgent circum- 
stances, should not be undertaken, as it is likely to be followed by myxce- 
dema of the tissues, an evil little less serious than that arising from the 
hypertrophied thyroid. 
It is said that the myxcedematous degenerations which have followed 
the operation will be prevented by leaving a fragment of the gland. 
The following table exhibits a collection of cases made by Dr. Baum of 
extirpation of the thyroid gland : 
EXTIRPATION OF THE THYROID GLAND. 
499 500 
SURGICAL AFFECTIONS OF THE GLANDS. 
No. 
Source of Information. 
Date. 
Sex and 
Age. 
Disease and Operation. 
Course of Disease.—Remarks. 
Kesult. 
Operator. 
1 
Phila. Jour. .Med. and Phys. Sci., 
1820. 
M., 11. 
Solid, lardaceous, reddish, lobu- 
Patient was deaf-mute. Existed from infancy. Extended from ear 
Death on table. 
Klein. 
vol. ii. p. 199. 
lated tumor, left side. 
to ear and to the third rib. Profuse hemorrhage. Weight 2 lbs. 
2 
Lancet, 1828-29, p. 351. 
1828. 
F., 24. 
Hypertrophy. Right half removed. 
Used iodine prior. 
Death, 15 days, in 
convulsions. 
Greene. 
3 
Lancet, 1830-31, p. 416. 
1830. 
M., 12. 
Fibro-cellular tumor. Left half 
Existed from infancy. Pressure on surrounding organs. 
Death, 18 hours, 
Dupuytren. 
removed. 
in convulsions. 
4 
N. Amer. Arch. Med. and Surg., 
1835. 
F., ad. 
Hypertrophy. Entire gland re- 
Existed 20 vears. Ulcerated, and excrescence grew. “ Intermit- 
Death. 
Smith (N. R.). 
vol. ii. p. 309. 
moved. 
tent fever” (?) caused. 
5 
6 
Lancet, 1840-41, p. 583. 
Lancet, 1844, vol. ii. p. 189. 
1840. 
M., 30. 
M., ad. 
Cystic tumor. Right half removed. 
Enlarged at isthmus. Portion re- 
moved. 
Began 10 years before operation. Leeches, iodine. Tapped and laid 
open. 
Has done operation several times with success. 
Recovery. 
Recovery. 
Massey. 
Liston. 
7 
Amer. Med. Times, vol. iv. p. 10. 
1861. 
F., 54. 
Gland fibroid,colloid,and vascular, 
Began at 12 years and steadily increased. Pressure. Orthopnoea. 
“ 
Yoss. 
removed entire. 
Iodine used. 
King. 
8 
Brit. Med. Jour., January 7, 
1864. 
M., 22. 
Tumor upon isthmus removed. 
Afterwards tracheotomy done for dyspnoea. 
Death. 
1865, p. 5. 
9 
Brit. Med. Jour, January 7, 
1864. 
M., 21. 
“ “ 
Existed long time. Iodine internally. Biniodide of mercury ex- 
Death third day. 
“ 
1865, p. 5. 
ternally. Then tracheotomy. 
10 
Brit. Med. Jour., January 7, 
1865. 
M., 21. 
“ “ 
Existed 3 or 4 years. Iodine internally and externally. 
Recovery. 
1865, p 5. 
Hamilton. 
11 
Dublin Quarterly Jour. Med, 
1865. 
F., 16. 
Hypertrophied and cystic. Entire 
Existed 6 years. Headache and dizziness. 
vol. xl. p. 318. 
removal. 
Recovery in 2% 
Cheever. 
12 
Boston Med and Surg. Jour., 
1865. 
F., 24. 
Hypertrophy. Entire removal. 
Began 1 year before operation. 
vol. lxxiii. p. 332. 
w'eeks. 
Greene. 
13 
Amer. Jour. Med. Sci., January, 
1866. 
F., 45. 
Hypertrophy. Right lobe removed. 
Began 26 vears before operation. Pressure. Orthopnoea. Weight, 
Recovery. 
1871, p. 80. 
1 lb. 9 oz. “ Hemorrhage fearful.” 
14 
15 
Amer. Jour Med. Sci., January, 
1871, p. 80. 
Amer. Jour. Med. Sci., January, 
1871, p. 80. 
1869. 
F., 40. 
F., 35. 
Hypertrophy. Right lobe removed. 
Hypertrophy. Entire removal. 
Began 7 years before operation. Dysphagia extreme. 
<4 
Pulsating everywhere. Aneurismal thrill and bruit. Right side cal- 
careous. Fearful hemorrhage. Secondary hemorrhage tenth day. 
Poland. 
16 
Guy’s Hosp Ilepts., Series iii., 
1870. 
F., 43. 
Tumor in connection with thyroid. 
Began 6 weeks before operation. Pressure symptoms. Had 18 
17 
vol. xvi. p. 484. 
Edinburgh Med. Jour., vol. xix. 
p. 252. 
Removed. 
Hypertrophied and cystic. Partial 
removal. 
children. Youngest 3 years old. 
Aneurismal signs after tapping and injection ; great hemorrhage. 
Death upon table. 
Syme. 
Spence. 
18 
Edinburgh Med. Jour, vol. xix. 
p. 252. 
Edinburgh Med. Jour., vol. xix. 
“ Great bleeding.” 
Was central and prominent, gradually increasing for many years. 
Recovery. 
19 
1871. 
F., ad. 
Cystic tumor removed. 
Watson (PH.) 
p. 252 
Much hemorrhage. 
20 
Edinburgh Med. Jour., vol. xix. 
1871. 
F., ad. 
Multilocular cyst. Entire removal. 
Tapped and injected with tincture of iodine when single cyst. Ar- 
p. 253. 
rested for a while. 
21 
Edinburgh Med. Jour., vol. xix. 
1871. 
F., ad. 
Multiple cyst. Entire removal. 
Catgut ligatures used. Anaemia and exophthalmos markedly di- 
“ 
p 254. 
minished. 
22 
Edinburgh Med. Jour., vol. xix. 
1872. 
F., ad. 
“ 44 
Had grown steadily for 23 years. Pulsated. Anaemia and exoph- 
“ 
23 
p. 254. 
Edinburgh Med. Jour., vol. xix. 
p. 254. 
1872. 
F., ad. 
<• ii 
thalmos. 
i, 
4 4 
Complete and Partial Extirpation of the Thyroid Gland. EXTIRPATION OF THE THYROID GLAND. 
501 
No. 
Source of Information. 
Date. 
Sex and 
Age. 
Disease and Operation. 
Course of Disease.—Remarks. 
Result. 
Operator. 
24 
N. Y. Med. Jour., vol. xviii. p. 93. 
1872. 
F., 21. 
Fibro-cystic tumor. Right half 
removed. 
Began at the age of 3 years. Grew till 17 years. None since. 
Dysphagia. Injected tincture of iodine and tapped. Circum- 
ference, 17inches. Weight, 2 lbs. 14 oz. 
Recovery. 
Fenwick. 
25 
1872. 
F., 18. 
Fibro cystic tumor. Right half 
removed. 
Existed 2J/J years. No pain, but rapid growth for 6 months. Press- 
ure on larynx and oesophagus. Used iodine, lead, and partial 
excision 6 months before. 
Recovery. No 
suppuration. 
Hodder. 
26 
Amer. Jour. Med. Sci., January, 
1873, p. 17. 
1872. 
F., 65. 
Cystic tumor. Removed. 
Existed 40 years. Very large. Burst and suppurated. 
Death in 39 hours. 
Holmes. 
27 
Med. and Surg. Reporter, vol. 
xxxii. p. 361. 
1874. 
F., 40. 
Cystic degeneration. Right lobe 
removed. 
Existed “ some months.” 
Recovery in 4 
weeks. 
Milligan and 
Tupper. 
28 
Med. Times and Gaz., February 
5,1876, p. 142. 
1875. 
F., 22. 
Hypertrophy and cystic tumor. 
Tumor and left lobe removed. 
Sudden dyspnoea 6 months before operation. Whisper; then 
aphonia after extraction of tooth. Dysphagia. Used galvanism, 
belladonna, and iodine. 
Recovery. 
Durham. 
29 
Brit. Med. Jour., January 9,1875, 
p. 59. 
1875. 
F., 46. 
Cystic tumor with osseous pedicle 
removed. 
Began 22 years before operation. Not grown much for three years. 
Tapped and injected tincture of iodine. Only blood escaped. 
Galvano-cautery previously used. Weight, oz. 
« 
Ticehur8t. 
30 
Brit. Med. Jour., February 28, 
1878, p. 260. 
1878. 
F., 28. 
Cystic tumor removed. 
Existed 14 years. Darting pain, giddiness, and palpitation after 
second tapping. Galvanic needles. Injected tincture of iodine. 
Wood. 
31 
Med. Times and Gaz., February 
22, 1879, p. 218. 
1878. 
F., 35. 
Removed entire gland. 
Size from egg to child’s head. Mean duration of treatment, 17 
days. 
Billroth. 
32 
Med. Times and Gaz., March 2, 
1878, p. 238. 
1878. 
F., 33. 
Cystic tumor. Entire gland re- 
moved. 
Existed 14 years. Lately grown very rapidly. Tapped and in- 
jected tincture of iodine. 
“ 
Wood. 
33 
34 
35 
Trans. Amer. Med. Assoc., vol. 
xxix. p. 260. 
Amer. Med. Times, vol. iv. p. 10. 
M., ad. 
Tumor. 
Vascular tumor. Entire gland. 
Cystic. Partial removal. 
Respiration and deglutition relieved, but difficulty returned upon re- 
suming business. 
| (These two cases are merely referred to by Dr. J. Wood.) | 
Died. 
Recovery. 
Minor. 
Unknowu. 
Post. 
36 
Lancet, 1877, vol. i. p. 387. 
1876. 
F., 40. 
Single movable cyst connected 
with thyroid removed. 
Pressure symptoms. 
Recovery. 
Jones. 
37 
Lancet, 1880, vol. ii. p. 339. 
1880. 
F., 23. 
Chalky, cystic. Right lobe ex- 
cised. 
Existed 3% years. Was 3J4 inches long, and 7 inches at largest 
part (around). Dysphagia after a time for 24 hours. 
U 
Purcell. 
38 
Lancet, 1881, vol. i. p. 953. 
1881. 
F., 66. 
Colloid and cystic. Hypertrophy 
of left lobe, atrophy of right. 
Existed 28 years. Weight, 1200 grammes. 
a 
Reverdin. 
39 
Lancet, 
1881. 
F., 19. 
Cystic. 
Existed 8 years. 12 by 15 centimetres. 
M 
«« 
40 
Brit. Med. Jour., 1881, vol. ii. p. 
779. 
1881. 
F., 51. 
Cystic, hypertrophied, and calca- 
reous. 
Existed 30 years. Almost complete aphonia, after removal by enu- 
cleation, for 6 weeks. 
u 
Reported by 
41 
Med. and Surg. Rep., Phila., 
vol. xlvi. p. 3. 
1881. 
F., 3. 
Entire removal. 
Existed 1 year. Weight, 8 oz. Extirpated by enucleation. 
M 
Cornell. 
42 
N. Y. Med. Rec., 1882, vol. xxi. 
p. 94. 
Med. Rec.; from Centralb. f. Chir., 
No. 43, p. 680, et seq., 1881. 
1881 
F., 22. 
Entire removal. 
Tapped and injected with tincture of iodine previously. 
(4 
Wyeth. 
43 
1881. 
F., 22. 
Adeno-cystoma. 
Existed 6 years. Weight, 394 grammes. 
it 
Baumgartner. 
44 
Med. Rec.; from Centralb. f. Chir., 
No. 43, p. 680, et seq., 1881. 
1881. 
F., 42. 
Follicular hypertrophy, right lobe. 
Existed 9 years. Weight, 135 grammes. 
ii 
<C 
45 
Med. Rec.; from Centralb. f. Chir., 
No. 43, p. 680, et seq., 1881. 
1881. 
M., 30. 
Follicular hypertrophy, both lobes. 
Existed 6 years. Weight, 160 grammes. 
it 
Complete and Partial Extirpation of the Thyroid Gland.—Continued. SURGICAL AFFECTIONS OF THE GLANDS. 
No. 
Sources of Information. 
Date. 
Sex and 
Age. 
Disease and Operation. 
Course of Disease.—Remarks. 
Result. 
1 
Operator. 
46 
Med. Rec.; from Centralb. f. Chir., 
1881. 
F., 22. 
Entire gland removed. 
Existed 6 years. Weight, 210 grammes. 
Recovery. 
Baumgartner. 
No. 43, p. 680, et seq., 1881. 
47 
Med. Rec.; from Centralb. f. Chir., 
1881. 
F., 44. 
“ “ “ 
Existed since childhood. Weight, 475 grammes. 
No. 43, p. 680, et seq., 1881. 
48 
Med. Rec.; from Centralb. f. Chir., 
1881. 
F., 45. 
“ « “ 
Weight, 701 grammes. 
“ 
“ 
No. 43, p. 680, et seq., 1881. 
49 
Med. Rec.; from Centralb. f. Chir., 
1881. 
M., 13. 
Right half of gland removed. 
Existed 2 years. 
“ 
No. 43, p. 680, et seq., 1881. 
50 
Med. Rec.; from Centralb. f. Chir., 
1881. 
M., 56. 
Entire gland removed. 
Existed 12 years. Extended beneath sternum. Weight, 280 
“ 
M 
No. 43, p. 680, et seq., 1881. 
grammes. 
51 
Med Rec.; from Centralb. f. Chir., 
1881. 
F., 24. 
Left half of gland removed. 
“ 
Mosetig-Moor- 
No. 46, p. 735,1881. 
hof. 
52 
Med. Rec.; from Centralb. f. Chir., 
1881. 
F., 41. 
Entire gland removed. 
In 48 hours 
sud- “ 
No. 46, p. 735,1881. 
den death from 
cei'ebral 
and ! 
pulmonary em- 
holism. 
53 
Med. Rec., 1882, vol. xxi. p. 94; 
F., 19. 
“ u a 
Removed in two operations on account of shcck in first. Aphonia 
Recovery. 
from Centralb. f. Chir., No. 46, 
for 3 months. Lesion of the recurrent laryngeal. 
p. 735,1881. 
54 
Gazette des Hopitaux, No. 133, 
F., 25. 
“ “ “ 
Existed 14 years. Recovery with aphonia. 
Richelot. 
1881. 
55 
Female. 
Monod. 
1881. 
56 
Boston City IIosp. Repts., 1882, 
F., 36. 
Solid tumor. 
Existed 14 years. Pain and dyspnoea. 
Cheever. 
p. 130. 
57 
Boston City Hosp. Repts., 1882, 
F., 23. 
Entire gland removed. 
Nearly 2 years’ standing. 
p. 130. 
58 
One lobe removed. 
p. 130. ’ 
girl. 
59 
p. 130. 
female. 
60 
Entire gland removed. 
Unknown. 
61 
Gross’s Surgery, vol. ii. p. 433. 
Harris. 
62 
Female. 
{< « <( 
\ Mott. 
63 
C< (( 
Recovered. 
| Maury. 
64 
U U 
j attended with great suffering. | 
Died. 
“ 
65 
Died. 
Packard. 
66 
Le Courier Medical. 
F., 29. 
Entire gland removed. 
Tumor the size of a child’s head. Suffocative attacks. Cardiac 
Recovered. 
: Tillaux. 
palpitation. 
67 
N. Y. Med. Record, May, 1878. 
F., 6. 
Entire gland cystic. 
The tumor had previously suppurated. 
Sands. 
68 
Lancet, June 11,1881. 
F, 06. 
Entire gland. 
Tumor of 28 years’ standing. 
“ 
Julliard. 
69 
Beck. 
70 
Medical News, Dec. 30,1882. 
F., 62. 
Carcinoma, entire removal. 
Adherent to trachea, first five rings of which were involved. 
Died. 
Gereter. 
Complete and Partial Extirpation of the Thyroid Gland.—Continued. RETROPHARYNGEAL GOITRE. 
503 
It will appear from an analysis of the preceding table, comprising 70 cases, 
that 34 were complete extirpations of the thyroid gland, and that of this 
number 29 recovered and 5 died. Thirty-six were incomplete or partial ex- 
tirpations, 26 of which recovered, 9 died, and in 1 the result is not given. 
Kocher,* in a collection of 193 cases of extirpation of the thyroid, furnishes 
information which is available for analysis in 173. One hundred and fifty- 
one of these were non-malignant, and of this number 23 proved fatal, 21 were 
carcinomatous, and 13 died. Kocher, in a series of 38 extirpations, lost 5 
cases. Billroth, in 50 operations, partial and complete, lost 6 cases. Professor 
Reverdin,f in 13 cases of removal of the thyroid, had a mortality of 3 cases. 
Hr. Welch's! statistics of extirpation of the thyroid gland show a mortality 
of 25 per cent. 
Hr. St. John Guret’s table contains 20 cases, of which 18 resulted in re- 
covery, 1 in death, and in 1 the termination was unknown. 
Retropharyngeal Goitre. 
A small portion of one of the lobes of the thyroid body may insinuate 
itself backward and inward behind the pharynx, and at length, by the various 
movements of the latter organ in deglutition, the erratic fragment may 
become partly detached from and independent of the main gland. When 
this isolated mass of lobules becomes hypertrophied, it is termed retro- 
pharyngeal goitre. It may appear either as a fibrous or as a cystic tumor. 
From its position the growth is likely to create much uneasiness. The larynx 
is often pushed forward, and somewhat out of the median line. This tumor 
can be distinguished from ordinary goitre by the swelling not obeying the 
usual movements of deglutition, and from a degree of difficulty being usually 
experienced in swallowing. 
Treatment.—The medical treatment required for retropharyngeal goitre 
does not differ from that suited to simple hypertrophy of the thyroid body. 
Should the increase of the growth give rise to dyspnoea and dysphagia of an 
urgent character, extirpation would be required. For this purpose, an incision 
is made on one side over the most prominent part of the tumor, dividing the 
skin and the superficial and deep fascia, and then the surgeon can enucleate 
the growth. The vessels involved in the operation should be sought for and 
tied before division. Czerny§ removed in this way a fibrous retropharyngeal 
goitre, and M. Boecker, of Strasburg, one of a cystic character. 
Carcinoma of the thyroid is rather unfrequent. Cases of this nature are 
recorded by Chassaignac, Welford, Wetz. Richmond, Smithe,|| and 
Two cases are reported by Franque, and one by Caesar Hawkins. The dis- 
ease occurs in two forms,—either as a distinct growth in the gland, or as a 
secondary deposit. 
Carcinoma, at its commencement, would be difficult to diagnose. The 
adhesion of the skin to the tumor, the tendency to invade the connective 
tissue, and the failure of the general health, are symptoms which belong 
to malignant, not to goitrous disease, and they would aid in establishing 
a diagnosis. 
The prognosis in cancer of the thyroid body is extremely unfavorable ; 
most of the cases have died from suffocation. 
Treatment.—There are no remedies which possess any power to arrest 
the progress of thyroid carcinoma. Whenever symptoms of suffocation ap- 
pear, the diseased mass should be removed merely as a palliative measure. 
The results of such operations have been noticed in connection with the 
subject of extirpation of the thyroid gland. 
* Correspondenzblatt. f Lancet, June 11, 1881. 
| Trans. American Medical Association, 1878, vol. xxix. 
$ La France Medicale, December 8, 1878. 
|| Deutsche Klinik, 1856, vol. xxxix. 
f Medical News, December 30, 1882. CHAPTER XXXV. 
SYPHILIS. 
Syphtlis is a term employed to designate a constitutional infectious disease, 
produced either by inoculation with a specific virus, or by hereditary trans- 
mission. This affection has received a variety of names, as lues, from the 
Greek word Xuw, to corrupt,—lues venerea, maladie venerienne. Of so dis- 
gusting a nature is this disease that no nation is willing to father it, but 
each has diligently striven to throw the discredit of its origin on some other 
country. The Italians called it the mal Francese. The Germans, following 
the example of the Italians, named it the Franzdsische Pocken. The English 
also formerly spoke of it as the French disease. In turn the French styled it 
the mal de Naples; the Moors, mal Espagnol; the Turks, mal des Chretiens; 
and the Persians, mal des Turcs. 
Attempts have also been made to trace tbe origin of syphilis to America, 
its appearance in Europe being ascribed to importation by the sailors of Co- 
lumbus on their return from the New World in 1498 and 1496; but there is 
abundant evidence to show that even before the first-named period the disease 
was prevalent not only in Italy, Auvergne, Lombardy, and Brunswick, but 
also in Saxony, Mecklenburg, and other parts of Germany, and, according 
to Fracastoro, in Asia and Africa. Nor does the accusation made by 
several medical writers, about the close of the fifteenth century and later, 
against the French, charging them with having introduced the disease into 
Italy during the invasion, rest on any better foundation ; for it is an undis- 
puted historical fact that the affection had pervaded the greater part of Eu- 
rope at least one year before Charles VIII. appeared before Naples, which 
was in 1494. That the French army served to disseminate the disease, not 
only in Italy, but also in Germany, Spain, and its own country, there can be 
no doubt. The Spanish army sent into Italy in 1495 to aid Ferdinand II. 
no doubt contributed largely to the spread of the disease among the Italians. 
So prevalent had the affection become in 1496 that in different parts of 
France and Germany public decrees were issued in order to arrest the spread 
of the plague. A clergyman of Ruffach, Matern Berlen, interpreted the 
great prevalence of the disease among the French at this time as a judgment, 
from heaven sent directly upon Charles and his army for having carried away 
the betrothed of the Emperor Maximilian, the Duchess Anne of Bretagne. 
Any knowledge which the Greeks may have had of syphilis must be in- 
ferred from their mythology rather than from extant medical writings. 
There are some authors who discover in the account given of the transfer 
of the worship of Bacchus from India to Greece, and of the failure of the 
Grecians to render due honor to the images of the god, an allusion to the 
disease under consideration, when it is stated that, as a punishment for their 
irreverence. Dens indignatus pudenda hominum morbo infestavit qui erat 
illis gravissimus.” A similar allusion is supposed to be made to the disease 
in the myth about the banishment of Priapus for his numerous seductions. 
That syphilis existed among the Romans there is reason to believe from 
the writings of both Celsus and A retains. Both of these authors speak of sores 
on the genitalia and of destructive ulcerations of the mouth, nose, and fauces. 
Allusions are also made by Galen and Archigenes to periosteal pains, and 
necrosis of the tibia, with serpiginous ulcerations, which were most probably 
of syphilitic origin ; and Martial has enriched epigrammatic literature by ex- SYPHILIS. 
505 
posing the physical entailments of the debauchee in terms which allow of no 
dubious construction. 
The writings of the Old Testament have also been adduced as testifying in 
the same direction. Although it is highly probable that the term “lepra” was 
used in a generic sense among the Jews and other Eastern nations to desig- 
nate a number of different cutaneous affections, yet there is nothing in the 
descriptions of diseases given in Leviticus or in lumbers to lead to the sup- 
position that syphilis existed among the Jews during their Egyptian captivity, 
their migration, or their early years in the promised land. 
The laws of Moses under the theocracy, which in their application to dis- 
ease and hygiene were very specific as to ceremonial observances, do not 
allude to any bodily infirmity which can possibly be construed as implying 
the existence of this pest. While the rite of circumcision (which some 
writers have thought was instituted with a view to protect against infection) 
no doubt had its sanitary advantages, yet the narrative of its institution 
shows that these were only incidental or secondary to a more elevated object 
in the highly typical ritual of the Hebrew people. 
The great antiquity of syphilis may be deduced from the writings of the 
Chinese and Hindoos, who at one time undoubtedly were the custodians of a 
high civilization and varied learning. Captain Dabry has shown, from the 
records of the first-named nation, that 2500 years before the Christian era the 
primary sore of syphilis was known, and that the disease, even at that re- 
mote period, was considered a very ancient affection. In India, a book by 
the distinguished Susruta, written as early as the year 400, describes the 
syphilitic lesion, and the manner in which it is communicated, with a par- 
ticularity that admits of little doubt as to the reference intended. 
Syphilis, therefore, may be regarded as a prehistoric disease, and we may 
believe that it dates back in its origin to that period when the race, overtaken 
by a great moral disaster, lost its primeval purity and physical perfection. 
Whatever its antiquity, it is evident that about the close of the fifteenth 
century of our era the disease assumed an epidemic prevalence, and in 
less than two years, between 1493 and 1495, spread over nearly the whole of 
Europe. It must not be forgotten that this period was one of unusual mili- 
tary activity, and that camp-life was dissolute, discipline lax, and little or no 
attention was given to army hygiene or to prostitution. These circum- 
stances were extremely favorable not only to the diffusion of the disease, 
but to its virulence. European armies, composed as they were at that day 
of different nationalities, were admirably adapted for the spread of physical 
pests, since when disbanded the soldiers carried to their respective countries 
the infectious diseases contracted in camp. Great fairs, religious pilgrimages, 
and maritime and commercial adventures, in like manner, constitute fertile 
media for diffusing communicable affections. It was most probably about 
this time also that the term syphilis (<ruv, “with,” and <pdiio, “I love”) was 
given to the malady by Fracastoro, who has not only drawn a vividly-colored 
picture of the affection in every stage, but has made it the subject of a 
poem, in which his hero, Syphilis, is charged with having brought the curse 
of this dreadful disease upon the earth for having insulted Apollo while 
the latter was serving as shepherd to King Admetus. 
When we come to study the geographical dissemination of syphilis, we 
find few spots on the face of the earth where the disease does not exist. In 
Iceland syphilis is said not to exist unless in rare instances, when it has been 
communicated by sailors or other foreigners who visit its shores; and even 
then there appear to be some climatic peculiarities which prove inimical to 
its perpetuation, as it is believed to die out. In some of the mid-Pacific 
islands the disease is uncommon, while in others it is extremely prevalent. 
According to Livingstone, it is unknown in Central Southern Africa. 
Notwithstanding the general prevalence of syphilis, there are places where 
the disease has displayed an extraordinary virulence, as in Sweden and Nor- 
way, along the Mediterranean and Adriatic coasts, in the seaports of China 506 
SYPHILIS. 
and Japan, in Northern Turkey, in Southern Africa, in Polynesia, and in 
Mexico and Central America. 
Syphilis is to-day one of the greatest curses of the world. It prevails in 
its most disgusting forms in all great commercial cities. It crops out often 
where least suspected, and, unless increasing age and prolonged successions 
shall cause a gradual mitigation of the disease (as appears to be already the 
case in China and some other old countries), it is destined to work irrepara- 
ble damage to the future generations of this country. 
Stages or Order of Syphilis.—Syphilis is either acquired or inherited. When 
acquired, it is the result of inoculation, or contact with a specific, contagious 
material; when hereditary, it is transmitted through parental antecedents. 
In the first form (that of acquired syphilis) the earliest lesion is found at 
the point of local contamination or contact, while in inherited syphilis the 
earliest external manifestations of the disease are not limited to a single 
locality, but may appear on different parts, and often on several parts of the 
body simultaneously. 
Acquired Syphilis is generally divisible into three stages, designated pri- 
mary, secondary, and tertiary,—the three acts in the syphilitic drama, as 
they arc styled by Ricord. 
The first, or 'primary, stage includes a local lesion, called the initial lesion, 
primary sore, or chancre, which is usually accompanied by some enlargement 
of the lymph-glands. 
The secondary stage is characterized by lesions of the skin and mucous 
membranes. 
The tertiary stage comprises lesions of the fibrous and vascular tissues, 
bones, and viscera. 
These chronological divisions are in a great measure arbitrary, as the disease 
does not always observe the prescribed order; yet the succession is so common 
that the arrangement has a clinical value which some writers think more 
than compensates for scientific, anatomical, or pathological inaccuracy. 
Baerensprung made but two stages, and these based on morbid anatomy,— 
namely, the hypersemie and the tubercular period. Yirchow, adopting a 
similar basis, classified syphilitic phenomena under two heads: the first em- 
bracing all those manifestations which in the chronologic system are described 
as primary, secondary, and tertiary; the second, those which are inflam- 
matory or neoplastic. Burton, of Dublin, subdivides the tertiary period into 
two, the characteristic lesions of the first being lymph-formations and those 
of the second gummy syphilides,—not communicated a second time in the 
same person. The disease, though classed by Hutchinson among the exan- 
themata, possesses certain peculiarities so dissimilar to the latter that it 
seems very much out of place in such company. Syphilis cannot be com- 
municated through the air, as are exanthematous affections like smallpox, 
scarlatina, or measles. It requires for its development inoculation, mediate 
or immediate. Hone of the exanthemata run so protracted a course or in- 
volve so great a variety of structures as syphilis, none are transmissible from 
parent to offspring, and no exanthem works such changes in the fluids and 
solids of the body that, after the individual has recovered, his blood is capable, 
by inoculation, of communicating the original disease to others,—a property 
which belongs to the syphilitic person. Even the exemption from second at- 
tacks is far less constant after syphilis than after exanthemata. As there is 
no well-defined line which sharply separates what are termed secondary and 
tertiary syphilides, I prefer to treat the subject under two heads, local and 
constitutional syphilis. 
Acquired syphilis, it is believed, can be contracted only in three ways,—by 
primary chancre, by inoculation with secondary lesions (especially mucous 
patches, which so often appear on the lips, tongue, and mammary nipples), 
and by inoculation with the blood of a person suffering from constitutional CHANCRES. 
507 
syphilis. A child may in this way contract syphilis from a nurse having a 
mucous patch on the nipple, or the child may in turn, if syphilitic, commu- 
nicate the disease to its nurse. The foetus generated by a syphilitic father 
frequently communicates the disease to the mother. For example, a lady 
under my care aborted at the fifth month (first pregnancy), the foetus ex- 
hibiting the unmistakable marks of being syphilitic. A short time before 
her miscarriage the mother was covered with characteristic roseola. The 
father, who had suffered from constitutional syphilis, had not at the time of 
marriage, nor for one year preceding, a single symptom of the disease. It 
is said that there is no direct interchange of maternal and placental blood; 
and yet, if such is the case, how can we explain the infection of the mother 
through the foetus ? 
It wTould appear from the experiments of Diday that the lesions which 
belong to the late period are not inoculable, although I do not regard this 
question as fully settled. There is no evidence to show that the disease 
is inoculable through any of the secretions of a syphilitic patient, though 
such secretions may be the menstruum for suspending the poison. Syphilis 
may also be communicated by sponges and instruments or drinking-vessels, 
pipes and stumps of cigars, wliicli have been used by a person laboring under 
the disease. A number of cases of syphilis communicated by tattooing have 
been reported by Petry, of Gratz, by Tardieu, Hutin, and Maury, the saliva 
of the operator, in these instances, having been employed to mix the coloring 
materials. In such cases no doubt can exist that the saliva was charged with 
the products of mucous patches in the mouth. Vaccination with lymph from 
a syphilitic subject has also been the medium of infection. Accoucheurs have 
frequently been inoculated in making the vaginal touch. Several cases in 
which the disease was contracted in this way have come under my observa- 
tion. The knife used in circumcision, the Eustachian catheter, the scratch 
from a nail, have all been media for communicating syphilis. 
There is no reliable evidence that the disease can he communicated from 
man to the lower animals. Various experiments have been made with this 
intent, but unsuccessfully. Trials made by Dr. White, of this city, upon 
monkeys at the Zoological Garden, in which fresh discharges from mucous 
patches and chancres were inoculated beneath the skin of the forearm, pro- 
duced only negative results. 
Chancres.—There are two venereal sores which have been called chancres, 
—namel}’, the indurated and the non-indurated. 
The first, or indurated, sore is sometimes called the Hunterian, infecting, 
or hard chancre; the second, or non-indurated, sore is called a soft chancre, 
or a chancroid, and is non-infecting. 
Until 1852 no distinction was recognized between the different venereal 
sores. At the above-mentioned period, Bassereau announced the doctrine of 
two distinct ulcers, the one entirely local and the other giving rise to consti- 
tutional disease. In 1854, M. Clerc not only confirmed the doctrine of Bas- 
sereau, but advanced a step further and christened the two lesions indurated 
and non-indurated, the former being the infecting and the latter the non- 
infecting sore; and it is from the latter authority that we receive the name 
chancroid. Three years later, in 1857, Bicord reiterated and confirmed the 
statements of his former pupils, accepting fully the dualistic view of the 
sores and their tendencies. 
In regard to the origin of the two primary sores, and their capacity to 
become generalized, syphilographers differ. Those who are called unicists 
contend that the sores are the products of the same virus, both capable of 
producing constitutional symptoms, while others, the dualists, regard these 
sores as entirely unlike, believing that the indurated chancre alone possesses 
the power to produce constitutional syphilis. Hunter believed in two dis- 
tinct sores, one specific and the other non-specific,—an opinion in which he 
was joined at that time by Abernethy and by Adams. I am not disposed to 508 
SYPHILIS. 
recognize two distinct sources of origin, or, what is equivalent to this, two 
distinct venereal poisons, one giving rise to hard chancre and the other to 
soft chancre; but that the element of induration, or hardness, characteristic 
of the Hunterian chancre, marks a most important difference not only in the 
physical components of hard and soft chancres, but also in the quality of 
infection, which appears to belong chiefly, possibly entirely, to the former, 
admits of no doubt. 
The two doctrines in regard to the syphilitic virus—namely, the doctrines 
of duality and unity—have been warmly maintained by their respective 
champions. Those who assert that the two local lesions—the hard and the 
soft chancre—arise from two essentially different poisons adduce in support 
of their views,—1st, the period of incubation which belongs to hard chancre, 
the lesion rarely appearing earlier than three weeks after inoculation, while 
that of chancroid lasts only as many days; 2d, the element of induration, 
which is a characteristic of chancre, but not of chancroid; 3d, inability to 
effect self-inoculation from the products of the hard lesion, while auto-inocu- 
lation is the constant property of the soft chancre; 4th, formation of the 
primary lesion, which in hard chancre is papular, ending in a trivial ulcer, 
with little discharge, and the edges of which are very slightly elevated above 
the fundus of the sore and are based upon a parchment induration, while in 
chancroid there is first a vesiculo-pustular stage, terminating in a deep 
ulcer, with perpendicular sides and irregular edges, having a purulent dis- 
charge and without induration; 5th, multiple indolent enlargement of the 
inguinal glands, without tendency to suppurate,—an accompaniment of the 
hard chancre,—the adenitis following the soft chancre being phlegmonous, 
not usually involving an entire group of glands, and having an invariable dis- 
position to suppurate, the pus having the same inoculable quality as the 
original sore; and, 6th, the generalization of hard chancre by constitutional 
infection, extending in its various manifestations, it may be, during the life 
of the individual,—phenomena altogether different from anything belonging 
to chancroid, which has no power to produce a constitutional disease. 
In answer to these arguments, the unicists affirm that a difference in the 
period of incubation of the two sores does not exclude the idea of similarity 
of origin. Three or four children may be vaccinated at the same time, and 
yet in no two of them may the local signs of the pustule appear at the same 
period. A number of persons may be exposed to the contagion of smallpox, 
but rarely is it the case that any two sicken at the same time. Hydrophobia 
may arise four or five days after the patient has been bitten, or the poison 
may lie dormant for as many years. 
They say, also, that the induration claimed as the exclusive property of 
chancre is often deceptive, and so closely resembles what is called inflam- 
matory infiltration in the chancroid, that the distinction cannot always be 
satisfactorily made. 
The dualists answer that these are exceptional cases, not affecting the 
general rule, and, moreover, that the observer, even under these circum- 
stances, can distinguish the nature of the two sores by their antecedent 
history. 
The non-auto-inoculability of hard chancre, as affirmed by the dualist, 
is denied by the unicist, on the strength of the experiments of Boeck, Biden- 
kap, and Hjort (who claim to have produced soft chancre by inoculation 
with a modified secretion taken from hard chancre), and those of Ivobner, 
who also claims to have succeeded in producing chancres with the secretions 
both from chancre and from mucous patches, inoculated on the same person. 
The answer which the dualist makes to the above statement is this,—that 
the experiments reported by the authorities named are open to adverse criti- 
cism, inasmuch as the chancres had been subjected to a preliminary treat- 
ment by irritants, inducing suppuration, before inoculation was produced; 
that one of the experiments of Bidenkap, repeated subsequently at the 
Ilopital du Midi, utterly failed to produce the results first claimed ; and that, CHANCRES. 
509 
moreover, several others following in the same line, but without the pre- 
liminary treatment, were equally unsuccessful. 
Wiggleswortb, Pick, Kraus, and Lee have shown by numerous experiments 
that the pus of scabies and acne pustules, though producing no result when 
inoculated on sound persons, will, when introduced into the skin of syphilitic 
patients, produce sores corresponding to chancroids, and that these sores 
can be reproduced by repeating the inoculations with the pus which they 
furnish. 
The experiments of Kaposi and Yidal, at first sight, seem to be fatal to the 
doctrine of the specific character of chancroid, if auto-inoculability is to be 
the test, since these observers have succeeded in reproducing pustules for 
three generations in non-syphilitic persons by inoculation with the pus of 
ecthyma. It must not be overlooked, however, that these inoculations were 
all made on syphilitic patients. To displace chancroid from its position in 
venereal disease, as a specific lesion, will require that the same results follow 
inoculations made on persons in health, or those free from this disease. 
To the statement of the dualist that constitutional syphilis does not follow 
chancroid, the unicist replies by saying, first, that neither does syphilis in- 
variably follow a sore which has the external appearances of chancre; and, 
second, that the general disease has often followed what was believed by 
competent observers to be a soft chancre. Thus the unicist at last takes 
refuge in the fallibility of human judgment, in consequence of which errors 
of diagnosis are likely to occur in distinguishing between the two lesions. 
In deliberately weighing the testimony of these two opposing sects, I dis- 
cover nothing which induces me to modify the views which I have constantly 
maintained on this subject, and which were formed after an experience of 
twelve years in the venereal wards of the Philadelphia Hospital, an institu- 
tion unusually rich in cases of this class. My own views may be summarized 
as follows: 1. That the syphilitic virus is a purulent secretion, containing 
some subtile material, possibly a particle of living matter, and that pus 
charged with this material is capable of producing, under favorable circum- 
stances, either chancre or chancroid. To this extent, therefore, I am a unicist. 
2. That chancre and chancroid are the products, the former of this supposed 
germinal matter, and the latter of the purulent component of the secretion. 
3. That hard chancre alone can become generalized or produce constitutional 
syphilis, chancroid being simply a contagious local lesion, without any power 
to cause constitutional infection. The possibility of converting a chancre into 
a chancroid, or vice versa, I have no reason to doubt; but to effect the first it is 
necessary to introduce, either intentionally or accidentally, an inflammatory 
element of a high or suppurating grade, by which the specific qualities of the 
lesion will be destroyed, and the sore converted into a soft ulcer or chancroid ; 
to effect the last, that is, the transformation of the chancroid into a chancre, 
it is requisite that the former shall have a new inoculation with the original 
virus of the latter. , 
A third chancre—the mixed—has been treated of in the literature of 
syphilis; a sore produced by the inoculation of a chancre with the matter 
from a chancroid,—the tertium quid being a lesion combining in itself the 
properties of both sores. The experiments which were made and alleged to 
have resulted in rendering the chancre auto-inoculable ought to have been 
made upon persons who were not the subjects of syphilis, in order to ascer- 
tain the liability of the general system under the circumstances to become 
affected. This, however, was not done. 
Syphilitic virus.—In what the peculiar virus of syphilis consists has never 
been determined. Neither chemistry nor anatomy has thrown any light 
on the subject. Beale believed the active principle of infection to be a living 
disease-germ, a molecule of living matter similar to that which has been re- 
garded as the active agent in the cattle plague, smallpox, etc. Otis enter- 
tains a similar view, believing the contagious principle to be connected with 
a degraded white corpuscle. 510 
SYPHILIS. 
Manner of entering the system.—Although there is reason to believe that 
the syphilitic poison may enter the system directly through the blood, yet 
the ordinary route is through the lymph-vessels, as will appear from the 
uniformity with which bubo follows chancre. 
The theory of Otis, which, though not proved, is both ingenious and 
plausible, assumes that the syphilitic contagion resides in a degenerated or 
degraded white corpuscle, which, having been overtaken by some accident, 
loses that peculiar force which is necessary for the organism to develop into 
healthy tissue, yet retains certain vital properties, as amoeboid movements 
and proliferation, and by contact with other white or healthy corpuscles 
communicates to them analogous qualities; that the diseased germ is capa- 
ble of influencing or affecting only germinal or embryonic matter, having 
no effect on formed matter; and that as the current of the fluids which 
permeate the tissues is in the direction of the lymphatics, and as every 
abrasion or inoculation is in direct communication with the latter, it is 
through the lymphatic system that constitutional infection occurs. The 
contents of these vessels, being made up of embryonal matter, are rendered 
contagious by the intrusion of the diseased cell, the first evidence of which 
is seen in the enlargement of the lymph-glands into which these vessels 
penetrate. A considerable delay next ensues before the glands permit the 
poisoned lymph to pass into the emergent lymphatics. At length the de- 
tention is overcome, and the stream flows on, until it enters the thoracic 
duct, and finally is turned into the blood-vessels, through which it is dissem- 
inated to all parts of the system, manifesting itself as constitutional syphilis. 
According to this theory, the dominant feature in all syphilitic manifestations 
during the active period of the disease (secondary) consists in localized cell- 
proliferation and accumulation, and, moreover, it is only during this period 
that syphilides are inoculable or transmissible. The later or tertiary lesions, 
consisting only of formed or effete matter, are purely personal, and not 
susceptible of being communicated. 
Chancroid—Soft Chancre.—Chancroid is the name given to a venereal sore 
which resembles, in several respects, true chancre, and which, as has been 
stated, may be caused by the purulent secretion of the latter. It is there- 
fore proper to describe it at this time. The two lesions are, no doubt, 
of equal antiquity. Chancroid, unlike chancre, is a local ulceration, and is 
not followed by constitutional infection. It is evident from the writings 
of Hippocrates, Celsus, Galen, Paulus iEginetus, and other ancient physi- 
cians, as also from those of a later period, particularly Guillaume de Salicet 
and Guy de Chauliac, that a difference between infecting and non-infecting 
sores on the genital organs was very anciently recognized, and that these 
sores, in all probability, answered to hard and soft chancres. The same dis- 
tinction, but with more definite and accurate notions regarding syphilitic 
disease, was entertained by Hunter, Abernethy, Carmichael, and Kicord, the 
latter of whom clearly distinguished between sores followed by general symp- 
toms and those purely local in their effects. Bassereau, however, in 1852, 
succeeded, by chemical and other means, in showing that the two chancres 
were not congeners, each depending for its existence on a sore like itself. 
Chancroid is self-inoculable, the resulting ulcers possessing the same prop- 
erties as the primary sore. The peculiar property of communicability is sup- 
posed, by some, to depend on the presence of certain low forms of animal or 
vegetable life. The experiments of Rollet indicate that the virus, if there is 
any, resides in or about the corpuscular products of the ulcer, inasmuch as 
the separation of these from the secretion renders the remaining portion 
harmless and inert. The persistence and virulence of the inoculability are 
exemplified in the various experiments which have been made with the 
purulent discharge of the ulcer. It has been frozen and thawed, mixed with 
other animal poisons, as vaccine, gonorrhoeal, and syphilitic, reduced in 
strength by dilution with several times its own volume of water, introduced CHANCROID. 
511 
into cancerous growths, and yet, treated in these various ways, its power 
to reproduce itself by inoculation remains undiminished. This property, 
however, is destroyed by acids, alkalies, and alcohol. 
The purely local effect of the chancroid secretion, and the absence of any 
tendency to induce constitutional symptoms, have been abundantly estab- 
lished by the repeated inoculations of Bollet, Hiibbenet, Bassereau, Puche, 
and many others. 
Seat of chancroid.—Soft chancre affects the same regions as does its more 
dangerous companion, the indurated sore. Of 1271 cases in the male, col- 
lected by Sturgis from the tables of different syphilographers, 1194 were 
located on the genitals, and of this number 826 were seated on the glans 
penis. Urethral chancroid is more common in the female than in the male. 
The uterus, head, and face are singularly exempt from this lesion; indeed, 
Bicord at one time taught that the chancroid never appeared on the face 
or scalp, although later observation has shown that no part of the body is 
necessarily free from liability to inoculation. 
Whether chancroid can be communicated from man to the lower animals 
is still a disputed point. 
Number.—Soft chancre, if not multiple at first, soon becomes so from the 
discharge of a single sore coming in contact with the adjacent parts. Pa- 
tients not unfrequently present three or four sores, and even twelve or fifteen 
have often been seen at one time on the genitals. Labarthe saw, in the wards of 
the Lourcinc, a woman on whose person were seventy-five chancroids. Bicord, 
in 254 examples of chancroid, observed 48 single and 206 multiple cases. 
The tendency to reproduction and multiplication of chancroid is not lessened 
by repeated inoculations. Bicord notices an instance in which 2200 effective 
inoculations were made at different times on the same person. 
The greater frequency of chancroid over chancre in former days is shown 
in the statistics of Puche. In an analysis of 10,000 chancres, 1955 were 
found belonging to the indurated, and 8045 to the .soft variety. But the 
growing infrequency of soft chancres is now becoming a matter of common 
observation : thus, in 341 cases tabulated by Fournier, 126 were indurated, 
and 205 soft chancres. Of 1789 cases of chancre reported by Le Fort, 838 
were indurated, and 951 soft sores. About the same proportion appears in 
the statistics of Clerc and Labarthe. The conjoined statistics of Fournier 
and Cullerier, from the records of the Hopital du Midi, make the two varie- 
ties of chancre equal. 
Development.—Chancroid has no period of ijicubation, the sore developing 
in from twelve hours to three days,—the time depending altogether on the 
nature of the surface with which the infecting agent comes in contact. If 
applied to an excoriated or raw part, the process will be rapid, in from twelve 
to twenty-four hours; but if to an unbroken surface, its action will be more 
tardy, and the ulcer may not form for three, four, or even twenty days. 
In a collection of 52 cases of chancroid by Foui’nier, 13, or the largest 
number, appeared on the seventh or eighth day following coitus; the next 
largest number, 9, on the third day. The shortest period was on the first day 
following exposure, 6 cases; the longest, somewhere between the seventeenth 
and twentieth days, 2 cases. 
The tables of Sturgis record the history of 95 chancroids, the largest num- 
bers (10 and 12) occurring, the former on the tenth day, and the latter on 
the seventh day. Only 5 cases were developed on the day following coitus. 
In the tables of Debauge, which include 81 cases of chancroid, 24 appeared 
on the eighth day, 11 on the fifteenth day, 10 on the tim'd day, and 6 in 
twenty-four hours. If to the above there are added the chancroids tabulated 
by Millet, 201, we shall have an aggregate of 381 cases available for calcula- 
tion : 310 chancroids were seen within eight days succeeding impure exposure, 
or, according to Sturgis, in 81.3 per cent. 
The earliest sign of the operation of the virus is the presence, after twelve 
or fourteen hours, of inflammatory redness at the seat of inoculation. This 512 
SYPHILIS. 
redness deepens, and in the course of the second or third day a vesicle forms 
on the top of the inflamed patch of skin, and this vesicle soon becomes con- 
verted into a pustule. After the rupture of the pustule, a round or irregular 
ulcer is disclosed beneath, of considerable depth, 
with abrupt, steep, and xindermined edges, and 
covered with a grayish deposit. (Fig. 2050.) 
Though it is common to speak of the ulcer being 
round or oval, yet in reality the borders of the 
sore are subject to great variations, being some- 
times perfectly regular, and at other times ir- 
regular or ragged. The sides of the chancroid 
are equally variable with its margins: in one 
case they are steep and pei-pendieular, and in 
another shelve towards the crater of the ulcer 
with a gradual declivity. Neither at the cir- 
cumference nor underneath the sore is there 
any induration, unless in cases where the chan- 
croid has been the subject of irritation, either 
from friction of the clothing or from injudicious 
applications, in which case a very considerable 
degree of inflammatory induration may be pres- 
ent. The chancroid, when once formed, tends to enlarge its boundaries, and 
when several ulcers exist it is not uncommon for two or more to coalesce. 
The purulent discharge which exudes from soft chancre is highly charged 
with the contagious principle, and, flowing over the adjoining parts, it pro- 
duces other similar sores. Multiple chancroids, therefore, may arise from 
either primary or secondary inoculation. 
The duration of chancroid is variable. Under judicious treatment it usu- 
ally cicatrizes in three or four weeks; though there are not wanting instances 
where the ulcer has continued for many months, obstinatelyrefusing to heal. 
Pig. 2050. 
Multiple chancroids. 
Bubo.—Bubo occurs about once in every three cases of the non-indurated 
chancre. The virus is transported from the primary lesion to the inguinal 
glands by the lymph-vessels. Its presence, acting as a violent irritant, pro- 
duces an adenitis. Rarely more than one, or at most two, glands of the 
inguinal group suffer. 
When the chancroidal infection takes effect, the gland becomes tender and 
swollen, and the adenitis generally terminates in suppuration. The purulent 
fluid, possessing the contagious property of the original ulcer, may be inoc- 
ulated with the same result. In other words, the suppurating gland is es- 
sentially like the original sore, and may assume the same external characters 
as belong to chancroidal ulcers, including depth, irregularity of the edges, etc. 
Chancroidal suppurative adenitis furnishes two kinds of purulent matter. 
One kind is found in the periglandular connective tissue, and is entirely 
harmless, being the result of simple inflammation excited by the arrest of 
the contagion in the gland. The other is virulent and specific, containing 
the inoculable principle. Hence, one may inoculate with the pus from the 
exterior of a suppurating bubo, in the early stage of the adenitis, without 
any marked effect, while pus taken from the centre of the gland will produce 
the characteristic chancroid. In a short time, however, the central pus finds 
its way to the surface, after which the contagium becomes generally diffused 
and the purulent fluid at every point is alike inoculable. Though the lymph- 
gland first receiving the virus may retain it for a time, and prevent its 
passing onward, yet when suppuration and disintegration of the gland take 
place the poison is often communicated to adjoining members of the gland- 
group, and what was at first monoglandular bubo becomes polyglandular. 
The position of the bubo is in part determined by the seat of the soft 
chancre. When the latter is on one side of the median line of the penis in 
the male, or on one labium in the female, the bubo will occur in the groin of CHANCROID. 
513 
the corresponding side. When the chancroid occupies the fraenum the bubo 
is likely to appear simultaneously in both groins, since the lymph-vessels of 
the two sides form a net-work at this point. In consequence of the peri- 
glandular connective tissue, as well as the substance of the gland, being the 
seat of inflammation in chancroidal bubo, and the infiltration accordingly 
being both peripheral and central, the characteristic almond-shaped form of 
the affected gland is lost in the general swelling. 
Bubo is less common in women than in men. This difference is thought 
to be attributable to the less direct communication or course in women be- 
tween the lymph vessels and the inguinal glands. But this explanation is 
not quite satisfactory, since whatever obstacle to the passage of the virus in 
the case of the female may be offered by the tortuous disposition of the lym- 
phatics is more than compensated for by the short distance between their 
origin and their destination. The termination of the lymphatics of the female 
generative organs on the mucous surface of the parts within the pelvis, and 
not in the inguinal glands, offers an explanation more consistent with the 
anatomy of the parts. For the same reason, urethral chancroid in the male 
is seldom followed by inguinal bubo. 
The idea was formerly entertained that a bubo may arise by the absorp- 
tion of the chancroidal virus independently of a pre-existing chancroid (bubon 
d'emblee'); but this opinion receives no support from clinical observations, 
and is at the present time generally abandoned. 
Pathology.—In examining a vertical section of a soft chancre, properly 
prepared for microscopic study, the epidermis and rete mucosum are seen ab- 
ruptly terminating at the border of the ulcer, the crater and sides of which 
are lined by granulation-tissue (Fig. 2051), continuous with the cutaneous 
Fig. 2051. 
Section of a chancroid . a, epidermic layer; b, rete mucosum ; m, rete nnicosum interrupted in the cavity of 
the ulcer; «, granulations; v, vessels. 
papillae. Throughout the entire thickness of the derm and the underlying 
connective tissue there is an inflammatory infiltration of wandering cells. 
There is, however, no sclerosis of the walls or narrowing of the lumen of 
the minute blood-vessels, and consequently no specific induration, the cell- 
infiltration being confined to the adventitious tunics. The infiltration is ac- 
companied by softening and disappearance of the connective-tissue fibrils, so 
that at the focus of disease, or among the granulations of the crater, a large 
number of pus-cells accumulate. Chancroid, therefore, does not in its morbid 
anatomy materially differ from simple or non-specific inflammation of the 
skin, though between it and hard or infecting chancre there is a marked dis- 
similarity, the latter having between the corneous and middle layers of the 514 
SYPHILIS. 
epidermis an infiltration of cells, while it retains also the connective-tissue 
components of the derm, and is attended with vascular sclerosis, but with 
very little if any suppuration. These peculiarities explain the characteristic 
induration of true chancre. 
Prophylaxis.—All persons who are rash enough to expose themselves to 
the risks of impure intercourse are not equally susceptible to contagion. Gen- 
erally, those who, congenitally or after operation, have a short foreskin are 
least liable to become affected, the hardness of the glans from habitual ex- 
posure being unfavorable to the absorption of the virus; while those with 
a redundancy of prepuce are very prone to become inoculated. Measures 
may be adopted after connection which lessen the liability lo infection. 
The most effective preventive is thorough washing with carbolic acid soap 
or thymol soap, taking care that no spot on the glans, on the post-coronal 
region, or in the crevices of the foreskin escapes. Women should employ in 
such ablutions large vaginal injections of a solution of sulphate of zinc, alum, 
or dilute alcohol, at the same time being careful to wash thoroughly the 
external genitalia. 
Treatment of Chancroid.—Considerable difference of opinion in regard 
to the treatment of chancroids exists among practitioners, some recom- 
mending the use of powerful caustics, while others abstain from all active 
remedies. 
The caustics which have been employed at different times are nitrate of 
silver, acid nitrate of mercury, nitric acid, sulphuric acid, alone or with pul- 
verized charcoal, bromine, etc. The destruction of the sore has been some- 
times effected by means of the actual cautery. These heroic remedies were 
universally employed at one time, under the impression that by an early 
cauterization of the sore the peculiar virus which was supposed to give rise 
to the lesion might be destroyed and the system protected against invasion. 
Those who at present continue to employ active caustics base the practice 
on the necessity of destroying the contagious nature of the ulcer and substi- 
tuting a healthy for an unhealthy action. 
No advantage is gained by the use of powerful caustics in the treatment 
of chancroid; on the contrary, these remedies often do harm by the severe 
pain, the inflammatory swelling, and the glandular enlargement which fre- 
quently follow their employment. The practice of indiscriminately cauter- 
izing venereal lesions is objectionable in another point of view,—the char- 
acteristics of the sore being so changed by the resulting inflammation and 
its products that the diagnosis is rendered uncertain. 
These sores can be healed by much milder measures. Attention to cleanli- 
ness and the use of gently-stimulating remedies is all that is necessary. The 
ulcer should be washed daily with weak carbolated water or a solution of 
permanganate of potash, and then dusted over with a powder consisting of 
equal parts of gallic acid and iodoform, or it may be dressed with very dilute 
nitric acid (half a drachm of the acid to one pint of water), applied by soak- 
ing a dossil of lint in the mixture and laying it over the chancroid. There 
should always be interposed between the foreskin and the glans a soft piece 
of patent lint, in order to keep the contiguous surfaces apart and prevent new 
inoculations. 
Should the chancroid become indolent and its granulations appear pale, 
with no tendency to cicatrization, a dressing of sulphate of copper (cupri 
sulphatis, gr. iij, aquas fontanae, will favor the work of repair. The 
practice of occasionally touching the ulcer with a crayon of nitrate of silver 
(fifty per cent.) will often be followed by a beneficial effect. Whatever remedy 
is used, a rigid attention to cleanliness must be imperatively enjoined. The 
parts, at the renewal of every dressing, should be washed in hot water, 
which may be medicated with advantage by adding to the liquid a little 
laudanum or a few drops of the tincture of the chloride of' iron or some 
chlorinated soda. Unless some unusual interruption to the repair of the ulcer 
occurs, the sore will generally close in the course of twelve or fifteen days. CHANCROID. 
515 
Complications.—Not unfrequently, however, the chancroid is overtaken by 
some complication which seriously disturbs the process of repair, and which 
demands no small degree of judgment in order to ai’rest the morbid action 
and establish a new and healthy one. 
These complications are inflammation, phagedaina, sloughing, phimosis, 
paraphimosis, balanitis, and diphtheritic transformations. 
The causes concerned in their production are both general and local; 
indeed, there is no ulcer the healthy progress of which is more easily dis- 
turbed, or which is so prone to assume a formidable aspect on the application 
of an irritant. The friction of the clothing, contact with soiled dressings, 
lack of proper cleanliness, indiscriminate intercourse, together with the 
usual excesses of a dissolute life, rarely fail to convert a simple into a 
complicated chancroid. The cases of this nature which are admitted into 
metropolitan hospitals come, in most instances, from the loathsome slums 
and dens of pi’ostitution, into which gravitate the dregs of all races and 
colors. To the above causes must be added a vitiated atmosphere, which 
is often no inconsiderable factor in determining destructive inflammation in 
specific sores. 
Inflammation of soft chancre is characterized by a livid discoloration and 
swelling, not only of the ulcer, but of the surrounding pai’ts, including the 
prepuce and even the entire organ. The discharge from the chancroid loses 
its purulent character, and becomes thin, ichorous, or sanious. The pain is 
sometimes very severe, and is often attended with considerable febrile dis- 
turbance, headache, and lumbar soreness. Unless soon brought under control, 
the inflammation may terminate in gangrene. 
In the treatment of an inflamed chancroid every tangible cause of irritation 
must be sought for and, as far as possible, removed. The patient should be 
confined to bed, the diet restricted, and a gentle cathartic administered, fol- 
lowed by a febrifuge mixture, to which may be added an alkaline bromide 
or a small amount of morphia, if there is much nervous restlessness. The 
best local application will be a hot flaxseed-meal poultice, which, as soon as 
the inflammation and swelling subside, may be exchanged for a lotion of lead- 
water and laudanum. Thi’ee or four days usually suffice, under this treat- 
ment, to bring the disease under control, when the ulcer can be managed by 
the means which were employed before the complication arose. 
Phagedcena.—This formidable form of ulceration, induced by causes not 
materially differing from those concerned in creating the inflammatoiy chan- 
croid, resembles very much the disease known as hospital gangrene. Except 
among the lowest class of prostitutes, or those who cohabit with them, this 
variety of ulceration of soft chancre is not often seen. Its progress, when 
once established, is not always uniform, the destruction of tissue sometimes 
being quite slow, at other times very rapid. The ulcer perishes by install- 
ments, and in consequence of this fact the specific character of the sore is 
retained, fresh inoculations of new tissue taking place in the progress of the 
destructive erosion. The extension of the ulcer is irregular both in outline 
and in depth. I have seen the penis and scrotum stripped of their integument- 
ary covering in a few days, the ulcerative process not extending deeper than 
the skin, while in other cases the disease, instead of being limited by the sub- 
cutaneous tissue, extends in depth, destroying the glans penis and laying 
open the urethra, and in some instances giving rise to serious hemorrhage. 
The pain is severe and burning, and the discharge from the ulcer sanious and 
intermixed with fragments of disorganized tissue. (Eig. 2052.) The ulcer- 
ation occasionally assumes the serpiginous form, enlarging its boundaries 
unequally in different directions, and while perhaps healing at one place con- 
tinues to invade the adjoining tissues in the same irregular manner. 
The treatment of phagedsena comprises both local and constitutional reme- 
dies. There is no time for temporizing. Not only is it necessary to destroy 
the ulcer, but a new and healthy action in the contiguous tissues must be 
excited. These indications are best fulfilled either by a potent caustic or 516 
SYPHILIS. 
by the actual cautery. Bromine and fuming nitric acid applied freely to the- 
ulcerating tissues are among the best local remedies which we possess fo» 
arresting the disease. Rarely is it necessary to make 
more than two applications with either of these prep- 
arations in order to bring the destructive process to a 
halt. Whether these agents or the actual cautery be 
employed, their application must be immediately fol- 
lowed by hot flaxseed-meal poultices, not only as being 
grateful to the sensations of the patient, but with a 
view to hasten the separation of the devitalized tis- 
sues and to favor the growth of a new crop of granu- 
lations. After the slough has dropped out and gran- 
ulations begin to fill up the chasm, it will only be 
necessary to protect the ulcer against irritants by 
covering it with a piece of lint moistened with lime- 
water, or by penciling the surface daily with a little 
iodoform. The aromatic wine applied in the same 
manner as the lime-water is also a very good dressing. 
With Ricord, a strong solution of potassio-tartrate of 
iron addressed to the phagedenic ulceration, and also- 
taken internally, was a favorite remedy; but, while it cannot be regarded 
as inert, I am not prepared to believe that this agent possesses any specifio 
influence over the ulceration under consideration. 
The constitutional treatment is highly' important in phagedama, since the 
subjects of this destructive ulceration are often persons whose constitutional 
powers have been much impaired by excesses of various kinds: hence the 
necessity, after regulating the bowels, of administering a nutritious dietr 
with anodynes to relieve pain and restlessness, and tonics, such as quinine 
and iron, or the compound tincture of cinchona. Stimulants will olten be 
required to energize the action of the heart, the best being whisk}', wine, or 
the liquid extract of malt. 
Phagedama may end in gangrene. 
Gangrene.—When mortification attacks the chancroid, it will be known by 
the dark or livid discoloration of the ulcer and surrounding parts, deepening 
into black, by burning pain, and by marked constitutional symptoms, such as 
a small, frequent pulse, hot skin, dry, brown tongue, headache, restlessness, 
some delirium, and entire loss of appetite. 
Bromine is no less efficacious in arresting the extension of gangrene than 
in putting a stop to phagedama, and it should be used in the same manner 
as when emplo}md for the latter. Nitric acid is scarcely less efficient. Car- 
bolic acid is also employed, principally, however, for purposes of disinfection. 
Poultices should follow cauterization, so as to hasten the separation of the 
dead from the living parts. Any loose sloughs should be picked away, though 
it is best not to be premature in the use of the scissors or the knife, as serious 
hemorrhage might follow. During the process of separation, Platt’s chlorides, 
the potassio-tartrate of iron, or permanganate of potash should be frequently 
used as a wash for the removal of fetor. The general strength is to be sus- 
tained by milk, concentrated broths, tonics, and stimulants. Opium will be 
required to allay restlessness and procure sleep. 
Phimosis.—The inflammation accompanying chancroid may extend to the 
foreskin, causing phimosis. When the contraction is very close, rendering 
it impossible to retract the prepuce, the discharge will be retained about the 
glans penis, greatly increasing the local irritation, and completely concealing 
the chancroid from view. 
An attempt should always be made in these cases to overcome the compli- 
cation by external applications, rather than to resort to operative measures. 
The extremity of the penis should be buried in a hot poultice, which must 
be renewed every five or six hours. At each dressing the condition of the 
parts will be improved by bathing them well with hot water and laudanum. 
Fig.2052. 
Phagedana. CHANCROID. 
517 
Sometimes hot fomentations, with a decoction of chamomile, hops, or poppy- 
leaves, will give greater comfort than do the poultices. In order to dislodge 
any accumulations which are retained beneath the foreskin, and at tlio same 
time reach the ulcer, injections of water containing carbolic acid, sulphate of 
zinc, chlorinated soda, or nitrate of silver should be employed. If, in defiance 
of these measures, the phimosis refuses to yield, and it becomes important to 
expose the chancroid, it will be necessary to slit up the prepuce on a director, 
to cauterize the ulcer with nitric acid, and to apply the acid to the edges of 
the wound in order to prevent their inoculation, after which the parts should 
be swathed in a lotion of laudanum and water. 
Serpiginous ulceration of chancroid is an exceedingly obstinate complica- 
tion, and often defies for a long time the best-applied efforts to induce the 
repair of the sore. The chancroid slowly enlarges its boundaries in different 
directions, the edges of the ulcer having a sinuous or irregular outline, and 
the granulations being feeble and pale. 
Aside from constitutional treatment, local remedies are of very little bene- 
fit. Cod-liver oil, the various preparations of iron, wine,—especially Bur- 
gundy,—sea air, and a generous diet constitute for the most part the general 
regimen to be adopted, while the local means consist in modifying the nutri- 
tive processes at the border of the ulcer by stimulating applications, such as 
nitric acid, carbolic acid, bromine, and iodoform, and good is sometimes done 
by paring away the borders of the sore and starting the work of restoration 
anew. 
The diphtheritic complication consists in the deposit of aplastic lymph over 
the surface of the chancroid, which effectually opposes the growth of the 
granulation-tissue and thus renders the ulcer indolent and stationary. It is 
occasionally seen in syphilitic patients whose reparative forces are naturally 
feeble. The ulcer must be aroused by stimulating applications, such as the 
dilute acid nitrate of mercury, sulphate of copper, or nitrate of silver, and 
at the same time effort must be made to tone up the system by tonics and 
generous living. 
Paraphimosis, when of a character which threatens the vitality of the 
organ, will demand prompt attention. Reduction should bo effected by the 
appropriate manipulation. An anaesthetic, previously administered, will con- 
duce to the success of the efforts of the surgeon to overcome the constric- 
tion. Should these efforts fail, the knife must not be withheld, and it should 
bo followed, as in phimosis, by cauterization of the chancroid and of the 
wound. • 
Balanitis.—The existence of a balanitis leaves the surface both of the 
glans and of the prepuce in a condition favorable to inoculation: hence the 
propriety of cauterizing an}r suspicious points which appear on their surfaces. 
Chancroid in women.—The treatment of chancroid in the female is to be 
conducted on the same general plan as that already laid down for the male. 
Bubo.—The treatment of chancroidal bubo must be regulated by the par- 
ticular stage at which the affection is seen by the surgeon. If seen early and 
before the inflammation has made any material progress, an abortive plan 
should be adopted. This, to bo advantageously carried out, requii’es that 
the patient should be confined to the recumbent position. The diet must 
be restricted, the bowels freely opened with an aperient, and to tranquillize 
the circulation the neutral mixture in combination with tincture of aconite 
or tincture of veratrum viride should be administered every two or three 
hours: 
Tincturas Veratri Viridis, gtt. xxx; 
Liquoris Morphias Sulphatis, ; 
Misturas Potassae Citratis, f^vss.—M. 
Sig.—Dessertspoonful every two hours. 
A few leeches, when they can be obtained, may next be applied very near 
the swollen gland, after which a mixture consisting of two parts of tincture 
of iodine and one part of tincture of belladonna should be applied. To 518 
SYPHILIS. 
obtain any satisfactory effects from this remedy, it should be laid on with a 
camel’s-hair brush for not less than ten or fifteen minutes, or as long as the 
skin can be made to take it up, after which firm compression must be made 
over the bubo by a compress and a spica bandage, or by means of a bag con- 
taining a quantity of shot. Iodoform enjoys some reputation as a resolvent 
in cases of chancroidal bubo, and may be applied in the form of an ointment. 
Blisters have also been employed with decided benefit, but only when the 
active inflammation has boon subjugated and there remains a certain degree 
of tenderness and hardness about the affected gland. When the inflamma- 
tion has become well established, all hope of securing its resolution is vain; 
suppuration is inevitable, and it is a waste of time to persevere with abor- 
tive remedies. The time has arrived to apply emollient poultices and 
thus hasten the maturation of the abscess. As soon as fluctuation is discov- 
ered, a free incision must be made and the pus evacuated. In planning the 
incision, it will be well to make it in the vertical direction. Some advise 
the crucial cut, in order to offer the freest outlet for the matter, so as to 
prevent as much as possible the burrowing which so often occurs in bubo. 
The abscess having been opened, the poultice should be continued for one 
or two days, after which a pledget of lint moistened with carbolated oil, or 
a piece of sponge similarly treated, should be laid over the gland and secured 
in place either by adhesive plaster, a spica roller, or a sling of the groin. 
The bleeding which follows the opening of a bubo rarely continues more 
than a few minutes. Should it persist, it can readily be controlled either by 
a compress and bandage, or by packing the wound with pellets of lint. 
Very frequently it will be found that instead of healing kindly there is a 
tendency to the formation of sinuses lined with imperfectly-organized gran- 
ulations. These sinuses extend their channels in different directions through 
the interglandular connective tissue. The untoward process may continue 
until the connective tissue has been destroyed and the glands are left isolated 
or detached from one another. The discharge in such cases is generally 
thin and watery, and contains very little healthy pus. The skin over the 
affected region becomes of a dark-red, livid, or purple color. 
The remedy for such a state of the tissues is to pass a director along each 
sinus and lay it freely open, dissecting or scooping out the individual glands 
as they appear, after which the wound is to be packed with carbolated lint 
in order to favor granulation and cicatrization. 
The general health must not be neglected in cases of this kind. It will 
often be found necessary, in addition to local treatment, to direct good food, 
along with tonics and cod-liver oil. 
Other complications of bubo, such as serpiginous ulceration, phagedfena, 
etc., are to be treated according to the rules prescribed for similar conditions 
of chancroid. 
LOCAL SYPHILIS. 
Chancre. 
As chancre constitutes the first act in the syphilitic drama, it will be neces- 
sary, in treating of the subject under consideration, to speak first of this 
primary lesion. 
A period of incubation always precedes the development of indurated or 
infecting chancre. This interval between the first external evidence of dis- 
ease and the reception or absorption of the poison, first distinctly described 
by Cazenave, varies in different cases: it will be found in a majority of in- 
stances to be comprised between eighteen and days, the average 
period being from twenty to twenty-four days. Fournier furnishes examples 
in which this period was prolonged until seventy-five days. Bumstead and 
Taylor have seen no cases extending beyond fifty days. The shortest period 
of the stage of incubation which lias been observed was noted in the cases 
mentioned bj’ Didaj7 and Otis,—namely, twenty-four hours. The irregularity CHANCRE. 
519 
in the period of incubation depends upon a variety of circumstances. When 
the virus comes in contact with an abraded surface, the interval between 
exposure and the appearance of the sore will be short; but if the poison is 
lodged in a follicle, its absorption will be slow. 
Chancre appears in the form of a hard papule, erosion, ulcer, or desqua- 
mation. The first sign of the visible operation of the poison, when the ob- 
server is fortunate enough to witness the disease on its earliest appearance, 
and when there has been no precedent abrasion of the skin, will be observed 
as a red pimple having either a flattened or an elevated surface, very dis- 
tinctly defined. This point or surface soon begins to desquamate, and may 
never become an open sore. More frequentl}7, however, the physician does 
not see the primary lesion until after a distinct crack, erosion, or ulcer has 
formed, at which stage, in case an ulcer exists, the sore is slightly concave, 
its margins somewhat elevated in consequence of the multiplied cell-prolifera- 
tion increasing the layers of the epidermis, its sides sloping towards the 
centre, and the crater of the ulcer studded with minute papillary eminences 
or hypertrophied papillae of the derm. The surface of the sore is usually 
slightty covered with pus, a thin pseudo-membrane, a few epithelial scales, 
and some minute fragments of necrosed skin-elements. 
The abraded variety of chancre is believed to be most common. Accord- 
ing to Bassereau, it occurred one hundred and forty-six times out of one hun- 
dred and seventy cases of indurated chancre, the source of the contagion 
being derived in most instances from secondary lesions. 
The chief characteristic of the dry, scaly form of chancre consists in a 
localized accumulation of epidermic cells with a parchment induration. 
When the chancre appears as a crack, the sides and bottom of the ei*osion 
exhibit a shining or polished appearance, and are covered with a grayish or 
olive-colored membranous film, except when occurring on the skin, where it 
is covered by a scab. The sore is either quite dry, or discharges a little thin 
serous fluid. The size of the sore varies from that of a pea to that of a half- 
dime. Little, if any, pain is experienced in the development of chancre, and 
hence its existence may never be suspected until accidentally discovered. 
The lesion is often so small as to escape notice. This fact will explain those 
cases of constitutional syphilis in which the patient is unable to refer to any 
time when a primary sore existed. 
The painlessness of chancre is thought to be due to the fact that the exuda- 
tion, which separates the nerve-fasciculi from their sheaths, is non-inflamma- 
tory. This anatomical explanation is plausible, but I am disposed to believe 
that the absence of pain is to be attributed to local anaesthesia, the result of 
zymotic changes wrought by the syphilitic poison or ferment on the blood. 
Shortly after the appearance of the chancre, that is to say, ordinarily be- 
tween the eighth and the fourteenth day, a very important change is observed, 
—namely, induration, the most characteristic feature of the infecting sore. 
That the period between inoculation and induration varies greatly in dif- 
ferent patients is evident from the analysis presented by syphilographers. 
Sigmund, in two hundred and sixty-one cases, gives the average at seventeen 
days. In forty-five cases recorded by Fournier, the average was thirty-one 
days. Le Fort found the average time to be nineteen days, while Chabalier 
and Diday fix the period respectively at eighteen and fourteen days. Occa- 
sionally induration has been observed as early as the second or third day; 
in one instance, reported by Dr. R. W. Taylor, in twenty-four hours. On 
the other hand, there are instances in which this change does not appear 
until after the lapse of a month ; and in a case recorded by Bumstead, in- 
duration was not noticed until after a period of fifty days. 
This induration, which commences in the papillae, extends into the deeper 
portions of the derm, and into the subdermic tissue immediately underlying 
the chancre; and it is so well defined and characteristic as to be quite dis- 
tinguishable by the touch. It does not, as a rule, extend beyond the mar- 
gins of the sore, at which boundary it is usually very sharply, even abruptly, SYPHILIS. 
defined from the contiguous portions of the skin, and when carefully exam- 
ined by the fingers is found to underlie the entire ulcer, feeling like a thin 
piece of parchment, or, as described by Bell, like a split pea; occasionally the 
induration may bo most conspicuous at the circumference, where it is some- 
times irregular in thickness. The extent of induration is determined in a 
measure by the location of the sore, being less when the latter is situated 
near the frsenum or on the anterior part of the glans penis. Babington and 
others believo that the induration precedes the ulceration in chancre. 
A vertical section of the chancre, as described, would present a central 
cup-shaped depression, covered with a grayish granular false membrane, con- 
tinuous at its circumference with the epidermis, but thinner than normal. 
The rete mucosum, or soft cellular layer covering the papilla?, quite thick at 
the circumference, is very thin beneath the floor of the ulcer, while the con- 
nective tissue of the derm is greatly thickened by infiltration, constituting for 
the most part the induration felt under the sore. When an ulcerating 
chancre is examined after the work of repair has commenced, it will be seen 
that the epidermis and rcte-mucosum layers thin out as they approach the 
margin of the sore, over which they are entirely absent, the space being oc- 
cupied by hypertrophied papilla?, over the surface of which are scattered 
pus-corpuscles and fragments of epidermic cells. (Fig. 2053.) 
Fig. 2053. 
Section of indurated chancre: a, epiderm; b, rete mucostim stopping at the point of ulceration; c, pus-cor- 
puscles and false membrane; d, papilla?; n, vessels; t, superficial induration of connective tissue ; m, deep indura- 
tion, that of connective tissue beneath the papilIre ; v, indurated vessels. 
The anatomical elements of the induration consist of a cell-infiltration which 
occupies not only the 
meshes of the connective 
tissue of the derm, but also 
the walls of the blood- 
vessels. (Fig. 2054.) The 
lymph-vessels are found 
crowded with lymph-cor- 
puscles at some places, 
particularly after the in- 
duration has existed for 
a short time. (Fig. 2055.) 
At other places these ves- 
sels are empty. (Fig. 
2056.) The connective 
tissue around the seba- 
ceous and sudoriferous 
follicles, and that also 
around any nerve-fila- 
ments which may be 
present in the sclerosed 
region, are likewise filled 
with new cell-elements. 
The activity of the glandular epithelium, imparting a swollen appearance to 
Kio. 20'>4 
Section of four vessels in the indurated part of chancre, showing infil- 
tration of walls of vessels, t,l, and their canals also crowded with lymph- 
cells, a, a, a, a; e, e, surrounding connective tissue, also infiltrated. CHANCRE. 
521 
the follicles, which is characteristic, may be merely the result of local hy- 
peraemia. 
The surface of the in- 
durated chancre is cov- 
ered with a scanty, gran- 
ular secretion, coagula- 
ble with alcohol, which, 
examined microscopic- 
all}', is found to con- 
tain pus-corpuscles and 
lymph-cells in different 
stages of degeneration. 
(Fig. 2057.) The fatty 
granular matter is inter- 
mingled with vegetable 
spores and rod-shaped 
bacteria. The pseudo- 
membrane which covers 
the floor of the chancre is 
made up of closely-inter- 
woven fibrils, its texture 
resembling in intricate interlacing the fibres of a sponge. The meshes of 
the membrane contain corpuscles resembling lymph-elements in appearance. 
(Fig. 2058.) 
The induration of 
chancre rarely extends 
beyond a month, and in 
a fortnight longer the 
ulcer usually undergoes 
spontaneous healing, 
though a peculiar hard- 
ness at the base of the 
site of the chancre may 
persist for years. 
It is possible for a 
chancre to possess the 
power of infection and 
yet lack altogether the 
element of induration; or, 
if this does exist, it may 
not be detectable. Yidal 
and others have noticed 
such cases. In one of 
my own patients, a med- 
ical student, there was 
no trace of induration present, and had it not been for the dry and eroded ap- 
pearance of the sore I should have dismissed all thought of contagiousness. 
Fig. 2055. 
c 
Section of an indurated chancre, exhibiting new cell-forms, which 
swarm in the connective tissue of the derm ; and lymph-corpuscles filling 
the lymphatic vessels, l, and veins, v. 
Fig. 2050. 
Section of the indurated portion of a chancre : a, artery ; v, vein; /, lym- 
phatic; c, connective tissue; e, vasa vasorum. 
Fig. 2057. 
Epidermic cells, pus-cells mingled with granular material, desquamated epidermic cells, and corneous cells. 
Seat of chancre.—The ordinary site of genital chancre in the male is near 522 
SYPHILIS. 
the freenum of the penis, on the glans penis, at the corona, on the prepuce, 
at the iunetion of the nenis with the scrotum, or near the pubes, in the 
meatus or in the urethra. 
Chancre also occurs at 
the verge of the anus, on 
the lips, the eyelids, the 
tongue, the nose, and, 
more rarely, on the face 
and hand. In the female, 
chancre is usually situated 
on the labia majora, the 
fourchette, the nymphae, 
at the orifice of the vagina, 
—rarely, if ever, in the canal,—on the cervix uteri, near to or in the urinary 
meatus, within the anus, between the folds of the mucous membrane, or on 
the groin. The nipple is frequently inoculated 
by contact with secondary lesions. The ex- 
emption of the vagina from chancrous ulcera- 
tion is attributed to the numerous layers of 
epithelial cells with which its mucous membrane 
is covered, and also to the absence of glands. 
Fournier, in a collection of 471 chancres oc- 
curring in males, found only 26 which were not 
seated on some part of the genital organs. Of 
the 445 genital chancres, 314 were on the glans 
and foreskin. (Fig. 2059.) Clerc, in 394 chan- 
cres, analyzed with a view to their position, 
found 171 similarly located in the balano-pre- 
putial fold. The cervix uteri was the seat of 
chancre 13 times in 249 chancres occurring in 
females, according to Fournier. Martin, in an 
analysis of 45 cases of chancre in females, found 
33 genital and 12 extragenital. Fournier, in 
249 chancres in the same sex, found 114 on the 
labia majora, 55 on the labia minora, only 1 in the vagina, and 13 on the 
cervix uteri. 
Urethral chancre, giving rise to a discharge from the canal, was for a 
long time regarded as gonorrhoea. Its situation is generally either just 
within the meatus or in the fossa navicularis. Robert observed the lesion 7 
times in 300 cases of gonorrhoea, and, according to the statistics of the 
HOpital du Midi of Paris, urethral chancre occurred 49 times in 471 cases. 
Jullien, in 1773 chancres, reports 89 in the meatus urinarius, and 17 in the 
canal of the urethra. The period of primary incubation in instances of 
urethral inoculation is usually more prolonged than elsewhere, the urine 
probably being to some extent antagonistic to the poison, either by diluting 
or expelling it. 
Subpreputial chancre, when accompanied or followed by phimosis, may 
also be mistaken for gonorrhoea. 
The diagnosis between urethral chancre and gonorrhoea will be assisted by 
observing the contrasts in the following comparison : 
Fio. 2058. 
False membrane from surface of a chancre : t, series of trabeculae forming 
a net-work ; c, c, spaces in the trabeculae; a, epidermic cell. 
Fig.2059. 
Indurated chancre near the fraenum. 
URETHRAL CHANCRE (HARD). 
GONORRIKEA. 
Incubation of disease not less than twelve days. 
A single lip of the urinary meatus intensely 
red and swollen. 
Discharge thin, serous, probably bloody. 
Ardor urinro trifling, and at the extremity of 
the canal. 
No chordee. 
Induration can be discovered. 
Discharge and ardor urinre appear much earlier. 
Both lips swollen. 
Discharge thick, purulent. 
Ardor urinse severe, and extending back along 
the canal. 
Chordee. 
No induration. CHANCRE. 
523 
In subpreputial chancre with phimosis, the induration can often be felt 
through the skin, the inflammatory symptoms are rarely of a high grade, 
the discharge is thin and serous, the swelling is not oedematous, the orifice 
of the prepuce is not ulcerated, and tho inguinal glands are enlarged ; all 
these symptoms being reversed in non-syphilitic inflammation or ulceration. 
Extragenital chancres are widely distributed. 
Labial chancre is the most frequent of the extragenital lesions, both in men 
and in women, amounting to something less than one-half of tho cases, the 
inoculation occurring in the act of kissing. Chancre of tho lips appears 
usually as a painless papule with an indurated base, or as a crack or an 
ulceration. When in the last-named form, the ulcer is generally somewhat 
painful, and is attended with considerable swelling and a firm infiltration. 
The inoculation is greatly favored if a fissure or abrasion of the lip existed 
before the application of the contagium. The submsjxillary lymph-gland 
becomes affected in tho course of eight or twelve days after the lesion is 
developed. 
Labial chancre may readily be confounded with epithelioma. Patients 
have been brought to mo for operation under the impression that the ulcer 
was carcinomatous. By attending to the following considerations a correct 
diagnosis may be reached : 
CHANCRE. 
EPITHELIOMA. 
A history of exposure to syphilis; frequently 
ayphilidcs patent to the eye. 
Not peculiar to any age. 
Without unusual sensibility or pain. 
If on the lip, either lip may suffer. 
Submaxillary lymph-glands early involved. 
Ulcer often increasing rapidly. 
Odorless, or nearly so. 
Induration sharply limited by the ulcer. 
Heals rapidly under specific treatment. 
No such history necessarily. 
Generally after middle life. 
Burning or lancinating pain. 
Very much more common on the lower than 
on the upper lip. 
Lymph-glands slow to become enlarged. 
Extension generally slow. 
Odor offensive. 
Induration some distance beyond the sore, and 
fading gradually into the surrounding parts. 
Refuses to heal under any treatment. 
Chancre of tonsils.—Chancre, when seated on the tonsil, the uvula, or the 
lateral half-arches, is often regarded as simply one of the effects of ordinary 
sore throat. The error I havo known to be frequently committed. The 
experienced eye will always recognize some features of the secret enemy. 
The extreme regularity of the edges of the ulcer, the very gradual slope of 
its sides, the scanty secretion, and, when touched with the finger, the con- 
stantly-prescnt induration, and the absence of acute inflammatory symptoms 
or soreness, are all symptoms which should awaken suspicion and lead to 
a close inquiry into the antecedent history of the patient, the surgeon at the 
same time carefully scrutinizing the body in search of external manifesta- 
tions of the constitutional disorder. If doubt still remains, the disappear- 
ance of the ulcers under the use of iodide of potassium or mercury will reveal 
their true origin. 
Anal chancre.—Chancre of tho anus comes next in order of frequency, 
constituting about one in every twelve cases of the lesion in the male, and 
one in every four in the female. The ulcer will be brought into view by un- 
folding the plications of the mucous membrane at the verge of the anus. It 
may be readily mistaken for fissure, which in the early stage it strongly re- 
sembles. Fissure, however, is an exceedingly painful affection, the paroxysms 
coming on a short time after defecation, and continuing often for many hours. 
Chancre, on the contrary, is generally unattended by severe pain ; the exist- 
ence of the sore may not, for a time, be suspected, and it is followed by en- 
largement of the inguinal glands. Chancre also yields to internal remedies, 
fissure only to operative measures. 
Mammary chancre in the female comes next in frequency to the anal lesion, 
constituting about one in every ten cases of extragenital sores, and is gen- 524 
SYPHILIS. 
erally derived from mucous patches on the lips or tongue of a syphilitic infant 
When seated on the integument near the base of the nipple, the character- 
istic appearance of the chancre is that of an oval papule or erosion with 
indurated base, and often with adherent crusts. When seated on the nipple, 
the lesion may readily pass for a simple fissure. The significant induration 
and the invariable painless enlargement of the axillary glands, however, 
reveal the syphilitic origin of the sore. 
Digital chancre.—Chancre of the finger I have witnessed five times, and 
in every case the unfortunate victim was a physician, the disease having been 
contracted in discharging the usual duties of an accoucheur. The sore is 
generally seated on the index finger, either near the root of the nail or 
on the dorsal aspect of the proximal phalanx. Digital chancre is often ex- 
tremely difficult to heal. It commences as a papule, pustule, or crack, rest- 
ing on a deeply-imbedded induration. When ulcerated, the edges of the 
sore are thickened, having a purple or a livid color. The discharge from 
the ulcer is thin, scanty, and serous. Enlargement of the supra-cond}Tloid 
lymph-gland follows the appearance of the lesion, and later the axillary 
glands become affected. 
The rarer sites for extragenital chancre are the gum (extremely un- 
common), the tongue,—one in every ten cases in the male, much less fre- 
quent in the female,—the face, nose, eyelids, abdomen, thighs, and nates. 
Chancre of the tongue is followed by enlargement of the submaxillary 
lymphatic gland. When seated on the face, the submaxillary gland suffers; 
when on the eyelids, the pre-auricular glands are involved, and when on the 
abdomen, thighs, or nates, the inguinal glands. 
Rectal chancre is exceedingly rare, and scarcely occm-s except as the result 
of unnatural intercourse. It is not improbable that some cases of syphilitic 
stricture of the bowel are the result of a primary sore. 
Number.—Indurated chancre is generally solitary. Fournier states this to 
be the case three times out of ever}r four. When multiple, the lesions ap- 
pear almost simultaneously, the number rarel}" exceeding three or four, 
though as many as eight, ten, and, in two cases given by Fournier, the very 
unusual number of nineteen and twent}r-three have been observed. 
Inoculability.—Infecting chancre, as a rule, is not auto-inoculable; that 
is, the products taken from the infecting sore of a person and introduced 
into the skin of the same individual possess no power to produce a second 
chancre. It is the knowledge of this fact which enables the physician, when 
doubt exists as to the exact nature of a particular chancre, to establish a di- 
agnosis by inoculating the patient with the secretions of his own sore. While 
the statement made that the indurated sore is not auto-inoculable is true 
in a largo proportion of all cases of this lesion, there are a few exceptions 
in which by inoculation a second chancre is produced possessing all the con- 
tagious properties and tendencies of the first. That such is the case can 
scarcely be doubted in view of the testimony of Mr. Lane, who witnessed 
seven thousand inoculations. It is possible, by irritating a hard chancre to 
the extent of causing suppuration and mingling the pus thus formed with 
the other products of the sore, to secure an inoculable virus; and it is also 
true that by inoculating an indurated chancre with the virus of a soft 
chancre or chancroid, a compound or mixed sore (Rollet’s chancre) can be 
obtained, which will combine in itself the properties of both chancre and 
chancroid. 
Diagnosis of Chancre.—The physician is often called upon to determine 
at a very early period the nature of an excoriation, crack, or ulcer seated 
on some part of the genital organs, and it behooves him to be extremely 
cautious in forming a diagnosis; indeed, in many cases, before the unmis- 
takable peculiarities of the initial lesion have shown themselves, no positive 
opinion should be ventured, even when the circumstances preceding the 
local sore may be all favorable to its specific character. When, however, a 
papule, erosion, or ulcer, after a period of twelve or fourteen days, without CHANCRE. 
525 
any local irritation whatever, takes on induration, and when this induration 
is accompanied or followed by a painless enlargement of the lymph-glands 
in direct relation through the lymphatics with the sore, it is scarcely pos- 
sible not to regard such a lesion as syphilitic, and to predict the near approach 
of constitutional manifestations. 
Chancre may be confounded with chancroid, herpes, epithelioma, and gon- 
orrhoea. Between chancre and chancroid the differential signs may be stated 
as below: 
CHANCRE. 
CHANCROID. 
Originating from contagion, derived from a 
chancre, a secondary lesion, or the blood of a per- 
son affected with syphilis. 
Has a period of incubation from twelve days 
to six weeks. 
Commonly seen on the genitalia; not unfre- 
quently on the lips, nipples, or fingers. 
Commences as a papule, erosion, tubercle, or 
ulcer, though it may pass through all its stages 
with ulceration. 
Usually single or solitary, or, if multiple, the 
different lesions occur at the same time. 
Slow in its progress; often rapid in healing. 
In form, round or oval. 
Very superficial, slightly cup-shaped ; may be 
raised above the surrounding surface. 
Edges or sides of the lesion smooth, sloping 
gradually towards the centre, and adherent. 
Surface smooth, polished, red, copper-colored, 
glazed, and covered with a diphtheritic layer or 
crust. 
Secretion scanty, serous, rarely auto-inoculable. 
Induration present in almost all cases, sharply 
defined and circumscribed, parchment-like in 
feel, readily movable over the subjacent parts; 
persistent; disappears under constitutional treat- 
ment. 
Originating by inoculation with pus from a 
similar sore, or from the discharges from a chancre 
of a person affected with syphilis. 
No period of incubation. 
Rarely seen anywhere save on the prepuce or 
the glans penis. 
Commences either as a pustule or as an ulcer. 
Very often multiple, and often from consecutive 
auto-inoculations. 
Advances rapidly; slow in healing. 
In form, irregularly round or oval, the borders 
somewhat scalloped. 
Excavated, scooped out, deep. 
Edges or sides perpendicular, abrupt, and un- 
dermined. 
Uneven, ragged, grayish, or of light-red‘Color. 
Abundant, purulent, and auto-inoculable. 
Induration accidental, induced by irritants; 
lacks abrupt definition, fading off gradually into 
the surrounding parts; a mere inflammatory in- 
filtrate, which renders the ulcer fixed, and dis- 
appears with the cicatrization of the sore. 
The differential features of chancre and chancroid when located on the 
cervix uteri may be contrasted as below: 
CHANCRE OF THE CERVIX UTERI. 
CHANCROID OF THE CERVIX UTERI. 
Almost always single. 
Surface little if at all elevated above the sur- 
rounding parts; borders sharply defined. 
Generally small in the extent of tissue involved, 
and without an area of surrounding inflamma- 
tion. 
Color of the lesion grayish, and covered with a 
false membrane. 
Not auto-inoculable. 
No sore at the same time on the external geni- 
talia. 
Multiple as often as single; two or more may- 
become confluent. 
Marked excavation; edges undermined and ir- 
regular, with evident loss of tissue. 
Quite frequently extensive, with surrounding 
inflammation. 
Color yellowish, without any false membrane. 
Auto-inoculable. 
One or several sores on the external genitalia at 
the same time with the sore on the cervix uteri. 
Follicular inflammation of the cervix uteri can be distinguished from 
chancre and chancroid by the diminutive size of the ulcers as compared 
with those peculiar to venereal disease. The follicular ulcers are also slightly 
excavated. 
Herpetic eruptions simulate in some respects chancre and chancroid. 
There are several characteristics belonging to herpes which are valuable in 
forming differential diagnosis. For example, herpes begins in a number of 
small vesicles, which tend to become confluent. The ulcers are very super- 
ficial, and are often painful, their edges irregular or serrated, and the secre- 
tion from the sores is inoculated with difficulty. Herpetic ulcers often occur 
as the result of mechanical irritation, as from friction of the clothing or from 526 
SYPHILIS. 
irritating dressings. Crops of the eruption are often seen to follow in quick 
succession, and generally the disease yields promptly to external remedies. 
Indurated bubo.—Indurated bubo is the almost invariable accompaniment of 
indurated chancre. This peculiar enlargement of the lymph-gland was first 
noticed by Gaspard Torella about the end of the fifteenth century. The 
glands affected are those in nearest relation to the initial lesion. The super- 
ficial lymph-vessels of the generative organs, of the lower extremities, lower 
part of the abdomen, perineum, and buttock terminate in the subcutaneous 
lymphatic glands of the groins. Hence the inguinal glands are the ones 
affected by indurated chancre located within the bounds of the above-named 
regions (Fig. 20G0); the epitrochlear gland, above the internal condyle of 
the humerus, in chancre of the fingers 
or forearm; the axillary glands, in 
chancre seated over the thorax or on 
the nipple ; and the glands over the sub- 
maxillary gland, when the sore is on the 
lips, tongue, and face. AVhen the chancre 
is on the penis of the male or the clitoris 
of the female and is central, or when 
the lesions are multiple and on both 
sides, the contagion may enter the in- 
guinal glands of both sides and bilateral 
buboes follow. 
The uniformity with which indurated 
bubo follows indurated chancre will ap- 
pear from the statistics of Bassereau 
and Fournier, which conjoined amount 
to 645 cases of hard chancre, and of 
which number the lymphatic glands 
were involved 615 times. So generally 
do writers on syphilis concur in the con- 
sociation of the indurated chancre and 
indurated bubo that the almost constant 
companionship of the two affections 
may be accepted as an established fact. 
The chronological relation of the two indurations is nearly identical; the 
sclerosis of chancre and that of the glands being often simultaneous, or that 
of the latter following the former by a scarcely appreciable period of time. 
The clinical peculiarities of indurated bubo are hypertrophy of each ingui- 
nal gland of the group implicated; the facility with which the affected glands 
can be slid about in their connective-tissue investment; hardness and round 
or oval shape of the gland, with absence of the usual signs of inflammation, 
as l-edness, heat, pain, or tenderness. Indurated bubo exhibits little or no 
tendency to suppurate, and when the formation of pus does occur it is due 
to an attack of acute inflammation being engrafted upon the enlarged glands; 
and even under these circumstances the discharge is neither very copious 
nor purulent, consisting usually at first of a puriform liquid, and finally of 
a thin, ichorous, straw-colored fluid, and not inoculable. The infrequency of 
suppuration in syphilitic bubo is shown in an analysis of 968 cases of in. 
durated glands of' the groin by Bassereau, Rollet, and Fournier, 35 of which 
number suppurated. 
The lymph-vessels, which are the only channels of communication between 
the chancre and the indurated bubo, frequently suffer in common with the 
glands in which they terminate. The poison which they transport causes 
lymphangitis, and consequent coagulation of the contents of these vessels. 
In this condition they can be felt as hard, knotty cords beneath the skin of 
the penis. Later on, all the lymph-glands in the body participate in the 
affection. 
The anatomical characteristics of syphilitic bubo consist in an enlai’ge- 
Fig. 2060. 
Indurated inguinal glands. CHANCRE. 
527 
ment of the follicles of the rete mucosum, though the fibres of the latter 
remain unchanged. The irregularities seen on the surface of the gland, on 
divesting it of its capsule, are due to the hypertrophied follicles. There is 
no adhesion between the capsule and the surrounding connective tissue, 
which explains the facility with which the glands move under the finger. 
The number of cell-elements in the lymph-spaces is greatly increased ; some 
of these are very large, particularly in lymph-spaces around the follicles, and 
contain a number of blood-corpuscles. 
In contrasting the syphilitic with the chancroidal bubo, points of differ- 
ence are found sufficiently numerous to enable the observer, without much 
difficulty, to refer each to its proper origin. 
BUBO OF CHANCRE. 
BUBO OF CHANCROID. 
The invariable consequent of chancre. 
Without precedent inflammatory symptoms. 
Occurs a short time after chancre. 
Several glands of the groin affected at the same 
time. 
Extremely hard. 
Glands movable. 
Integument slides freely over the glands. 
Unaccompanied by pain. 
Chronic in its course; seldom ending in sup- 
puration. 
Not affected by local treatment. 
The result of chancroid or of some inflamma- 
tory or purulent infection. 
Always preceded by inflammatory symptoms. 
Irregular in the time of its appearance. 
A single gland affected. 
Moderately hard. 
Glands not movable. 
Skin adherent. 
Painful. 
Acute in its course; terminates generally in 
suppuration. 
Benefited by local treatment. 
The inflammation of the lymph-vessels which may follow both chancre 
and chancroid also present differential peculiarities. 
LYMPHITIS OF CHANCRE. 
LYMPHITIS OF CHANCROID. 
Lymph-trunks feeling very hard. 
Overlying skin unchanged in color and pain- 
less. 
Chronic in its course, and finally ends in reso- 
lution. 
Not affected by local applications. 
Moderately hard. 
Red and painful. 
Acute, and ends oftener in suppuration. 
Benefited by local treatment. 
Prognosis.—The prognosis of chancre has both a local and a general im- 
portance. Yiewed simply as a local sore it cannot be regarded as a danger- 
ous lesion, as in most instances it is quite amenable to treatment. When, 
however, chancre becomes the subject of phagedsena or of gangrene, with 
or without hemorrhage, it may cause considerable mischief from the rapid 
extension of the morbid process, unless attacked by vigorous measures at 
the onset of the complication, when its power to do harm will be greatly 
lessened. A chancre located on the tongue, or on some other part within 
the mouth or fauces, may interfere very much with nutrition, in consequence 
of the inconvenience, often positive suffering, attending the acts of mastica- 
tion and deglutition, and also from the vicious character of the discharges 
which proceed from the sore and which find their way into the stomach. 
Chancre of the rectum might lay the foundation of stricture, or, if seated on 
the conjunctiva, of a violent inflammation of the eye. I have seen the lip 
dreadfully mutilated from the ravages of a chancrous lesion. 
The most serious feature connected with chancre is its relation to the con- 
stitutional disease which almost invariably follows its presence. The greatest 
difference exists in regard to the severity of the secondary and other sequels. 
Nothing can be predicted on this point from a study of the primary lesion. 
In one case the period of incubation may be short and the constitutional out- 
break violent, while in another person the time of incubation may be long 
and the succeeding general symptoms quite mild. Every practitioner who 
has had much experience with syphilis will have observed that sometimes 
the disease yields very kindly after a brief period of treatment, giving no 
signs of the general infection for years, possibly none during the life of the 528 
SYPHILIS. 
patient; at other times the syphilitic manifestations are constantly cropping 
out, and can be held in abeyance only by uninterrupted treatment. This 
difference cannot be explained by any peculiarity in the virus, but is to be 
attributed to constitutional peculiarities of the persons who have been the 
subjects of s}rphilis. The evidence in support of this view is to be found 
in the cases, frequently observed by syphilograpbers, of two persons exposed 
to the same source of contagion, one of whom is subsequently attacked by 
an aggravated, persistent, and relapsing form of syphilis, and the other 
with the mildest and most easily managed variety of the disease. If the 
subject who contracts syphilis has inherited a strumous organization, or is of 
a lymphatic temperament, it may be confidently assumed that the treatment 
will be less satisfactory than when the virus invades the constitution of an 
individual in other respects sound. Intemperance, debauchery, pregnancy, 
and bad hygienic surroundings are all causes which impart unusual intensity 
and obstinacy to syphilitic disease. The fact, however, that syphilis, having 
once gained the citadel, may never be dislodged, that its conquests may 
extend not to one portion only, but to every tissue and organ of the body, 
and that it is susceptible of being transmitted from generation to genera- 
tion, is sufficient to cast an appalling shadow over the whole future of a 
person who has become the victim of the disease. 
Treatment.—Is it possible that constitutional syphilis can be prevented 
by destroying a chancre at the moment of its first appearance ? This ques- 
tion has been answered differently by different syphilographers, some eon- 
tending that abortive treatment may be employed in many instances with 
success, while others with equal confidence maintain a contrary view, al- 
leging that even before the primary lesion has developed into a recogniza- 
ble sore the mischief has been done ; in other words, that the moment the 
virus comes in contact with the surface, under circumstances favorable for 
its absorption, the ’work of contamination begins, and that the characteristic 
induration is the evidence not simply of a peculiar local morbid process, but 
of a poison already generalized. Of course this doctrine excludes altogether 
the idea of incubation. I am disposed to think that the interval between 
cause and effect—that is, between the reception of the virus and the consti- 
tutional implication—is not so short as the friends of the above doctrine would 
have us believe. At the same time, it is too short in most cases to be avail- 
able for the successful employment of abortive measures. It is true that 
there is not wanting evidence to show that a certain order is observed in 
the syphilitic invasion: first, the primary lesion; next, the glandular affec- 
tion ; and, last, the generalization of the poison. This phenomenal procession 
is indicated by the fact that if from any cause a syphilitic bubo is attacked 
by destructive inflammation, the system often escapes contamination. 
Many practitioners, on the ground that syphilographers disagree in regard 
to the possibility of aborting the disease, believe that the patient should have 
the benefit of the doubt, and accordingly recommend the removal of the 
chancre as early as possible, either by excision or by cauterization with acid 
nitrate of mercury. 
Auspitz and Paul Unna furnish 23 cases in which excision of the chancre 
was performed. Fourteen of these escaped constitutional syphilis, 9 were 
affected. In contrast with the above, we have 32 cases of excision of chancre 
by Bumstead, Zeissl, Mauriac, and Newman, without in a single instance 
preventing the development of general syphilis. M. Mauriac also performed 
excision in 6 cases of indurated chancre at different periods, from fifty hours 
after the appearance of the sore until the sixteenth day, and in all before 
any gland-infection was discoverable, and yet in not one case was the general 
disease prevented. 
In my own practice, I am content with keeping the chancre dressed with 
a piece of lint which has been well moistened with black-wash, enforcing the 
utmost attention to cleanliness, by directing frequent ablutions with carbo- 
lated water, and protecting the parts against the friction of the clothing. CHANCRE. 
529 
Intercourse should be positively forbidden, as it cannot fail to disturb the 
progress of the sore towards healing, besides subjecting other persons to 
the risk of a similar inoculation. Under this treatment the sore usually 
heals in the course of twelve or fourteen days, though the induration may 
continue for an indefinite period, and disappear only under constitutional 
treatment. 
The more violent methods of treatment are generally powerless to prevent 
constitutional infection, and, as regards the cauterants, have the disadvantage 
of protracting the healing of the ulcer. There are patients, however, whose 
minds are greatly perplexed unless some heroic measures are adopted for 
destroying the primary lesion; and if their fears cannot be allayed in any 
other way than by excision or by cauterization, one or other of these plans 
may be adopted. 
When cauterization has been employed, the separation of the slough will 
be favored by keeping the parts covered with a warm-water dressing during 
the day, and with a flaxseed-meal poultice at night. When the dead tissue has 
been detached, lint soaked in black-wash or in aromatic wine and placed over 
the parts will form the best application. It must not be overlooked that the 
ulcer which results may still retain the characteristics of the original sore. 
As long as induration exists about a chancre, it should be regarded with 
suspicion, as a sore still charged with a power for evil. 
When it has been ascertained that the lesion is an indurated chancre, and 
that consequently constitutional symptoms will, in all probability, follow, 
it is proper to consider the possibility of adopting some course of treatment 
with a view so to modify the poison and lessen the intensity of its operation 
that the external manifestations, when they do appear, shall be slight and 
of brief duration. Here, again, there is a want of agreement among prac- 
titioners, some being in favor of inaugurating a constitutional treatment at 
once before any general symptoms appear, while others are content to wait 
until an outbreak occurs. There are objections to both plans of treatment. 
If the first is adopted, and the usual secondary manifestations are prevented 
or postponed, it leaves the patient in a state of dread uncertainty as to 
whether his system has been poisoned or not by the original sore, a state 
often worse in its effects on the mind than the disease itself. If, on the 
other hand, no constitutional treatment is directed, the induration about the 
chancre, it is said, will continue for a long time, and the secondary manifesta- 
tions often assume an aggravated type. I know of no reason why the con- 
stitutional treatment should not begin as soon as the diagnosis is assured. 
The remedies to be used will be indicated in detail when the treatment of 
syphilis is reached. 
Complications.—The complications of chancre do not differ in their nature 
from those which disturb the orderly progress of chancroid, nor is it neces- 
sary to modify the plan of treatment. 
The adenopathic sequels of chancre require no special therapeutics other 
than those proper to the general disease, except in cases where an accidental 
inflammatory element is engrafted on the affected glands, the existence of 
which will be readily recognized by increased swelling, tenderness, and a 
certain degree of redness. These symptoms will most likely yield to rest in 
the recumbent position, and the free use of tincture of iodine and belladonna 
over the inflamed glands, conjoined with a moderate degree of pressure, 
either by a compress and spica roller or by a bag of shot. If suppuration 
occurs, the abscess must be laid open and treated in all respects like a sup- 
purating or chancroidal bubo. 
Constitutional Syphilis. 
At a period varying from six to eight weeks after the appearance of the 
indurated chancre, or sixty or seventy days after inoculation, the first general 
manifestations of the syphilitic poison appear in a series of lesions affecting 530 
SYPHILIS. 
the skin and mucous membranes. There are many exceptions, it is true, 
in regard to the time intervening between the initial lesion and the outbreak 
of constitutional phenomena. Instances are recorded where that period ex- 
tended over three or four months; and it is not improbable that even a much 
longer time may elapse during which the virus remains dormant. I once 
attended, in consultation with the late Dr. Wallace, of this city, a gentleman 
from California who had been affected with an obstinate iritis. Believing 
the disease to be syphilitic, I suggested the propriety of administering mer- 
cury, as the inflammation had resisted other treatment, and under its use 
the patient rapidly recovered. On asking this man if at any time previously 
he had suffered from constitutional syphilis, he replied that never in all his 
life had there been a single mark of the disease on his person. Eleven years 
previously he had a small abrasion on the glans penis, which healed sponta- 
neously in a few and for which no treatment whatever had been em- 
ployed. This patient had no motive for concealment, and, I believe, told the 
truth, and that the diagnosis in his case was correct was proved by his sub- 
sequent history. While the action of the virus may be tardy in declaring 
itself, it is equally true that it may be rapid in its general action, the out- 
break of constitutional symptoms taking place even before the primary sore 
cicatrizes. 
Generally, secondary syphilis is introduced by precedent constitutional 
disturbance. These prodromes vary much in their severity, often being so 
slight as almost to pass unnoticed. Usually, however, there is a period of 
undefined discomfort affecting both the mind and the body. A gloomy, de- 
spondent feeling takes possession of the patient, totally unfitting him for 
business. There are impaired appetite, a changed color of the skin, a dull 
and anxious countenance, broken and restless sleep, generally disordered 
secretions, fugitive pains in the head, joints, and limbs, often worse at night, 
and general muscular soreness and lassitude. Added to these symptoms 
there is fever, the temperature sometimes reaching 102° to 104°, especially 
in the after-part of the day, with some increase in the frequency of the 
pulse. These symptoms may continue for some days. At length the cul- 
mination of this general disorder takes place by an eruption over the body, 
when the former symptoms subside. 
During the period when the syphilitic virus is at work in the system, or 
rather during its first evolution, marked changes occur in the blood. These 
changes, as shown by the investigations of Grassi and Wilbouchewitch, con- 
sist in a decrease of the red corpuscles and an increase of the white corpus- 
cles and albuminous portion of the fluid. It is this multiplication of leuco- 
cytes with the loss of red corpuscles which gives rise to the anaemia so com- 
monly present in syphilitic patients ; and to the same cause may be ascribed 
other phenomena which belong to the early history of the disease, such as 
irregularities in the action of the heart, vertigo, epistaxis, and headache. 
The fever which attends the evolution of syphilis, though of brief duration, 
may assume an intermittent or continued type. When appearing as an in- 
termittent, its non-malarial nature can be determined by observing that the 
order of the stages of the paroxysm is never well defined, that the attacks ai’e 
nocturnal, and that they are not influenced by the exhibition of quinine. 
More difficulty will be experienced in the diagnosis when the fever is con- 
tinued. Especially is this true in severe cases, when the symptoms resemble 
those of typhoid fever. In cases attended with eruptions the disease may be 
confounded with variola, rubeola, scarlatina, or rheumatism. The fact, how- 
ever, that syphilitic fever is rarely attended with any very marked disorder 
in the functions of the different organs, would be a sufficient reason for exclud- 
ing the idea of typhoid fever. The absence of intense backache, high febrile 
excitement, and mental disturbance would differentiate it from smalipox; and 
as the prodromes of syphilis are unattended by catarrh or by severe throat 
symptoms, it is not probable that they would be confounded with either 
measles or scarlatina. Greater difficulty will be experienced in diagnosing CUTANEOUS ERUPTIONS OF SYPHILIS. 
531 
between syphilitic fever and rheumatism, and until the eruption makes its 
appearance this diagnosis may be impossible, though rheumatic fever is usually 
more sudden in its onset than syphilitic fever, and can generally be referred 
to some atmospheric change. Rheumatic fever expends much of its force 
upon the articulations, the latter becoming red and swollen, and it is often 
attended by free perspiration, none of which symptoms characterize syphilis. 
Cutaneous Eruptions of Syphilis. 
The cutaneous manifestations of syphilis were all grouped by Alibert under 
the head of syphilides. There was nothing in the name which conveyed 
any correct idea of the nature of the lesions or of their chronological order. 
The term syphilodermata, much used at present, is more definite, though 
open somewhat to the same objections as syphilides. Adopting the plan 
employed by Willan in regard to the systematic disposition of cutaneous 
diseases arising from ordinary causes, Bietl classifies syphilodermata under 
seven different orders, and this, with very slight variations, is the classifica- 
tion generally accepted by modern syphilographers. 
Classification of Syphilodermata. 
1. Erythematous. 
Diffuse. 
Macular. 
Papular. 
Papules. 
Small. 
Large. 
2. Papular. 
Papulo-squamous. 
Vegetating. 
Papulo-tu bercular. 
Yaricelliform. 
Eczemiform. 
Herpetiform. 
3. Vesicular. 
Acneform. 
Impetiginous. 
Ecthymatous, 
4. Pustular. 
5. Bullous. 
Pemphigus. 
Rupia. 
6. Gummatous. 
Serpiginous. 
Vegetating. 
7. Tubercular. 
To these genera some add another, the pigmentary syphiloderm, first de- 
scribed by Fournier. 
General characteristics of syphiloderms.—The eruptions of syphilis possess 
oertain peculiarities which serve to distinguish them from all other cutaneous 
affections: 
1. Color.—Syphilitic eruptions are never intensely red, hut have usually a 
dull brownish-red, pinkish-red, or often a copper color. These varying colors 
are due to the changes which take place in the extravasated blood. 
2. jForm.—The lesions are in most instances round, and when a number of 
these are grouped together they tend to arrange themselves in a crescentic 
form. 
3. Symmetry.—The lesions are generally symmetrical or bilateral, occupying 
corresponding portions of the two sides of the body. 
4. Mixed character.—Syphilodermata of different genera and species often 
exist at the same time ; that is, a papular may be seen alongside of a vesic- 
ular or an erythematous eruption. 
5. Non-febrile nature.—The existence of syphilitic eruptions without any 532 
SYPHILIS. 
marked febrile disturbance is an exceedingly common occurrence, and serves 
to distinguish them from the ordinary exanthemata. 
6. Anaesthesia.—Syphilitic eruptions are not usually attended with itchiness. 
Indeed, the sensibility of the skin within the affected region is less than 
normal. 
7. Glandular lesions.—Syphiloderms are always accompanied by enlarge- 
ment of the lymph-glands in the regions occupied by the eruptions. 
8. The influence of mercury.—All the cutaneous lesions of syphilis are usually 
controllable by mercury. 
This syphilide, commonly described as roseola, is one of the earliest and 
most common of the general manifestations of secondary syphilis. The 
eruption follows the primary lesion at a period of from six to fourteen 
weeks, and appears over the front of the neck, chest, and shoulders; alsn 
upon the arms and the abdomen. So insignificant are the signs which 
usher in the eruption, and its duration is often so brief, that it may even 
escape observation and be quite unsuspected. The patches of the syphilide 
vary greatly in size, ranging from that of a millet-seed to that of a dime. 
They are round or oval in form, and have a pinkish or red color, which in 
the later stage of the eruption assumes a yellowish and finally a brownish 
hue. The patches of color are sometimes closely aggregated, giving a mot- 
tled or marbled appearance to the surface,—erythematosa diffusa; at other 
times they are distinct, with irregularly-defined borders, — erythematosa 
macula; and, lastly, they may be slightly raised and retain their color on 
pressure,—erythematosa papula. While the chest, neck, and shoulders are 
regions common to all the varieties of the erythematous syphiloderms, }*et 
we find that beyond this common domain they are very unequally distributed. 
Thus, the diffused erythema clings to the trunk, the macular appears on dif- 
ferent portions of the arms, face, and head, and the papular over the upper 
portion of the abdomen, the thighs, and the palms of the hands. These 
varieties exhibit also some diversity of color,—the diffused being pink, the 
macular a dark yellow, not effaced by pressure, and the papular copper- 
colored. 
The erythematous syphiloderm is believed by Otis and others to be due 
to capillary congestion and transudation from vaso-motor paralysis, each 
patch answering to the independent territorial distribution of the minute 
arteries. 
Diagnosis.—Erythematous syphilides resemble in some respects non- 
specific or common erythema, rubeola, and the eruption caused by copaiba. 
By contrasting the characteristics of each, the diagnosis will not he difficult. 
Erythematous Syphiloderm. 
ERYTHEMATOUS SYPIIILIDES. 
NON-SPECIFIC ERYTHEMA. 
Often appears without fever or other functional 
disturbance. 
Not attended with pruritus. 
Pre-existing chancre and bubo. 
May continue for weeks. 
Is not subject to sudden recessions. 
Slow in coming out. 
Often accompanied by fever and gastric dis- 
order. 
Generally itching. 
No such antecedents. 
Brief in its duration. 
Sudden disappearance. 
Sudden. 
ERYTHEMATOUS SYPIIILIDES. 
RUBEOLA. 
Subjects chiefly adults. 
Not preceded by catarrhal symptoms. 
Red patches round or lenticular. 
Continues for weeks. 
Subjects children or young persons. 
Preceded by catarrhal symptoms. 
Patches of color crescentic. 
Subsides gradually after four or five days. 
No itching. 
Pinkish tint. 
Eruption persists. 
Not necessarily following the use of drugs. 
ERYTHEMATOUS SYPIIILIDES. 
Itching. 
Claret tint. 
Soon fades away. 
Only appears after using copaiba. 
ERYTHEMA FROM COPAIBA. PAPULAR SYPHILODERM. 
533 
Papular Syphiloderm. 
Papular syphiloderm consists in small, firm, conical or flat elevations 
having a pinkish or coppery color, devoid of fluid contents, with little ten- 
dency to suppurate, and terminating in resolution or desquamation. This 
syphilide occurs in small and large papules. 
The small papules appear at somewhat irregular periods. They may 
even anticipate the erythematous syphiloderm or develop among the later 
syphilides. The usual time at which they follow the chancre is three or 
four months. The papules are very small, some conical and others flat, 
have a pinkish or copper color, and occur in different parts of the body at 
the same time, either singly or in groups. Location has something to do 
with their appearance, those on the palms of the hands being surmounted by 
layers of epidermic scales, whilst those occupying the head often contain some 
purulent matter, which, mingled with flattened epithelium and a few blood- 
norpuscles, forms a dark crust or scab. The skin lying between the papules 
exhibits also an unhealthy appearance, becoming dingy in color, wrinkled, 
and desquamating. These papules, when not attacked by constitutional 
treatment, continue for several months, but under general remedies, espe- 
cially those of a mercurial nature, they will disappear in twenty-five or 
thirty days. 
The other variety, or the large papule, differs from the former in size, 
being often as large as a quarter- or half-dollar. At first the elevation is free 
from epidermis, but when farther advanced the desquamation is well pro- 
nounced, and, as the epidermis at the circumference of the papules remains 
intact, there is formed a characteristic ring or well-defined border, which, 
however, is common to both the small and the large variety of papules. The 
color of the latter is distinctly coppery. These papules are formed on the 
limbs, scrotum, shoulders, breast, neck, face (especially about the corners of 
the nose and around the mouth), and head. On the latter they are fre- 
quently seen to assume a certain orderly grouping, forming the segment of 
a circle, to which the name of corona Veneris has been applied. 
As the papules are generally covered with epidermic scales, this syphilide 
has received the name of papulosquamous, also that of psoriasis. The differ- 
ent appearances presented by the papules in various localities do not indicate 
any difference in the pathological essence of the disease, but are determined 
wholly by anatomical peculiarities. Thus, on the palms of the hands and 
on the soles of the feet the accumulation of scales is considerable, because in 
these regions the epidermis itself is thick. Near the flexures of the joints, 
also, the papules are frequently seen dry and scaly, while on the aspect of 
flexion the moisture caused contact of opposite surfaces sometimes gives 
to the papule the appearance of a mucous patch. 
Pathology.—In large papules the inflammation extends deeper than to 
the papillae. All the elements of the derm and those of the subcutaneous 
areolar and adipose tissues participate. The capillaries are dilated, and leu- 
oocytes are seen penetrating between the fibres of the connective tissue, and 
also surrounding the vessels of the adipose structures. The effect of this 
cell-intrusion is to render active the stable cells of the former, the fibres 
becoming somewhat swollen, and to cause the absorption of the latter. An- 
other change which has been observed, and one which explains the deep 
copper color belonging to the papular syphilide, is an accumulation of extrav- 
asated blood-corpuscles between the papillae and the rete mucosum. The 
abnormal histological changes may be considered to consist in hypertrophy 
of the papillae, proliferation of the colls of the rete mucosum and epidermic 
layers, with a layer of blood-corpuscles capping the papillae, and an inflam- 
matory infiltration of the subdermoid, connective, and adipose tissues. 
Diagnosis.—The papular syphiloderm is liable to be mistaken for eczema 
and psoriasis. In eczema there are itching, burning, and a moist oozing from 
the inflamed surface, features which do not belong to the syphilitic eruption. 534 
SYPHILIS. 
Psoriasis resembles the papular affection much more closely than does 
eczema, and will require a closer scrutiny to establish the lines of distinction. 
In psoriasis the eruption is red, not copper-colored, as in the syphilitic papule; 
exhibits a preference for the extensor aspects of joints, especially the elbows 
and the knees; and the epidermic layers which cover the patches of the 
eruption are thick, not sharply defined from those of the sound skin, and, 
Avhen detached, the lesions beneath are found almost on a level with the sur- 
rounding skin; in all these respects the reverse of the papular syphiloderm. 
Moreover, in psoriasis the lesions are always stubborn, persisting for years, 
are not affected by mercurial treatment, and have only an accidental relation 
to syphilis. 
Vesicular Syphiloderm. 
Vesicular eruptions are quite uncommon. They show a preference for the 
neck, face, and genital organs. When they do appear, it will usually be before 
the primary lesion has healed, or when the wandering pains and throat-symp- 
toms begin. The vesicles vary in size from a mustard-seed to half a dime. 
They are acuminated, contain a serous fluid, with numerous lymph-cells, 
and when small either form in groups or are scattered irregularly over the 
surface, having a close connection with the hair-follicles. The large vesicles, 
spherical or hemispherical in form, bear a resemblance to the vesicles of 
chicken-pox (varicelliform). They are surrounded by a copper-colored ring. 
The lesion passes through the stages of vesicle, pustule, and squama, the 
last, or scaly stage, being the most persistent. 
In the simplest form of the vesicle the serous exudation takes place in 
the epidermis, though the cells of the rete mucosum do not entirely escape 
the excavating process which is often seen in syphilitic skin-lesions. Should 
the inflammation prove to be severe, both the rete mucosum and papillary 
layers of the derm suffer from inflammatory infiltration. When the vesicles 
disappear, the only traces of their existence will be seen in yellowish spots 
or stains, which remain. The exception to this is in cases where the inflam- 
mation has been severe and the papillary layer of the derm has suffered, 
when a cicatrix will mark the site of the previous lesion. 
Pustular Syphiloderm. 
The pustular manifestations of syphilis occur under three forms,—namely, 
acne, impetigo, and ecthyma,—and are always the evidence of a lowered 
vitality. It would be proper to speak of these syphilidcs as papulo-pustular, 
combining as they do the characters of papule and pustule. The pustules 
may exist separately or in groups, the contiguous lesions often becoming 
confluent. It is very uncommon to find this syphiloderm associated with 
any of the earlier manifestations, as the erythematous or the papular. The 
face, scalp, and shoulders are the most common sites for the eruption. 
The acneform, in point of time, is the first or earliest in appearance of 
the three varieties. It commences as a copper-colored, conical, papular emi- 
nence, surmounted by a slight elevation of the epidermis, the serous contents 
of which are rapidly transformed into a muddy, purulent fluid, the entire 
process being completed in one or two days. As the pustule desiccates, a 
dark crust remains, which in turn is followed by layers of epidermic scales. 
After the disappearance of the lesion there is left a gray or copper-colored 
discoloration. 
Syphilitic acne differs from ordinary acne in being often seen over the 
thighs and the abdomen, in having sebaceous contents, in leaving no cicatrix, 
and in the copper-colored stain which is left in the skin after the disappear- 
ance of the lesion. Those eruptions which accompany the use of the iodide 
of potassium also have some resemblance to acne, but could be distinguished 
from the latter by inquiring into the antecedent history of the patient. 
The pustule of smallpox also resembles syphilitic acne, but the intense BULLOUS SYPHILODERM. 
535 
lumbar pains and high vascular excitement which generally usher in variola 
would furnish important differential information. 
Syphilitic Impetigo.—This lesion consists of a number of little flat pimples 
or pustules seated on a papule and aggregated into irregularly-shaped groups 
or patches. The pustules are covered with yellowish or brownish crusts, 
which, by the confluence of the pustules, sometimes extend over a consider- 
able surface. These crusts often become large, do not readily separate from 
the skin, and, when detached, expose an ulcer of considerable depth, wThich 
leaves, after it heals, a copper-colored cicatrix. The impetiginifoi’m syphilide 
may coexist with both the erythematous and the papular lesions. Indeed, 
the latter, in those regions which are richly supplied with follicular glands, 
such as the hairy scalp and the face, are susceptible of being transmuted 
into the former. 
Syphilitic Ecthyma.—This eruption is seen in two forms, the superficial 
and the deep. In the first variety the pustules are large, flat, occasionally 
with central depressions, and rest on a reddish-brown base. The crusts, 
which form early, are dark or yellowish-brown, having considerable thick- 
ness, and when they drop off leave a copper-colored stain. The regions 
chiefly affected are the shoulders, back, and limbs. The deep variety of 
ecthyma differs from the superficial chiefly in the size of the crusts, which, 
in consequence of the abundant suppuration, increase by successive stratifi- 
cations until large, conical, greenish, or brown scabs are formed, beneath 
which are deep, foul ulcerations extending down to the papillary layer of the 
derm. The lower extremities are the common seat of the syphiloderm, often 
termed rupia. It is among the later syphilitic manifestations, and always 
betokens a constitution deeply damaged by the poison of the disease, and, if 
appearing early, indicates great peril to the life of the patient. 
Pathology.—The procession of pathological changes which result in the 
formation of the pustulo-cutaneous lesions begins with inflammation and cell- 
infiltration of the derm, giving rise to a circumscribed thickening or papule, 
on the surface of wThich a transudation takes place into the corneous layer 
of the epidermis, forming a vesicle, the contents of which consist of a straw- 
colored fluid containing lymph-corpuscles, which soon become purulent, con- 
stituting a pustule. The pustule thus formed opens, and its contents, together 
with the epidermic scales, harden into crusts or scabs. The depth of the 
underlying ulceration will be determined by the severity of the inflammation, 
often involving the entire thickness of the derm. 
Bullous Syphiloderm. 
The bullous syphilide is distinguished by the presence of a bleb containing 
a tolerably clear, thin fluid, which afterwards becomes opaque, reddish, and 
thick. The two varieties under this head are rupia and pemphigus. Both 
are among the later manifestations of syphilis, belonging on the border-line 
between the early and late periods; and they occur in constitutions broken 
down by the ravages of the syphilitic poison. 
Rupia.—In rupia the blebs consist of large elevations of the epiderm, 
containing a serous or sero-sanguinolent fluid, which, like that in the vesicle 
of the pustular lesion, becomes purulent, and, escaping, dries into a crust, 
and, with the accumulating layers of epidermic scales, forms a scab not un- 
like that of ecthyma, beneath which there goes on a process of ulceration 
even more extensive than that of the pustular syphilide. 
Syphilitic Pemphigus is one of the hereditary entailments of this protean 
disease. It appears on the palms of the hands, on the soles of the feet, and 
on the anterior surface of the forearm of new-born children, as bullae filled 
with a colorless or a reddish serum. 536 
SYPHILIS. 
The essence of the anatomical changes in bulhe is an inflammatory infil- 
tration of the derm, in which the papilla} are swollen, and a transudation of 
serum and lymph and red corpuscles is poured into the space between the 
epidermis and the rete mucosum, forming the bleb, and also between the rete 
mucosum and the papillary layer. 
Gummatous Syphiloderm. 
The gummatous syphilides appear as firm nodules of different sizes, vary- 
ing from a pea to a hickory-nut, deeply imbedded in the skin or subcutaneous 
tissue. These masses are round, smooth, movable, and usually painless, un- 
less when in contact with a nerve. The favorite sites for gummata are the 
face, scalp, shoulders, and thighs, though no region is exempt from this for- 
mation. These lesions are not confined to the subcutaneous connective tissue, 
but develop also in the submucous tissue and in internal organs. They oc- 
cur both solitary and in groups, and belong to the latest accidents of this 
ever-changing disease. The skin covering gummy neoplasms ordinarily re- 
mains unchanged as long as the degenerative changes in the tumor are 
wanting. The gumma is an unstable product, and after an uncertain period 
of time a process of softening begins, by which the mass is rendered soft 
and fluctuating, during which the overlying skin assumes a peculiar red 
color, ulcerates, and through the opening thus formed is discharged a glairy, 
syrupy, or gummy fluid with more or less unhealthy pus. Circumscribing 
this gummy abscess there exists a wall of induration similar to that which 
surrounds and limits ordinary phlegmon. The discharge continues until the 
dead connective tissue disintegrates and is ejected, after which the hollow 
ulcer fills up with granulation-tissue, and cicatrization follows, leaving a 
depression resembling in many respects that 
which marks the site of an old sinus which 
once led to dead bone. 
Pathology.—Gummata are lesions of the 
connective tissue, the derm remaining un- 
harmed until the inflammation which ac- 
companies the softening of the neoplasm 
begins. Commencing in the adipose tissue 
of the skin, the infiltrate extends into the 
subcutaneous connective and fat tissues, the 
fibres and lobules of which are literally 
overwhelmed by swarms of cells; even 
the blood-vessels of the district do not 
escape. The walls of the small arteries, 
veins, and capillaries are both surrounded 
and infiltrated by cells, and their interior 
choked by fibrinous coagula mingled with 
endothelial and lymph corpuscles. (Pig. 
2061.) A cellular inundation like that de- 
scribed cannot fail to devitalize by pressure 
the fat and connective tissue of the part, 
and hence follows an effort of nature to re- 
move the damaged material, at which time 
commences the work of softening by a 
granular and fatty metamorphosis of the 
cells, especially of the connective-tissue 
fibres, and absox-ption of the fat lobules. 
Gummata, when appearing eai'ly, should 
always be regarded as veiy serious compli- 
cations ; indeed, at no time, early or late, can they be deemed other than 
sei'ious. 
Though l’esembling cold abscess somewhat in appeai’ance and in the sub- 
Fin. 2061. 
Section of a gumma: b, layer of epiderm; c, 
papule, under which is connective tissue, d; 
t, orifice of the ducts of a sweat-gland ; m to 
n, gummatous tissue, or the inflamed con- 
nective and adipose tissue beneath the derm. ONYCHIA. 
537 
jective character of the symptoms, yet the history of a pre-existing chancre 
and the gummy quality of the discharge, as in gummata, will remove any 
doubts which may be entertained in regard to the character of the disease. 
In like manner those instances of acute gummata which are met with in 
infantile syphilis, and which have been noticed by Eynecker, may be differ- 
entiated from the boils of strumous subjects, their contents not being com- 
posed of pus and connective-tissue debris, as in the latter affection. 
Tubercular Syphiloderm. 
Tubercular lesions occur as hard masses in, and rise above the surface of, 
the skin. To the touch they are firm, smooth, round, or flat, and present a 
peculiar red color. Though differing very little from gummata, either in 
pathology or in the time of their appearance, they seldom attain the bulk 
of the latter. Like the gummy tumors, they develop singly or in groups. 
The latter are often formed into circles, more or less complete. They are 
usually observed on the face, forehead, neck, and thighs. 
The two varieties of the syphilitic tubercle are the dry and the suppura- 
tive. The first is a copper-colored syphilide, covered with epidermic scales. 
The second forms in groups, is characterized by ulceration and suppura- 
tion, and answers to the serpiginous syphiloderm of some syphilographers. 
The ulcers frequently have a crescentic shape, are covered with a gummy 
pus, and are exceedingly intractable, often continuing for years. 
Pathologically considered, the only difference between tubercles and gum- 
mata is locality, the former being confined to the derm, while the latter are 
seated in the subcutaneous tissue. 
These two neoplasms belong to the late or tertiary period of syphilis. 
From the surface of ulcerating gummata and tubercles foul granulations 
or vegetations often spring up, which, with their unhealthy secretions, imi- 
tate not remotely malignant ulceration. The disease with which syphilitic 
tubercular ulceration may be confounded is lupus. The peculiarities of each 
are placed in contrast below : 
TUBERCULAR SYPHILITIC ULCER. 
LUPUS. 
Ulcers separate or distinct. 
Met with chiefly in adults. 
Surrounding induration marked. 
Ulceration occurs quickly. 
Tubercles dark-red or brick color. 
Ulcers deep and circular. 
Crusts thick and greenish. 
Cicatrization smooth. 
Previous history of syphilis. 
Ulcers run together. 
Generally before adult life. 
Slightly indurated. 
Slowly. 
Much lighter. 
Ulcers superficial. No prevailing form. 
Thin and mahogany-colored. 
Corrugated. 
Not necessarily. 
SYPHILITIC AFFECTIONS OF THE CUTANEOUS APPENDAGES. 
Not only does the skin suffer from secondary syphilis, but also the nails 
and the hair. 
Onychia. 
The matrix of the nail is made up of modified skin-elements, and is sub- 
ject to the same eruptions as the latter. Syphilitic onychia occurs under 
two forms, the dry and the moist, both being the result of inflammation 
of the matrix, and they are rarely disassociated with some form of skin- 
eruption. 
The dry variety is attended with but slight local inconvenience. It will 
often be of so mild a character that little will be observed save a brittle state 
of the nail, which is mai’ked by transverse lines and vertical cracks or fis- 
sures, accompanied by some shrinking of the skin from the lateral border of 538 
SYPHILIS. 
the nail, also at the exterior or free border. Onychia is usually associated 
with the papular or scaly syphilides. In other instances the nail becomes 
thickened by the accumulation of laminae, its surface grows rough and rigid, 
and the color changes from the normal flesh-tint to a dirty yellow. 
The moist form of onychia is chiefly distinguished by ulceration and sup- 
puration. The suppuration may be confined to the root of the nail or to the 
groove formed by the inversion of the skin, the discharge often being ichor- 
ous and offensive ; or it may commence in the subungual part of the matrix, 
displacing the nail (which is frequently strewn with white spots and softened 
and warped), and exhibiting a moist, fungous, dark, unhealthy, granulating 
surface. The extremity of the finger often is swollen and has a purple or 
violet color, and the nail, which has been gradually loosening, falls off, its 
regeneration taking place as the repair of the ulcerated matrix advances. 
In neither the dry nor the moist variety of onychia is there any pain,—an 
important diagnostic feature. 
It is in connection with the pustular, gummy, or tuberculous general 
manifestations that these suppurating disorders of the matrix are seen in 
their fullest perfection. 
When the inflammation is limited to the groove at the root and sides of 
the nail, it is termed perionyxis, and resembles the ordinary “ run-round” in 
every respect, except in the absence of pain. 
Alopecia. 
Alopecia, or falling of the hair from the head and other parts of the body, 
is among the commonest accompaniments of syphilis; indeed, it is frequently 
the first perceptible evidence of a generalized poison occurring during the 
open state of the primary lesion, even before the outbreak of exanthemata. 
Six to eight weeks from the appearance of the chancre is about the usual 
time for the dropping of the hair. When occurring at a later period it is 
for the most part associated with eruptions—acneform or pustular—of the 
scalp, in which the hair-follicles participate. 
The shedding of the hair may be local or general. Sometimes the process 
of depilation extends by installments, one spot recovering its hair while 
another is invaded b}7 baldness, until the entire scalp has been traversed; at 
other times the alopecia becomes general, the hair continually dropping out 
over the clothing, or collecting at night upon the pillow. So slight is the 
connection with the follicles that often merely running the fingers over the 
head will bring out the hair in considerable quantities. Frequently the eye- 
brows, eyelashes, beard, and the hair over the pubes, as well as on other 
parts of the body, may drop out. As the follicles in most instances remain, 
a new covering follows the loss of the old, but the new crop of hair in its 
turn may share the fate of the first, to be succeeded by a third crop. The 
loss of the hair from the eyebrows is almost peculiar to syphilis. As a rule, 
the hair is never as thickly set after it has once become affected, though 
complete and permanent baldness (calvities) is rarely, if ever, ascribable 
to syphilitic disease. When the hair of a syphilitic patient is not repro- 
duced, it is generally a local deficiency, due to the former presence in the 
scalp of pustular syphilides, the suppuration of which has destroyed the 
follicles. 
Early falling of the hair in generalized syphilis indicates a widely-diffused 
and all-pervading poison, to dispossess which will be an arduous and often 
discouraging task. 
In all cases, before the shedding begins, the hair loses its soft, glossy ap- 
pearance, and becomes harsh, dry, and faded or tarnished, without any itching 
or inflammation to indicate what is about to take place. 
There is an alopecia which occurs late in secondary syphilis, and which 
is one among several grave manifestations of a seriously disordered nutri- 
tion. MUCOUS PATCHES. 
539 
Bassereau, as quoted by Lancereaux, states that falling of the hair and 
nails was not among the manifestations of the disease when first observed, 
and did not appear until forty years later. Fallopius makes a similar state- 
ment. It is more than probable, however, that these symptoms existed from 
the beginning, and among the multiform manifestations of the disease were 
overlooked. 
Epidermic Accumulations often occur on the palms of the hands and soles 
of the feet in patches of considerable thickness, having a light-gray color. 
These patches, dropping off in flakes, leave the papillary layer of the derm 
scarcely concealed by a thin layer of epithelial cells, the parts remaining 
white or spotted for some time. 
Another affection of the epidermis is that termed pityriasis. It consists in 
an abundant, bran-like desquamation from the hairy scalp, forehead, eye- 
brows, and face, without any loss of hair. Occasionally it is the result of a 
previous papular eruption. 
SYPHILIS OF THE MUCOUS MEMBRANES. 
Exanthemata and Mucous Patches. 
Secondary syphilitic manifestations affecting the mucous membranes are 
among the earliest and most unvarying evidences of constitutional syphilis. 
Such lesions make their appearance generally within the sixth or eighth 
week after the development of the initial sore, and are the most common 
sequences of chancre, and often the most annoying, on account of their 
tendency to recur. 
Syphilitic erythema of the mucous membranes is the same affection as 
cutaneous syphilitic erythema, differing only in its location. The usual seats 
of the disease are the mouth, fauces, tonsils, pharynx, and larynx. As it is 
not uncommon to meet cases of secondary syphilis accompanied with an 
irritative cough, and in some instances with both gastric and intestinal dis- 
orders, it is fair to assume that the erythematous inflammation may extend 
from the larynx into the trachea, bronchi, and smaller air-passages, and also 
from the pharynx to the intestinal mucous membrane. 
Instead of a general diffused redness of the mucous membrane involved, 
the vascularity may appear only in irregular patches, sharply circumscribed. 
When the inflammation invades the larynx, though there may not be any 
embarrassment to the respiration, nor any cough, the voice often changes in 
quality, losing its compass, and becoming a little hoarse or rough, while the 
volume of sound is not unfrequently lessened in spite of the increased effort 
made in producing it. 
Syphilitic Erythema, or Angina. 
Mucous Patches. 
Few persons who are affected by constitutional syphilis escape mucous 
patches. The regions specially selected by these lesions are, in the order of 
frequency, the verge of the anus in the male; the vulva, anus, cervix uteri, 
and breast in the female; the tonsils, tongue, soft palate, and half-arches, the 
cheeks, lips, angles of the mouth, and the glans penis and prepuce. Among 
the rarest localities invaded by mucous patches are the vocal cords, the con- 
junctive, and the external auditory meatus. 
When mucous patches form near an angle of the mouth they frequently 
extend into the commissure of the lips, forming fissures (rhagades). 
The moist papules, often termed condylomata, are of the same character 
as the mucous patches, differing only in location. The favorite sites for 540 
SYPHILIS. 
the moist papule are the scrotum, perineum, buttocks, the verge of the anus, 
the inner and upper aspect of the thighs (Fig. 2062), and between the toes. 
Mucous patches, as 
they appear inside of 
the mouth, are grayish- 
white lesions, having a 
striking resemblance to 
a surface washed with 
nitrate of silver. They 
have well-defined, often 
irregular edges, and are 
not elevated above the 
surrounding parts. The 
discharges which flow 
from or adhere to these 
patches are exceedingly 
contagious. 
Moist papules, or con- 
dylomata, are elevated 
above the level of the 
surrounding skin, and 
have a red, smooth, and 
moist surface. 
Pathologically con- 
sidered, these patches 
consist in an inflammatory thickening of the different layers of the derm. 
Among the accidental complications which frequently overtake these 
lesions are ulceration, hypertrophy, and pseudo-membranous formations. 
The ulcers are produced by a sudden desquamation, or shedding of the epi- 
dermic layers, leaving exposed the rete mucosum, which appears as a shining, 
red surface, somewhat moist. These ulcerations as they appear in the buc- 
cal cavity usually occupy the tonsils, half-arches, or soft palate. Those of 
a superficial character are often multiple, while those which are deep or ex- 
cavated are generally solitaiy. 
The superficial ulcers are usually sharp, well defined, and irregular, 
are more or less undermined, and their surfaces covered with a strongly- 
adherent, grayish-white or yellow layer of lymph, no induration being 
present. 
The deep ulcer, on the contrary, is surrounded and underlaid by a hard 
inflammatory infiltration ; its sides are steep, its edges everted and irregular; 
and adherent to the surface of the ulcer is a dark-gray or dirty yellowish 
incrustation, the discharges from which are very foul. 
Both the superficial erosions and the excavated ulcers of the oral mucous 
membrane often appear before the primary sore is healed, or very soon after 
its disappearance, coexisting quite frequently with the early exanthemata of 
the disease. Whatever may be the character of these ulcerations of the 
mucous membrane, they are often unattended with pain, and in many in- 
stances their presence escapes the notice of patients altogether, until recog- 
nized by the medical attendant. 
The excavated sore is sometimes an exception to this rule. It is prone 
to be attacked by active inflammation, when both pain and swelling will 
be present, and in this condition a rapid destruction of tissue may follow, 
often perforating the soft palate, or even destroying it entirely; and occa- 
sionally, should the ulcer be on the hard palate, it causes necrosis of the 
underlying bone, thus establishing an opening between the mouth and the 
nose. 
In hypertrophy the papillae of the mucous patch become irregularly elon- 
gated, forming soft, red or gray elevations, according as they occupy the 
mucous membrane or the skin. When a number of the papillae become 
Fig. 2062. 
Condylomata. SYPHILIZATION. 
541 
greatly elongated, massed in groups, and crowned with layers of epidermic 
cells, they form the fungating, vegetating, or papillomatous lesions. 
The diphtheritic transformation or complication of a mucous patch con- 
sists in the formation over its surface of a membrane made up of closely- 
interwoven threads of fibrin, with pus-cells in the interspaces of and beneath 
the new formation. 
TREATMENT OF EARLY SYPHILIS. 
Syphilization. 
This term was introduced into the literature of syphilis by Dr. Auziaa 
Turenne, a physician of Paris, who announced the theory that the disease 
might be prevented or cured by repeated inoculations of the patient with 
the syphilitic virus. He was led to this conclusion by the results witnessed 
during a series of experiments, in which the inoculations by repetition lost 
all power of reproduction. Sperino, of Turin, also asserted that multiplied 
or repeated inoculations would not only after a time render the human sub- 
ject pi’oof against infection, but, when the latter had become generalized, 
would eradicate all the resulting manifestations. Professor Boeck, of Chris- 
tiania, Sweden, another zealous advocate of syphilization, paid a visit to this 
country, during which I met and talked with him, partly with the view of 
giving currency to the new discovery. Being based, like many other novel 
procedures in medicine and surgery, on false assumptions, syphilization was 
doomed from the first to an ignominious downfall. 
The numerous experiments, amounting to several thousands, made by the 
three physicians who have been named, proceeded on the supposition that 
all venereal sores arose from one syphilitic virus. When, however, the ex- 
istence of non-syphilitic venereal sores was established, the practice imme- 
diately fell into disuse and discredit; civil prosecutions were even instituted 
by the victims of these experiments against their medical attendants. 
In our present state of knowledge in regard to the properties of the two 
venereal sores, we know that these inoculations must have resulted in one of 
two ways. If the patient operated on was at the time free from constitutional 
syphilis and the virus employed was derived from chancre, the disease was 
doubtless in most instances communicated to the unfortunate subject; if the 
virus employed was chancroidal, whether the patient was syphilitic or*not, 
the inoculations wTould be successfully repeated, but with gradually lessening 
effect; and if the virus was from chancre ‘and the subject syphilitic, no 
constitutional effect whatever would follow. In the radical difference of 
properties, therefore, of the two lesions lay not only the misleading re- 
sults of syphilization, but also the dreadful consequences of the error which 
it embodied. 
Constitutional Treatment of Early Syphilis.—The proper period at which 
to commence constitutional treatment is on the first appearance of gen- 
eralized syphilis. Earlier than this 1 do not think it is desirable to employ 
specific remedies, as their use is calculated to break in upon the orderly 
evolution of the disease, and often leaves both physician and patient in 
anxious doubt in regard to the nature of the primary lesion. Certainly the 
immediate employment of constitutional measures cannot prevent the infec- 
tion of the general system. It will be necessary, however, to exhibit some 
internal remedies in order to relieve the mental anxiety which always op- 
presses a patient who has been unfortunate enough to contract a venereal 
sore, and who indulges the fond delusion that the poison may be arrested, 
neutralized, and rendered harmless before it reaches the system at large. 
Conceding to this feeling, it will not be amiss to direct the use of four or five 
drops of nitro-muriatic acid in a wineglassful of water three times a day, or 
a pill of quinine and iron, with an occasional warm bath. When, however, 542 
SYPHILIS. 
the cutaneous and mucous lesions make their appearance, the signal for spe- 
cific treatment has been displayed. 
What is the treatment? According to my judgment, there is but one 
treatment suited to earty syphilis, and that is the mercurial. 
The use of mercury as an anti-syphilitic agent dates back to the latter 
part of the fifteenth century. Administered under the impression that it 
was necessary to induce salivation, and rashly employed by charlatans, this 
remedy fell into disrepute in consequence of the disastrous effects which too 
often followed its use, so that at the beginning of the sixteenth century there 
were already two parties formed,—the mercurialists and the anti-mercurial- 
ists. A few of the latter party (Herman, in England, and Lorimer, of Vienna) 
carried their opposition to mercury to the ridiculous extent of charging this 
remedy with being the cause both of the early and the late manifestations of 
syphilis. Notwithstanding all the objections made to the use of the drug, 
it is stronger to-day in the confidence of the profession than ever it was at 
any other period since its introduction into the therapeutics of syphilis. 
The different ways in which mercury is best employed in the treatment 
of syphilis are by the mouth, by inunction, by fumigation, by baths, and by 
hypodermic medication. 
The particular form in which mercury enters the system is still a subject 
of discussion. Some authorities believe that when taken by the mouth it is 
by combination with the hydrochloric acid of the stomach converted into a 
bichloride; while others believe that the different preparations of mercury 
are decomposed either in the stomach or after they enter the circulation and 
return to the metallic state. I do not think that we are prepared, as yet, to say 
exactly what mutations the different salts of mercury undergo in the system, 
or how they act in antagonizing the syphilitic poison. Clinical observation 
establishes be}7ond controversy the power of mercury not only to resolve in- 
flammation, but also to promote the removal of its products, by favoring their 
transformation into forms (fatty, for example) which bring them into a state 
in which they are capable of being absorbed and removed out of the system. 
If this view of the physiological action of mercury is correct, it is not dif- 
ficult to understand the peculiar efficacy of the drug in early syphilis, the 
lesions of which are chiefly confined to the lymph-vessels, the lymph-glands, 
and the derm. 
At one time the adminisHation of mercury was supposed to be fatal to the 
integrity of the red corpuscles of the blood, and consequently calculated to 
cause anaemia. When mercury is given in large doses, and to the extent of 
inducing ptyalism, it doubtless causes anaemia; but if exhibited in small 
quantities the contrary effect is produced,—namely, that of favoring haema- 
tosis. The doctrine that judicious mercurialization is favorable to blood- 
enrichment appears to have been established by the observations of Keyes. 
We have, therefore, from this double action of the drug—from its power to 
stimulate the process of destructive cell-metamorphosis, and at the same time 
to improve the condition of the blood—a very valuable specific remedy. 
Among the preparations of mercury exhibited by the mouth in the treat- 
ment of syphilis are the protochloride, blue mass, bichloride, protiodide, and 
biniodide. 
Of these different salts I have a very decided preference for the bichloride. 
In administering this remedy it should be given in small doses and continued 
for not less than eighteen months. The necessity for its prolonged use should 
be explained to the patient, in order that his or her interest may be secured in 
the treatment. The bichloride can be administered either in pill or in solution. 
The latter form is preferable. One-twentieth of a grain, dissolved in a tea- 
spoonful of the tincture of cinchona, or in the same amount of the compound 
infusion of gentian, should be given three times daily half an hour or an hour 
after meals. Should the salt, after a time, produce some disturbance of the 
bowels, the addition of two or three drops of laudanum—or, if the remedy 
is exhibited in pill form, one-eighth of a grain of opium—to each dose will S Y PHI LIZ A TI ON. 
543 
soon correct the gastric or intestinal derangement, after which the opiate 
should be suspended, or given only at such intervals as will obviate the incon- 
venience mentioned. If in the course of administration symptoms approach- 
ing ptyalism appear, such as fetor of the breath or tenderness of the gums, 
either to the touch or when the teeth are brought forcibly together, the dose 
of the bichloride should be diminished a third or a half. This is better than 
to lengthen the periods between the times of administration. 
If the specific action of the mercurial is delayed, and on account of the 
persistence of the eruptive lesions it is deemed desirable to hasten the consti- 
tutional impression, one drachm of mercurial ointment or the same amount 
of the oleate of mercury may be rubbed into the groins, the inner surface of 
the thighs, and the axillre, for several successive nights. Some practitioners 
apply the mercury to the soles of the feet; but the dense character of the 
skin offers more resistance to absorption than in the regions above named. 
Under this plan of treatment the S3rphilides gradually disappear; but 
whether this result is attained early or late,—that is, in one month or in six 
months,—the constitutional medication must not terminate, but must be 
maintained at least to the prescribed period, or about eighteen months, when 
generally it may be considered safe to abandon temporarily all treatment. I 
say temporarily, because I do not believe that the patient is free from the 
risk of relapse, or that the vanished lesions may not return. I therefore 
insist upon a periodical return to the mercurial treatment once every year, 
for three months, until five years have passed, when, if in the mean time no 
signs of the disease have cropped out, the patient may be considered reason- 
ably safe. 
In these periods of periodical treatment, following the first eighteen 
months, it will be desirable to combine with the mercurial the iodide of 
potassium. Five grains of the latter with the bichloride will constitute the 
proper dose. 
In patients of feeble constitution who contract syphilis, the association 
of some preparation of iron with the alterative will be necessary. If the 
bichloride is administered in solution, either the potassio-tartrate, the citrate, 
or the tincture of the chloride of iron can be added; if in the form of pills, 
the carbonate of iron. 
Some practitioners express a preference for the protiodide of mercury 
over other forms of the salt, and there may be personal idiosyncrasies which 
require a change on the part of the patient from the bichloride, and in this 
case the protiodide agent may be substituted, and be given in pill form in 
doses of one-quarter to one-half a grain thr'ee or four times a day. With 
many the sirop Gibert constitutes a favorite mode of exhibiting mercury. 
Its formula is as follows: 
Hydrargyri Biniodidi, gr. i; 
Potassii lodidi, gi; 
Aquae, f^i; 
Cola, et adde 
Syrupi, f§v. 
Sig.—One tablespoonful three times a day. 
A favorite formula of Eicord’s was,— 
Protiodide of Mercury, 
Extract of Lettuce, each grs. xlv; 
Extract of Opium, grs. xv; 
Confection of Rose, grs. xc. 
Make into sixty pills, and give one two 
or three times daily. 
Mercurial Vapor-Baths.—The intolerance of some patients to the internal 
use of mercury may render it necessary to secure the constitutional or 
antidotal effects of the drug through the skin and the lungs. The best 
method of accomplishing this is by setting the patient, disrobed of all 544 
SYPHILIS. 
clothing, and just before retiring to bed, upon a high stool, with a blanket 
or l mackintosh fastened around the neck, and suspended, cone-like, about 
the person and touching the floor. Beneath the stool is placed an appa- 
ratus (Fig. 2063) containing a little tin 
plate for the mercury, surrounded by a 
reservoir for water, and under this an 
alcohol-lamp. One scruple of calomel is 
to be placed on the cup and volatilized by 
the heat from the lamp, which at the 
same time develops sufficient vapor from 
the water to mingle some moisture with 
the fumes of the mercury. In fifteen 
or twenty minutes the calomel will have 
been volatilized, and will be deposited 
over the sux-face of the body as a fine, sub- 
limated dust, which is not to be removed, 
the patient retii’ing to bed, enveloped 
in a light blanket. The following morn- 
ing the sui’face of the body is to be wiped 
clean with a towel moistened with warm 
water, before the patient dresses for the 
day. These baths may be continued for 
six or seven successive nights, when given .in connection with other treat- 
ment; but if employed alone they should be kept up for five or six weeks, 
or until the syphilides have vanished, during which time the patient should 
remain in-dooi'S, unless the weather is quite dry and wai’m. A little tendex-- 
ness and swelling of the gums will generally follow, beyond which it is neither 
necessaiy nor desirable that the action of the remedy should be carx-ied. For 
this purpose calomel is to be preferred to all other forms of the salts. Mer- 
cury, employed in this manner, exerts an excellent effect on all syphiloderms, 
and when the stomach is irritable, or especially when cutaneous lesions prove 
stubborn, it should be preferred to other modes of treatment. 
Fig. 2063. 
Lee’s apparatus for volatilizing mercury. 
Hypodermic Use of Mercury.—The introduction of mercury into the system 
hypodermically is regarded with favor by many physicians, among whom 
may be mentioned Ilebra, Martin, Scarenzio, Liegeois, and Diday. The bi- 
chloride is the form of mercury to be used, and in doses from one-seventieth 
to one-fortieth of a grain, dissolved in distilled water and glycerin, and in- 
serted once in two days. The only precaution to be observed in the use of 
the remedy is to see that the point of the needle enters the subcutaneous 
connective tissue, and that the injection is forced by pressure into the sur- 
rounding parts; otherwise, if allowed to remain within a small compass, it 
may give rise to abscess. In one case, that of a young woman, whose medical 
attendant, not being familiar with the use of the hypodermic syringe, had 
merely inserted the point of the needle into the derm, as many as forty large, 
dark pustules were seen over the surface of the abdomen. "When this plan 
of treatment is adopted, the needle used for the injection should never be 
employed in non-syphilitic cases. 
Local Treatment of Early Syphilides.—Though local remedies independent 
of constitutional treatment possess little value, yet when conjoined with the 
latter they' are often useful, and are therefore entitled to a place in the 
therapeutics of syphilis. 
Treatment of mucous patches.—Mucous patches seated in the buccal cavity 
are generally difficult to treat, being constantly subjected to irritation from 
the movements of mastication and from contact with the various oi*al secre- 
tions. Those which are on the cutaneous aspect, especially where the 
opposing surfaces come in contact, as at the verge of the anus, or between 
the buttocks, are also somewhat rebellious. The moisture resulting from GUMMATA. 
545 
the contact of two surfaces furnishes an excellent soil for the growth and 
perpetuity of these syphilides. 
Cleanliness is of the first importance, wherever the lesions are situated. 
If in the mouth, the buccal cavity should be frequently washed with a solution 
of the chlorate or permanganate of potash. The tincture of myrrh, alone or 
added to a decoction of the berries of the Rhus glabrum, is aiso a pleasant 
and efficacious mouth-wash. 
As a local application to the patches, nitrate of silver, sulphate of copper, 
and tincture of iodine are among the most valuable remedies. 
In some localities, as on the verge of the anus, labia pudendi, buttocks, 
and thighs, the cure will be facilitated by clipping off the condylomata or 
cutaneous papules with the scissors and touching the bleeding surfaces with 
pure nitric acid. After such operations, dry lint should always be inter- 
posed between the contiguous surfaces, in order to keep the parts free from 
moisture. When operative measures are opposed, the growth of these cuta- 
neous lesions can be greatly repressed by keeping their surfaces well dusted 
with calomel and gallic acid, two parts of the former and one part of the 
latter. 
LATE SYPHILIS, AND SYPHILIS OF SPECIAL ORGANS. 
Gummata.—These lesions, which have already been described in connection 
with the syphilodermata, are among the later manifestations of syphilis, 
being rarely seen earlier than six or eight months, generally some years, after 
the commencement of the generalized disease. 
Ulcerations, both in the mucous membrane of the buccal cavity and in the 
skin, also result from gummata. The rationale, however, is different in the 
two cases. 
In ulcers following mucous patches the inflammatory changes are limited 
to the layers of the cutaneous and mucous derm, but in those following 
gummata the lesions occur first in the connective tissue which underlies the 
mucous membrane and the skin, and which is always the true seat of the 
gumma. These formations in the beginning appear as small, round, hard 
tumors, which move freely under the finger and occur singly or in groups. 
After a time they become adherent to the superincumbent skin or mucous 
membrane, rendering the bodies fixed, and foreshadowing a process of soft- 
ening, during which the surface over the lesion becomes red and finally breaks 
down, leaving an ulcerated opening, through which is discharged a viscid, 
gummy fluid. When gummatous ulcers heal, the resulting cicatrices are 
whitish and depressed. 
Diagnosis.—When it is taken into consideration that gummata are gener- 
ally indolent, firm, painless tumors, always freely movable, in the beginning, 
in the connective tissue,—whether submucous or subcutaneous,—and that 
they are found associated with other signs of syphilis, it is not probable that 
they will be confounded with any other morbid growth. When softening 
and ulceration have taken place, the gummy or syrupy character of the 
discharge, and the undermined edges of the ulcer, possess also a diagnostic 
value. 
Not unfrequently gummatous ulceration of the tongue has been confounded 
with carcinoma of the oi’gan. The differential features of the two affections, 
placed as below in contrast, will serve to make clear the diagnosis. 
GUMMATOUS ULCERATION OF THE 
TONGUE. 
CARCINOMATOUS ULCERATION OF THE 
TONGUE. 
Syphilitic history. 
Common to all ages after puberty. 
Often preceded by mucous patches. 
Ulcers single and multiple and on both sides. 
Preceded by abscess, with characteristic dis- 
charge. 
Not necessarily any syphilitic history. 
Almost peculiar to middle and advanced life. 
No mucous patches. 
Ulcer single and on one side. 
Without such precedents. 546 
SYPHILIS. 
GUMMATOUS ULCERATION OF THE 
TONGUE. 
CARCINOMATOUS ULCERATION OF THE 
TONGUE. 
Discharge neither ichorous nor abundant. 
Never seen on under surface of tongue. 
Ulcer not necessarily painful, or, if so, the pain 
is not lancinating. 
Lymph-glands not affected. 
Heals under general treatment. 
Both ichorous and abundant, with offensive 
odor. 
Sometimes seen on the under surface. 
Extremely painful, and pains shooting or dart- 
ing. 
Lymph-glands affected. 
Not affected by remedies, general or local. 
Glossitis.—There is a form of glossitis which occurs among the late syph- 
ilitic lesions, characterized by circumscribed patches of induration little, if at 
all, elevated above the common surface of the organ, but readily recognized 
by the touch, as well as by the color of the mucous membrane overlying the 
thickenings, which is quite smooth and shining, of a dark-red color, and 
devoid of moisture. 
The pathological changes observed on a microscopical study of syphilitic 
glossitis are the apparent absence of the papillae, especially the filiform,— 
apparent because, being deprived of the outer layers of epithelium, they do 
not rise into distinct elevation on the dorsum of the tongue,—also a free 
cell-infiltration in the connective tissue between the fasciculi of the intrinsic 
muscles of the organ, as well as that which lies between the latter and the 
epithelium. (Fig. 2064.) It is this compact cell-infiltration which causes 
the thickening or induration spoken of above. 
Fig. 2064. 
Section showing appearance of syphilitic glossitis : a, epithelial covering of the 
tongue; b, the underlying papillae; d, deep groove or depression; e, hyperplasia 
of the connective-tissue element of the organ ; m, m, muscular fasciculi. 
There is another variety of syphilitic glossitis, in yvhich the hyperplasia 
involves both the connective and the muscular components of the organ. 
The hypertrophy is frequently limited to the posterior part of the tongue, 
which presents an irregular, lobulated appearance. Both the superficial 
and the deep variety of glossitis, under the influence of local irritation, may 
undergo ulceration. This hypertrophic condition sometimes coexists with 
gumma of the organ. 
Larynx.—Syphilis of the larynx appears at variable periods after infection, 
sometimes in the secondary, more commonly in the tertiary stage; sometimes 
it is coincident with cutaneous roseola. 
Erythema, mucous patches, ulcerations, vegetations, and gummata are 
ordinary syphilitic manifestations observable in this part of the respiratory 
tract. SYPHILIS OF THE LARYNX. 
547 
Erythema may extend from the fauces, attacking the epiglottis, the aryteno- 
epiglottic folds, and the vocal cords on its way to the larynx. The appear- 
ances disclosed by the laryngoscope consist in a red or mottled inflammation 
of the mucous membrane of the larynx, either diffused or in patches, with 
some swelling. Though respiration is not affected, the voice becomes altered, 
being hoarse and lessened both in compass and in sonorousness, especially 
when an effort is made to speak in a loud tone. No complaint is made of 
pain, cough, or fever. The diminished power of the voice is probably due 
to partial paralysis of the vocal cords from the swelling. 
Mucous patches of the larynx have one common character,—the papular,— 
but present different appearances: sometimes such a patch is very small, not 
exceeding in size a grain of mustard-seed, though having the usual opalescent 
or gray surface of these lesions. The epiglottis and the aryteno-epiglottic 
membranes are favorite sites for these patches. In other cases they undergo 
ulcerative changes. 
The ulcerations, whether originating in erosions of the papular syphilido 
or in the softening of gummata, often become deep, ragged sores with per- 
pendicular sides, and are sometimes surrounded by inflammatory infiltra- 
tions. They may eventually cause perichondritis, ending in necrosis of the 
cartilages of the larynx. The healing of these ulcers is often followed by 
laryngeal stenosis, causing loss of voice and dj^spnoea. 
Gummata, being seated in the submucous connective tissue, form consider- 
able elevations of the laryngeal mucous membrane. They have a yellow 
color, and exhibit a decided preference for those parts of the larynx which 
lie above the vocal cords. 
Diagnosis.—The diseases with which syphilis of the larynx may be con- 
founded are non-specific laryngitis, tuberculosis, and carcinoma. 
Non-specific laryngitis has an acute history, is attended with great sore- 
ness of the throat, loss of voice, and dyspnoea, and commonly is traceable to 
exposure and cold, features altogether unlike those of syphilis. 
A comparison of the peculiarities of syphilis, tuberculosis, and carcinoma 
will enable a careful observer to avoid falling into an error in differentiating 
laryngeal diseases. 
SYPHILIS. 
TUBERCULOSIS. 
CARCINOMA. 
Antecedent and concomitant 
lesions usually discoverable. 
Symptoms appear suddenly. 
Ulceration not commonly mul- 
tiple. 
No cachexia. 
Ulcers round or oval, deep, 
with sharp-cut perpendicular 
sides, and with inflammatory 
swelling. 
Respiration not materially 
hurried on taking exercise. 
Without emaciation necessa- 
rily. 
Loss of voice late, and incom- 
plete. 
No physical signs indicating 
pulmonary disease. 
Cough slight. 
Expectoration muco-puru- 
lent. 
Improvement under treat- 
ment. 
Not necessarily so. 
Appear gradually. 
Multiple. 
Cachexia marked; pallid, 
clubbed fingers. 
Round and with marginal 
swelling; not deep. 
Respiration hurried. 
Attended with emaciation. 
Loss of voice early, and more 
complete. 
Physical signs of pulmonary 
tuberculosis. 
Cough severe. 
Expectoration more purulent, 
often in masses. 
No improvement. 
Not necessarily so. 
Neither so quickly as in syph- 
ilis nor so late as in tuberculosis. 
Generally single. 
Cachectic, sallow, waxy color. 
Ulcers with irregular, ragged 
borders. 
Respiration less hurried than 
in tuberculosis, and more so than 
in syphilis. 
Loss of voice late. 
No necessary pulmonic com- 
plications. 
Cough slight. 
Often blood expectorated with 
muco-pus. 
No improvement. 
Trachea and Bronchi.—Syphilitic trachitis affects either the upper or the 
lower extremity of the tube in preference to the central portion. Nodules 
occur in the mucous membrane, break down, ulcerate, and, after healing, leave 548 
SYPHILIS. 
cicatrices, which by contracting cause stenosis of the tube and subsequent 
dyspnoea and noisy respiration. 
Syphilitic bronchitis may appear during the first general eruption of the 
disease. Several cases of the kind are recorded by Byrne. The disease oc- 
curred in both the acute and the chronic form. The symptoms corresponded 
to those which belong to ordinary bronchitis; and that they were due to the 
syphilitic poison is rendered probable by the fact that the internal disease 
subsided on the appearance of the characteristic eruption. 
Lungs.—It can scarcely be doubted that the lungs of adults are frequently 
the seat of syphilitic lesions, such as gummy or white hepatization and 
fibroid degeneration. The subject, however, has not as yet been sufficiently 
studied to enable us to speak intelligently on the diagnosis, pathology, or 
clinical history of the disease as related to pulmonary tissue. Infantile pul- 
monary syphilis is a recognized affection, the pathology of which is well 
understood. 
The points which have been dwelt upon as diagnostic of syphilitic phthisis, 
and which distinguish it, to some degree at least, from ordinary tuberculosis, 
are the absence of any very marked constitutional disturbances (as indicated 
by a high temperature, frequent pulse, night cough, and profuse perspiration), 
the reasonably good general nutrition of the body, the symmetrical nature 
of the disease, the apices of both lungs being simultaneously attacked, the 
less marked percussion-dullness, and the exaggerated vocal resonance. When 
lung-symptoms are present, or symptoms answering to those of phthisis, and 
when the apices of the lungs are not involved, the pulmonary complication 
existing in an adult who is also suffering from generalized syphilis, and who 
at the same time is known to have no tubercular history, there is reasonable 
ground for believing that the pulmonary disease depends on the diathesis of 
the patient; and this conclusion will be corroborated if the lung-symptoms 
have supervened on some syphilitic lesion of the larynx and are unaccompa- 
nied by fever, and if on the administration of antisyphilitic remedies they 
begin to disappear. 
OKGANS OF SPECIAL SENSE. 
Syphilis of the Eye. 
The integument covering the eyelids is liable to be the seat of the same 
syphilodermata as other parts of the body. Mucous patches and gummata 
select the tarsal border of the lids. 
Syphilitic inflammation of the free margin of the lids frequently extends 
into the Meibomian follicles, the infiltration causing a considerable thickening, 
and sometimes ending in ulceration, with loss of the eyelashes. 
The lachrymal ducts and sacs suffer in common with other parts from 
syphilis; the effect is sometimes to produce narrowing of the canals, with 
epiphora and fistula. These lesions belong to the later phenomena of the 
disease, and are often secondary to periostitis or osteitis of the underlying 
hone. 
The gummy enlargements may be mistaken for ordinary tumors of the 
palpebrse, or for hordeolum. Ulcerations, when present, suggest the exist- 
ence of epithelioma. Concomitant or pre-existing lesions, and the effect of 
antisyphilitic treatment, will usually determine the diagnosis. 
Iritis.—Syphilitic iritis, though sometimes seen during the secondary 
period, belongs properly among the late or tertiary lesions. Three varieties 
of the disease exist,—the superficial, the deep, and the gummy. 
The first, designated by Virchow as peri-iritis, consists in an inflammation 
of the serous layer of the iris, the form usually seen when appearing among 
secondary syphilides. In the second or deep variety, the inflammatory SYPHILIS OF THE EYE. 
549 
changes are located in the parenchymatous structure of the iris. The 
former may, however, be converted into the latter. Gummata of the iris 
appear as small, light-colored elevations on the surface of the membrane. 
Symptoms.—The approach of syphilitic iritis is generally insidious. Often 
the first symptom observed is some degree of redness or increased vascularity 
of the eye, particularly near the corneo-sclerotic line. This sign is, however, 
preceded by a change in the color of the iris. That organ becomes dull, 
gray, or dark, and there are irregularity and incomplete mobility of the 
pupil. The striated appeai’ance of the structure also is partly lost. Some- 
times the surface of the iris is studded over with minute dark-red points, 
which are caused by extravasated blood. The disease appears first in one 
eye and then in the other, not often simultaneously in both organs. Supra- 
orbital pain in the severe form (parenchymatous iritis) is experienced. The 
vision is somewhat indistinct, though there is rarely either undue lachry- 
mation or photophobia. 
The tendency in superficial iritis is to closure of the pupil (more or less 
complete), and to an adhesion of the membrane to the posterior face of the 
cornea. The changes wrought on the iris are thickening, adhesions, either 
to the cornea or to the lens, and narrowing of the pupil. 
Diagnosis.—Syphilitic iritis is liable to be mistaken for rheumatic iritis. 
The differential characteristics of each may be stated as follows: 
SYPHILITIC IRITIS. 
RHEUMATIC IRITIS. 
Slow and insidious in its development. 
Sclerotico-corneal line of vascularity not 
marked. 
Cornea and aqueous humor dull, cloudy. 
Color of iris yellowish green. 
Synechia and pupillary obstruction with lymph 
common. 
Little intolerance of light. 
Condylomata of iris. 
Very little lachrymation. 
Dull expression of eye. 
Sudden; acute. 
Very marked. 
Clear. 
No such appearance. 
Rare. 
Great. 
None. 
Very much. 
Rather bright in early stages. 
Choroiditis.—Since the introduction of the ophthalmoscope into the study 
of diseases of the eye, we are able to recognize with considerable certainty 
a choroiditis which has a syphilitic origin. The disease may arise alto- 
gether independently of iritis, though not unfrequently the two affections 
coexist. 
One of the rational symptoms is indistinct vision, objects appearing as if 
viewed through a mist or haze. When pain is present, it will be particularly 
severe at night. 
Examined by the ophthalmoscope, the vitreous humor presents a dull, hazy 
appearance, due to the presence of numerous fine spots of opacity which are 
strewn over it, and which in some places are grouped closely together, giving 
somewhat the effect of ground glass to the appearance of this body. Thread- 
like filaments of opacity are also observed. The optic nerve is seen faintly 
and imperfectly defined, as through an intervening veil of mist. The vessels 
of the choroid in the early period of the attack are large and congested, but 
at a more advanced or later stage are seen to be greatly contracted, possibly 
not at all visible. Yellowish-white patches of exudation are also seen on the 
choroid, with spots at which the pigment has in part or entirely disappeared. 
Unless the iris is involved in the disease, the pupil remains normal, the aque- 
ous humor is clear, and there is no undue sensibility or lachrymation. 
The prognosis in syphilitic choroiditis is not unfavorable, if the disease is 
early recognized and prompt treatment is adopted. 
Retinitis.—Syphilitic retinitis occurs both as a primary and a secondary 
affection. When secondary, it is an extension from the choroid and the iris. 
Its onset is slow and the progress chronic, lasting often for months, and 550 
SYPHILIS. 
the disease is liable to end in some defect of vision by implicating the optic 
nerve (neuro-retinitis). 
The ophthalmoscopic appearances do not materially differ from those 
observed in ordinary retinitis, and can be certainly differentiated only by 
careful inquiry into the antecedent history of the patient. 
The auditory apparatus, though not exempt from syphilitic invasion, is 
not very frequently affected, and when attacked the cavity of the tympanum 
is the portion of the organ which most commonly suffers. Infantile syphilis 
of the ear is regarded by some aurists as not uncommon. Since the ear 
combines in itself a great variety of dissimilar structures, the syphilides 
which are met in the organ are quite various. Among them are chancre 
and eruptions on the integument of the auricle, and condylomata or moist 
vegetating papules in the external auditory canal and on the membrana tym- 
pani, the offensive discharge from which resembles that of suppurating otitis. 
The auriculo-mastoid groove may also become the seat of mucous patches. 
In the subcutaneous connective tissue and bone appear gummata, periostitis, 
osteitis, etc. Necrosis and exostoses are also among the accidents occasion- 
ally witnessed. Osteitis ending in necrosis of the bony canal may cause both 
the loss of hearing and facial paralysis, by the inflammatory formations 
encroaching upon the portio mollis and portio dura nei*ves. 
Instances are recorded in which syphilis has been communicated by the 
instruments of the aurist. 
Syphilis of the Organ of Hearing. 
Syphilis of the Olfactory Apparatus. 
The sense of smell may be diminished in acuteness or entirely lost by a 
syphilide of the olfactory nerve, arising independently of any surrounding 
lesion, or the nerve may share secondarily in the ravages of the disease as 
it attacks the different structures of the nose, particularly the periosteum 
and the bones. 
The nasal mucous membrane does not usually escape syphilitic inflamma- 
tion. The sign which reveals the presence of syphilitic lesions is a thin 
discharge, followed soon by a consistent and yellowish one, which excoriates 
the surrounding parts and accumulates in crusts about the nares, interfering 
with the free passage of air both in inspiration and in expiration, and pro- 
ducing a loss of smell and a feeling of obstruction. In some respects tbe dis- 
ease simulates both an ordinary and a strumous nasal catai’rh. The absence, 
however, of sneezing in syphilitic catarrh will, independently of a specific 
history and of preceding or concomitant lesions, serve to distinguish the dis- 
ease from common influenza; and as strumous catarrh is generally a disease 
of childhood and associated with cervical adenopathies, there will be little 
probability of mistaking it for a syphilide. 
The cartilaginous septum is frequently perforated by ulceration. 
When the inflammation extends to the periosteum and the bones, or begins 
primarily in the osseous walls of the nasal fossae, the discharges have an offen- 
sive odor. 
Frequently the spongy, fragile turbinated bones and the perpendicular 
septum, both cartilaginous and bony, are destroyed, and are either discharged 
spontaneously or admit of being picked away by instruments when detached. 
As a consequence of this destruction, the nose sinks in, causing a marked de- 
formity and alteration in the whole expression of the face. The palate-plates 
of the upper maxillary and palate bones may also be destroyed, opening a 
communication between the mouth and the nose. 
Gummy deposits frequently form in the connective tissue of the alee, with 
a strong tendency to terminate in ulceration unless combated by appropriate 
treatment; and even then the removal of the local disease is often followed 
by distortions of the cartilage. SYPHILIS OF THE ALIMENTARY TRACT. 
551 
SYPHILIS OF THE ALIMENTARY TRACT. 
Pharynx.—Syphilitic erythema of the pharynx is one of the early mani- 
festations of the disease. The later lesions of this region are ulcerative, the 
result of softening of tubercular and of gummy deposits. The ulcers mani- 
fest a decided* preference for the lateral rather than the posterior wall of the 
pharynx, though they not unfrequently extend to the latter. Under the 
mucous membrane a little nodule first appears, which gradually increases in 
size, and at length softens and ulcerates, leaving a sore with dark-red granu- 
lations and irregular borders. 
Pharyngeal syphilitic lesions have frequently been mistaken for epithelioma 
and for retro-phai’yngeal abscess. 
The circumfei’ential induration of epithelioma, however, and its want of 
mobility, are features which do not belong to non-ulcerating or ulcerating 
gummata, nor do the latter implicate the lymph-glands, as does carcinoma. 
Betro-pharyngeal abscess begins as a diffused swelling, sometimes with 
an acute history ; it is attended with pain, difficult deglutition, marked 
immobility of the pharyngeal wall, and at length fluctuation, peculiarities 
which serve to lessen the probability of confounding the abscess with 
syphilitic disease of the part. 
The prognosis is favorable in all cases when an early resort is had to the 
proper remedies. 
(Esophagus.—This part of the alimentary canal rarety becomes the seat of 
syphilitic disease. A case of stricture of the tube, which followed, no doubt, 
a previous gummy formation, was reported by the late Dr. Maury. The 
prominent symptom of oesophageal syphilis would be that resulting from 
mechanical obstruction,—namely, difficult deglutition. But, as this is present 
also in carcinomatous disease of the tube, it would of itself have little differ- 
ential value; yet, if at any time there have been mucous patches in the 
mouth, ulcerations in the fauces or pharynx, or any other external indications 
of syphilis, there will be little difficulty in referring the oesophageal lesion to 
the proper cause. 
Stomach.—Syphilis of this organ is also uncommon, though a sufficient 
number of cases have been observed by Engel, Cornil, Lancereaux, and others 
to establish beyond question its existence. The lesions observed have been 
cicatrices, sharply-circumscribed nodules (gummata) located in the sub- 
mucous connective tissue, and ulcers, formed* by softening and ulceration of 
the nodules. 
The symptoms of ulceration are pain, referred to the epigastric region, 
disordered digestion, eructations, and vomiting. As these signs are present 
in all gastric ulcerations, from whatever cause, it would not be justifiable to 
attribute them to a syphilitic origin, except when lesions of unmistakably 
syphilitic character are known to have existed. 
Intestines.—Syphilitic lesions of the small intestine, though rare, have 
been observed. Klebs and Virchow found them in the ileum and jejunum. 
As ulcerations and cicatrices of the small and large intestine have a varied 
causation (tuberculosis, typhoid fever, dysentery, etc.), more or less uncer- 
tainty will attend a diagnosis. In the lower half of the rectum and in the 
anus syphilitic ulcerations and stricture are quite common. These are, no 
doubt, produced in many instances by chancres. When exposed to view, the 
ulcerations are seen to have irregular, ragged borders, the thickening being 
confined chiefly to the inner wall of the gut. 
SYPHILIS OF THE PERIOSTEUM, BONES, AND ARTICULATIONS. 
Syphilis of the periosteum and bones is exceedingly common ; but the re- 
sults of the disease are less frequently noticed in the articulations, though 552 
SYPHILIS. 
among the advanced manifestations of syphilis such developments frequently 
occupy either the earlier period or the border-line between the early and 
later stages. 
The bones which are peculiarly vulnerable to syphilitic attacks are the 
tibia, clavicle, ulna, sternum, cranial, tarsal, palate, superior maxillary, and 
nasal. 
Bone rarely makes its appearance earlier than the twentieth 
month following the initial sore. 
The lesions which occur in the bones are both superficial and deep, and 
originate mainly from gummata, but in their final terminations vary from 
each other. 
Osteo-Periostitis.—Both the periosteum and the bone are involved in this 
lesion. An inflammation arises in the deep layers of the periosteum, between 
which and the bone numerous round cells accumulate; at the same time a 
secondary infiltration takes place between the laminae composing the perios- 
teum. This accumulation of cell-forms obstructs to some extent the venous 
circulation of the part, and thus causes oedema of the overlying subcutaneous 
connective tissue, and produces a swelling, which rises some distance above 
the common level of the sui*rounding parts, and to which the term soft node 
is applied. Nor does the tissue of the bone itself escape unharmed. The 
Haversian canals enlarge, the fat which they contain is replaced by a red or 
dark-gray gelatinous material, and the medulla is transformed into embryonic 
elements. 
Should the local conditions remain for some time undisturbed by treat- 
ment, the cells of the deep laminae of periosteum undergo ossification, 
forming osteophytes or exostoses, or hard nodes, which finally become unified 
with the bone on which they rest. The terms “ superficial” and “ parenchy- 
matous” exostosis, sometimes used by writers on syphilis, are designed to 
express, the former a node loosely attached to the bone, and the latter a 
node which has become solidly blended with the bone. Circumscribed sub- 
periosteal swellings are frequently seen over the head of a patient during the 
very early period of generalized syphilis, disappearing and returning accord- 
ing as the treatment is continued or abandoned. 
Eburnation.—When an osteitis, instead of lingering near the surface of 
a bone, extends inward, or when it has a central origin, the cavities which 
are formed by the gummy material, and which remain after the latter has 
softened, are filled by a new inflammatory product, in which, by the action 
of cytoblasts, additional lamellae are made to those normally inclosing the 
Haversian canals, rendering the latter more compact and dense, and consti- 
tuting a condition designated eburnation, or osteitis condensens. This process 
may far transcend the limits of normal nutrition, and cause a considerable 
hypertrophy of the bone. The bones of a syphilitic cranium in the museum 
of the University are over one inch in thickness. 
Porous or rarefying osteitis results from a grade of inflammation much 
more intense than that which is concerned in adding new bone-material to 
the walls of the Haversian canals, and thus contributing to the density of 
the osseous tissue. In porous osteitis, the proliferating cell-forms which 
crowd the Haversian canals soon produce erosion of their walls, forming 
small cavities in the lamellae, and opening communications between contiguous 
canals, which are occupied by the altered marrow. The bone, consequently, 
presents an abnormally open, porous, or spongy appearance. Notwithstanding 
the structural changes wrought by the gummous inflammation of the bone, 
if the disease is arrested by early and judicious treatment, or if the inflam- 
mation is reduced in intensity, the damage is often repaired by the recon- 
structing force of cytoblasts, in which process, from the new formation of 
lamellae, the rarefying osteitis may be converted into a condensing or ebur- 
nating osteitis. . 
Caries.—Syphilitic caries arises first in a soft, gummy accumulation that OSTEO-PERIOSTITIS. 
553 
forms in the spongy tissue of the bone, destroying, after a time, superincum- 
bent or compact layers of the osseous tissues, and forming an opening through 
which escapes a syrup-like or glairy fluid separating the periosteum from the 
bone. When several such gummy foci exist and find their way to the surface, 
the bone presents a worm-eaten or porous appearance. Frequently at the 
same time that gummata are causing the disappearance or thinning of the 
osseous lamellae by dilating the Haversian canals, another work is in progress, 
that of depositing new bone around the circumference of the damaged tissue. 
The process is analogous, in many respects, to that which goes on in the 
formation of ordinary abscesses, an investing wall of lymph being soon con- 
structed and afterwards increased in thickness while the pus is finding its 
way to the surface. The bones of the cranium often supply examples of the 
above lesions. 
Necrosis.—The death of bone when occurring from syphilis may originate 
either in denudation, caused by subperiosteal accumulations of gummata, or 
in excessive consolidation of the 
osseous tissue from a new forma- 
tion of lamellae carried to the ex- 
tent of filling up the Haversian 
canals and thereby destroying the 
blood-vessels. The most terrible 
devastation of tissue from this cause 
is sometimes seen in the cranium, 
the bones of which may become 
riddled with perforations. (Fig. 
2065.) In these perforations the 
destruction of tissue often begins 
on different surfaces of the bone, 
the gummy formation collecting 
beneath the dura mater and also 
beneath the pericranium. Occa- 
sionally an entire piece perishes en 
masse. In one instance I removed 
from the head of a syphilitic patient, 
at the clinic of the University Hos- 
pital, the entire frontal bone. It is remarkable that such extensive disease 
of the cranial bones can exist for years without any serious lesions of the 
brain. 
Abscess of bones from syphilitic disease is uncommon. 
Symptoms.—The symptoms which disclose the presence of bone syphilis 
are pain and swelling. The pain is extremely severe and distressing, and, 
what adds to the suffering, the exacerbations generally occur at night, after 
the patient retires to bed, thus preventing sleep. 
Fig. 2065. 
Necrosis of the cranium. 
Tubercular syphilitic lesions, except in location,—for they are seated, as 
has already been stated, in the derm,—do not materially differ from gum- 
mata. They appear either as dry or as ulcerating syphilides. The former 
consist of flattened, copper-colored papules, imbedded in the skin, and cov- 
ered with epidermic scales or crusts. The latter, or the ulcerating syphilides, 
are made up of an accumulation of new elements in the derm, which are so 
closely packed that the vitality of the parts is soon destroyed, and they are 
cast off as sloughs. When the lesions are contiguous, the infiltrated patches 
of skin coalesce, and deep ulcerations follow, the margins of which are 
horseshoe or crescentic in shape, and are often serpiginous. These ulcers 
are exceedingly difficult to heal, and may extend over a very large surface. 
(Fig. 2066.) 
In one instance I saw a tubercular ulceration which, commencing over one 
groin, gradually extended across the abdomen, reaching as high as the um- 
bilicus, and terminated on the opposite groin. After two years of unavailing 554 
SYPHILIS. 
treatment, both local and general, I advised a radical change of climate and 
surroundings; and although the patient was so feeble as to require to be 
Fig. 2066. 
Tubercular ulcerations. 
carried on a bed to the vessel, yet a sojourn of a year abroad resulted in 
complete recovery. 
Syphilis of the Hard Palate and Nasal Bones.—Although any part of the 
upper maxillary bones may bo attacked, yet the palate-plates are peculiarly 
liable to suffer. So stealthily does the disease approach that not unfre- 
quently considerable disorganization has been wrought before the attention 
of the patient is particularly attracted to the part. A little gummy swelling 
or elevation of the mucous membrane appears on the roof of the mouth, 
which at length softens and undergoes ulceration. A probe passed into the 
opening comes in contact with denuded bone, the separation of which it is best 
to leave to the operation of natural processes. The opening between the 
mouth and the nose which follows the removal of the necrosed plate does not 
subsequently close, but the resulting inconvenience can be met by adjusting 
a plate of vulcanized rubber or of gold. 
When the nasal bones are attacked by syphilis,—syphilitic ozsena,—its 
ravages are chiefly confined to the perpendicular septum of the ethmoid 
and to the turbinated bones, the destruction of which is followed by falling 
in or flattening of the organ. The development of the disease in the nasal 
fossre is announced by a muco-purulent discharge, an offensive odor, and an 
altered tone of voice. 
All forcible attempts to extract necrosed fragments prior to their sponta- 
neous separation, whether of the maxillse or of the bones within the nasal 
fossae, are improper. 
The lesions of periosteal and bone syphilis are met in both the early and 
the late period of the disease, though arising from different causes. Those 
which develop early in the evolution of syphilis, in some instances even be- 
fore any other general manifestation, as pain in the head and along the shin, 
involve the pericranium or the periosteum, and have an inflammatory causa- 
tion, while those which crop out later on are the results of gummata; and 
these last involve not the periosteum alone, but the osseous tissue also, and 
may lay the foundation for exostosis, caries, and necrosis. All these lesions 
are greatly under the influence of constitutional remedies, and most of them 
are entirely preventable by early treatment. SYPHILIS OF THE ARTICULATIONS. 
555 
Syphilitic affections of the muscles, first described by Theodosius, are not 
very common. Among the early manifestations of syphilis there are fugitive 
pains, which, following the course of the muscles, are regarded as rheumatic 
in their character. The myopathies, however, which belong to the later 
period of the disease are of a different nature, being fixed and somewhat 
difficult to dislodge. JSTo muscle, voluntary or involuntary, can be said to 
be exempt. The later lesions exhibit a marked preference for certain ones, 
such as those of the tongue, the flexor biceps cubiti, the sterno-cleido-mastoid, 
the gastrocnemius and soleus, the pectoralis major, and the adductors of the 
thighs. The lesion is seldom seen earlier than from eight to twelve months 
after the primary sore. There are pi-obably two forms of muscular syphilis, 
one a myositis and the other having a gummy origin. The dominant symp- 
toms in both varieties are contraction and hardness, but, in addition, in the 
gummatous form there are firm masses or tumors, which can be felt imbedded 
in the substance of the affected muscle. So painless is this lesion that the 
spastic contractions often will be first detected by noticing some abridgment 
in the movements of a joint with which the affected muscle is connected, as 
the elbow where the flexor biceps cubiti is diseased, or the occipito-atloid 
where the sterno-cleido-mastoid is involved. 
The pathological changes wrought by syphilis of the muscles are chiefly 
a sclerosis from new formation of connective tissue, subsequent wasting of 
the muscular fibrillae, and sometimes a deposit of calcareous salts. The final 
disposition of the syphilitic gummy products is not always the same. If 
early discovered and combated by constitutional treatment, they gradually 
disappear, leaving the muscle but slightly impaired either in structure or in 
function; but under different circumstances, when the disease is mistaken for 
rheumatism and is allowed to go on unchecked, the skin overlying the tumors 
may become red and tender, and the gummata soften and be discharged, 
leaving the muscle permanently shortened. A very characteristic case of 
the latter nature I saw in a patient from Delaware, in whom the lesion in- 
volved the muscles both of the thigh and the calf of the leg. 
The tendons and aponeuroses also form sites for gummy productions. The 
tumors may be felt as firm nodules, sharply circumscribed and lying in the 
midst of the fibres of the structure. They are liable to be mistaken for 
ganglions, being characterized, like the latter, by absence of inflammatory 
phenomena, by elasticity to the touch, and by their gummy contents. The 
coexistence, however, of pustulo-cutaneous or other external lesions traceable 
to a syphilitic origin will aid in removing any obscurity which may attend 
the case. 
Gummata of the tendons may soften and discharge, leaving ragged ulcers 
which are difficult to heal, though when once closed they may leave little or 
no structural alteration which interferes with the usefulness of the tendon 
or aponeurosis. 
Syphilis of the Muscles and Tendons. 
Syphilis of the joints appears very late, coming on many years (perhaps 
twelve to fifteen) after infection. It has been studied by Eichet, Folin, and 
Lancereaux. The articulations which are most frequently selected by the 
disease are the temporo-maxillary, wrist, knee, and hip. 
The symptoms are slight pains, most severe in the evening or night, and 
gradual swelling of the joint, unaccompanied by fever, and not attended at 
first with materially abridged movements. The disease rarely involves more 
than a single joint, and the knee is believed to be the one most frequently 
attacked. In one of my own patients, a man about sixty-eight years of age, 
the arthritis was located in the shoulder-joint. There was also necrosis of 
the inferior maxilla. Syphilitic arthritis follows no uniform course in regard 
to the particular component of the joint first affected. It may commence in 
Syphilis of the Articulations. 556 
SYPHILIS. 
the fibrous or ligamentous tissue, in the synovial membrane, in the perios- 
teum, or in the bones. There is generally some hydrarthrosis present, the 
fluid being more consistent than that found in non-specific arthritis, and in 
consequence imparting, on palpation, the sensation of a gelatinous, elastic 
material. Soft masses—gummata—can be discovered by manipulation in the 
fibrous envelopes and ligaments, at the sides of the tendo patellae, and in the 
interior of the affected joint. Enlargement of the articulating ends of the 
bones, the result of osteo-periostitis, constitutes occasionally one of the morbid 
features of the disease, conjoined with which there may be a localized erosion 
of the articular cartilages; and this is the most serious form of syphilitic 
arthritis. 
There is not much difficulty experienced in distinguishing this disease from 
arthritis the result of other causes. The quiet invasion, the absence of any 
very marked tenderness or sensibility of the joint, either on pressure or 
movement, the semi-solid or doughy elasticity of the swelling experienced 
on palpation, the absence of fever, and the evidence which may be gathered 
from a close inquiry into the antecedent and present history of the patient, 
will all give evidence of the specific nature of the arthritis. 
The greatest difficulty would be experienced in differentiating the form of 
arthritis under consideration from strumous joint disease, the physical signs 
being much the same in both. Any doubt on the subject could be removed 
only by ascertaining the former and present history of the case, and by 
the effect of alterative treatment, which, even in bad cases of syphilitic 
arthritis, exercises a marvelous control over the disease. 
Dactylitis.—Under this term is described, particularly by Taylor, of New 
York, a lesion of syphilis which usually affects one of the phalangeal joints 
of the hand or foot, generally the proximal, or the one in immediate connec- 
tion with the metacarpus or metatarsus. It may be either acquired or hered- 
itary, and is met in the latter part of early syphilis and also in late syphilis, 
though differing somewhat in the two cases. In the early stage it consists 
of a gummy formation in the ligaments and periosteum of the joint, as well 
as in the overlying integument, giving rise to a painless swelling, which on 
disappearing leaves the joint stiff. The other form, always very late in its 
appearance, begins as a gumma of the bone, the disease extending to all the 
components of the joint, not affecting the skin, and leaving the articulation 
anchylosed and useless. In a new-born infant recently under my care, in 
addition to dactylitis there was a gummy necrosis of a small portion of the 
upper maxillary bone and of the spine of the scapula. 
Diagnosis.—The diagnosis in dactylitis is a matter of practical importance, 
as contra-indicating operative measures. The disease might be confounded 
with paronychia, exostosis, and enchondroma. The absence of pain or other 
inflammatory phenomena would serve to distinguish it from paronychia. 
From exostosis the following differential points may be made,—namety, that 
in the latter the swelling is very hard, sharply defined, pedunculated, or ses- 
sile ; whereas in syphilitic dactylitis it is of irregular density, is fusiform in 
shape, and its limitations are not well defined. The disease, moreover, in ex- 
ostosis is chronic, painless, except when the bone comes in contact with a 
nerve, has no tendency to suppurate, and is not affected in the least by con- 
stitutional remedies; whereas in syphilitic dactylitis the enlai'gement is more 
rapid in its course, tends to eburnate rather than to suppurate, and is favor- 
ably affected by specific treatment. 
Between enchondroma and syphilitic dactylitis the analogies are very close; 
but, considering that the former affection often involves more than one bone, 
that it is not necessarily associated with any impairment of the general 
health, peculiarities which cannot be affirmed of the syphilitic disease, and, 
above all, that it is not a sequel of syphilis, nor at all amenable to anti- 
syphilitic treatment, it is not probable that any confusion in the diagnosis 
will follow. SYPHILIS OF THE HER VO US SYSTEM. 
557 
SYPHILIS OF THE NERVOUS SYSTEM. 
The syphilitic affections of the nervous system attracted the attention of 
medical writers as early as the sixteenth century, and from the days of Para- 
celsus down to the present time fresh contributions to the subject have been 
constantly accumulating. Through the labors of Ricord, Yidal, Lancereaux, 
Wilks, Yirchow, Charcot, Wagner, Gowers, Althaus, Mauriac, Cornil, and 
many others, our clinical and pathological knowledge of the effects of the 
disease on the nervous system is becoming more exact, though we are far 
from being able, as yet, to localize definitely some of these lesions. 
Cerebral Syphilis.—In early syphilis a number of very distressing symp- 
toms are sometimes present, the gravity of which is not commensurate with 
their severity. These are, 1st, cephalalgia, or pain which is experienced in 
the forehead and temples, and often in the back of the head. This pain is 
sometimes almost unendurable. It is intermittent, generally coming on in the 
evening or during the early part of the night, and disappearing towards 
morning. Though occasionally early cephalalgia is persistent and obstinate, 
yet generally its duration is brief, the headache subsiding spontaneously, or 
yielding quickly to treatment. 
2d. Supraorbital and frontal neuralgia is another symptom of early syphilis. 
The limitation of this pain to the regions supplied by the first branches of 
the fifth pair of nerves, and its darting or lancinating character, will aid in 
distinguishing it from the intracranial pain alluded to above. 
3d. Mental disturbances and deafness are also among the symptoms of early 
syphilis, but are mostly of a temporary nature. 
In meningeal syphilis the dura mater is the membrane which suffers most, 
though the arachnoid and the pia mater are not exempt from similar lesions. 
It is more than probable that in a certain proportion of cases the morbid 
changes observed in the latter membranes have been propagated secondarily 
from the dura mater. 
The symptoms which reveal syphilitic meningitis vary according to the 
extent and severity of the inflammatory changes. The most common symp- 
toms are constant headache, vertigo, epileptic convulsions, hemiplegia, and 
aphasia. There is a form of cephalalgia different from that described as be- 
longing to early syphilis, and of much more serious import. It may be distin- 
guished by its greater severity and intermittent character, the exacerbations 
of pain occurring usually in the evening or at night. The exacerbations, 
moreover, are rarely persistent. They generally subside spontaneously or 
disappear quickly under treatment. 
The pathological changes which are seen in the dura mater in cases of 
meningeal syphilis consist in inflammatory deposits between the membrane 
and the bone, both diffused and localized, forming gummata, adhesions, and 
thickening of all the meninges and their fibrous attachments to different 
portions of the encephalon. 
Syphilis of the Encephalon presents symptoms similar to those which follow 
meningeal lesions. Among the paralytic sequels hemiplegia is common ; in 
addition paralyses of certain muscles are frequently met, especially those of 
the eye and eyelids, giving rise to strabismus (most commonly external squint) 
and ptosis from involvement of the third and fourth pairs of nerves. The 
lesion often causes double vision, mydriasis, epilepsy, and general functional 
disturbances of the organs of special sense, choreic movements of the muscles 
of the face, or facial grimaces, muscular contractures, or tonic spasms, particu- 
larly of the muscles of the extremities. It is probable that general paralysis, 
ataxia, and disorders of the intelligence are sometimes of syphilitic origin. 
Syphilitic hemiplegia has certain characteristics by which it may be dis- 
tinguished from the ordinary form of hemiplegic disease. The diagnostic 
marks have been very carefully pointed out by Van Buren and 3£eyes, such 558 
SYPHILIS. 
as its very common occurrence before the age of forty, this kind of hemi- 
plegia being twice as frequent in early life as hemiplegia of a non-specific 
nature. There is also present invariably the precedent headache, and the 
attack comes on without loss of consciousness. Of course the differential 
diagnosis will be rendered more certain if concurrent specific lesions can be 
discovered. 
The pathological changes observed in syphilitic encephalitis consist in dif- 
fuse interstitial infiltrations, gummata, and obstructive lesions of the cerebral 
arteries, causing apoplexy and softening. The gummy tumors vary in size 
from that of a pea to that of a walnut. They occupy generally one or more 
points upon the external surface and the base of the cerebrum, and are found 
particularly on its anterior lobes; but they are rarely seen in the cerebellum. 
The preference manifested by the disease for the parts of the brain above 
mentioned explains in some measure the very common symptoms of aphasia, 
paralysis of the muscles of the eye, ptosis, and mydriasis. 
The brain-lesions, by pressure, may cause apoplectic symptoms; and when 
patients complain of disturbances of the oi’gans of sense, such as unusual 
sounds in the ears, coruscations of light before the eye, and disorders of tac- 
tile sensibility, the danger of an apoplectic seizure is imminent, and should 
be promptly met by constitutional treatment. Intellection is sometimes im- 
paired in late syphilitic disease, particularly when the patient has been for 
some time the subject of epilepsy. Weakened memory, hallucinations, and in- 
coherent thought and speech are among the symptoms observed in these cases. 
The diagnosis of syphilitic from ordinary epilepsy may be reached with 
reasonable certainty by taking into account the age of the patient, which in 
the syphilitic disease is rarely under twenty-five or thirty years, while idio- 
pathic epilepsy is met principally in persons very much younger. In addi- 
tion, in syphilitic epilepsy there are always certain forerunners, such as head- 
ache, neuralgia of the trigeminal nerves, vertigo, mental hebetude, threatened 
paralysis, and possibly a choked optic disk. Epilepsy resulting from syphilis 
rarely occurs earlier than the second year following the primary lesion, and 
generally comes on after the lapse of several years. It is very commonly 
due to gummata in the pia mater, which give rise to irritation of the cortical 
structure of the brain, and of course of the nerves of motion. 
The opinion has been ventured that as there are three typical lesions in 
intracranial syphilis,—namely, meningeal infiltration, gummata, and arterial 
obstruction,—a diagnosis of the structure involved might be based on the 
functional disturbances which follow ; lor example, cephalalgia is regarded as 
the dominant exponent of meningeal syphilis, epileptic seizures are thought 
to characterize gummatous brain syphilis, and instantaneous or unannounced 
paralysis indicates arterial occlusion. There are, however, so many excep- 
tions to these statements that no general rule can be formulated from them. 
The prognosis, though grave in the early manifestations of cerebral syph- 
ilis, is by no means hopeless, many cases recovering under well-timed treat- 
ment; but in the brain-lesions of late syphilis less encouraging results are 
to be anticipated. 
When one-sided paralysis exists, any prognosis not based on a knowledge 
of the causation of the lesion will be of no value. For instance, if the hemi- 
plegia is entirely due to the pressure of a gumma, an encouraging or hopeful 
view may be taken of the case, because this lesion can be favorably influenced 
by general treatment; while, on the other hand, if there is reason to assume 
that the paralysis is secondary to softening of a portion of one of the great 
motor ganglia of the brain from arterial obstruction, recovery of power in 
the disabled part is impossible, since there can be no regeneration of neurine 
to supply that which has been lost. 
Syphilis of the Spinal Cord.—Syphilitic affections of the spinal cord are less 
common than those of the brain. The symptoms are pains and often para- 
plegia, rarely hemiplegia. The portions of the body paralyzed will be deter- SYPHILIS OF THE TESTES. 
559 
mined by the region of the medulla spinalis which is implicated. When the 
lesion is located in the lumbar region (the most common seat) there follows 
paralysis of the lower extremities, bladder, and rectum. Additional muscles 
will be involved when the higher parts of the cord suffer. 
The pathological changes which have been observed in syphilis of the cord 
consist in diffused or localized gummata, involving both the meninges and 
the medulla, with hyperplasia of the neuroglia, the starting-point being a 
meningitis or myelitis of a chronic or subacute grade. 
The prognosis of syphilis of the medulla spinalis is very unfavorable. The 
lesion is often followed by extensive sloughing of the integument over the 
salient portions of the body, from pressure due to recumbency. 
SYPHILIS OF THE GENITO-URINARY ORGANS. 
In the male, gummy tumors may occur on the glans penis, in the external 
urinary meatus, behind the corona glandis, in the foreskin, and in the cor- 
pora cavernosa and corpus spongiosum. In the female, similar formations 
are met on the clitoris, vestibule, labia, vulva, and cervix uteri. These legions 
appear as pea-shaped nodules, and when they ulcerate they often resemble 
very much in appearance either chancroid or chancre, being cup-shaped, pain- 
less sores, with sharply-defined edges. From chancroid they may be distin- 
guished by their single or solitary character and the absence of the property 
of inoculability, and from chancre only by learning the previous existence 
of the latter, on the site of which gummy ulcers often form. 
When seated in the body of the penis, these tumors, by destroying or by 
compressing the cavernous structure, sometimes render a portion of the 
organ flaccid during erection, causing curvatures in different directions, ac- 
cording to the location of the induration, and they may thus disqualify the 
parts for executing the sexual act. 
I have many times seen hard, fibrous formations in the cavernous struc- 
ture of the penis, in persons over fifty years of age, which produced curva- 
tures during erection, but which were wholly independent of any syphilitic 
taint. Such nodules are not influenced by alterative treatment, and in this 
particular, aside from the fact that they have no tendency to soften, are 
unlike most syphilitic growths. 
Ulceration and cicatrization of the urethra are said by Yirchow to occur 
frequently during the later stages; but I have never met with such lesions. 
Syphilis of the Testes.—Syphilis of the testicle may be either an early or 
a late manifestation of the disease. When developing during the first period, 
that is, within four or six months after the primary sore, it is usually epi- 
didymitis which occurs, while orchitis appears years after chancre. 
Two varieties of syphilitic epididymitis and orchitis exist, one diffused or 
interstitial, the other circumscribed. 
The first consists in an inflammatory exudation, which is followed by 
atrophy of the gland, partly from the pressure of the infiltrate against the 
seminiferous tubes, and partly from sclerosis of the new connective-tissue 
elements which abound in the midst of the structure. 
Gummous orchitis differs from the interstitial only in the localization of 
the embryonic cell-forms, the aggregation of which forms distinct, smooth 
masses or nodules, which may be felt on the surface of the testicle, and 
which are also imbedded in the body of the gland. These lesions are fre- 
quently associated with effusion into the sac of the tunica vaginalis. Syph- 
ilitic orchitis is usually bilateral. Its approach is painless, and the affected 
organ has very little tendency to suppurate. 
In syphilitic epididymitis the inflammation selects the globus major, a val- 
uable diagnostic feature, which, taken in connection with the absence of 
acute symptoms, distinguishes it from gonorrhoeal epididymitis, in which 560 
SYPHILIS. 
the globus minor is implicated. In the latter variety the inflammatory 
phenomena become prominent; but not in the syphilitic form. 
The microscopic appearances presented, on examination of a section of 
syphilitic gumma from the testicle, are exhibited in Fig. 2067, in which it will 
Fig. 2007. 
Gumma from syphilitic testicle: a, a, seminiferous tubules; b,fatty degeneration of 
the new cell-elements. 
be seen that the interlobular connective tissue is infiltrated with round cells, 
as also the connective tissue surrounding the seminiferous tubes. There is 
likewise a great accumulation of epithelial cells in the tubes, the adventitious 
elements almost filling the tubes up. The new epithelial cells often undergo 
a swift fatty metamorphosis. 
The diseases with which syphilitic orchitis may be confounded are car- 
cinoma and tuberculosis. The individual characteristics when arranged in 
order for comparison furnish striking clinical differences, which will con- 
tribute to the solution of the diagnostic problem. 
TUBERCULOSIS OF THE 
TESTICLE. 
SYPHILITIC ORCHITIS. 
Tumor firm, surface smooth 
and uniform. 
Growth slow and painless. 
Skin remaining unattached 
to tumor. 
Both testicles generally af- 
fected. 
Skin over the tumor not 
marked by large veins. 
Inguinal glands, if involved, 
were so before appearance of 
the tumor. 
Size not excessive. 
Not often seen before twenty- 
five. 
Tends to fibrous formation. 
Cord not involved. 
Fungous protrusion not com- 
mon. 
Dyscrasia not conspicuous. 
No loss of flesh, as a rule. 
Tumor heavy and dragging. 
May continue for many years. 
Syphilitic antecedents. 
Influenced by treatment. 
CARCINOMA OF THE TES- 
TICLE. 
Elastic or soft, with a suspi- 
cious fluctuation. 
Growth rapid, with occasional 
shooting pains. 
Becomes attached to the tu- 
mor. 
Usually one testicle. 
Enlarged veins over the sur- 
face of the tumor. 
After appearance of the tu- 
mor. 
Remarkably large. 
May be at any age over it. 
Tendency to soft, white, brain- 
like substance. 
Cord liable to become in- 
volved. 
Common. 
Conspicuous. 
Emaciation marked. 
Bulky, but not heavy. 
Possibly for a few years. 
Not necessarily so. 
Not influenced. 
Hard, irregular, knotted. 
Rather slow, but painful on 
pressure. 
Becomes attached before ul- 
ceration occurs. 
One or both. 
Skin dark or lead-colored. 
No glandular involvement be- 
fore or after, as a rule. 
Size moderate. 
Near puberty. 
Tends to fatty or purulent 
formations. 
Frequent, but less exuberant 
than carcinoma. 
Not well marked. 
Slight. 
Moderately large. 
Intermediate in duration. 
Not so. 
Very slightly influenced. 
In all doubtful cases of enlarged testicle, before excision is determined upon, 
the patient should have the benefit of constitutional treatment. SYPHILIS OF THE KIDNEY. 
561 
Syphilis of the Spermatic Cord is exceedingly rare. The same may be said 
of syphilitic disease of the vesieulse seminales, and possibly also of specific 
lesions of the prostate body. 
Syphilis of the Uterus and Ovaries.—In only a single case have I seen a 
lesion in the uterus which could be referred to late syphilis. This was 
supposed to be carcinoma, but disappeared under treatment. Cases of the 
disease are recorded, and there are no anatomical or other known reasons 
which would exclude this organ from participating in the common fate of 
other viscera. 
The ovaries have been the seat of gummy tumors, the diagnosis being veri- 
fied both by the effect of general treatment and by post-mortem examinations. 
Several such instances have been reported by Lecorche, Lancereaux, Jullien, 
and others. 
Syphilis of the Fallopian Tubes.—Tumors possessing the characteristics of 
gummata have been observed in the Fallopian tubes, but beyond the case 
recorded by Bouchard very little is known on the subject. 
Syphilis of the Bladder.—Small submucous tumors in the bladder have been 
described as syphilitic tubercles or gummata, this opinion regarding their 
nature being based on the existence of concomitant lesions of an unmis- 
takable character. Both Polin and Yirchow described such tumors. The 
observations, however, are too few to admit of any conclusion as to the fre- 
quency of vesical lesions of this nature, though, from the irritability of the 
bladder which is not uncommonly seen in old cases of syphilis, it is highly 
probable that the organ frequently suffers from specific disease. 
Syphilis of the Kidney.—Though some difference of opinion has prevailed 
among writers in reference to admitting syphilis as a cause of renal disease, 
its potency in this regard can scarcely be questioned. Cases reported by 
Meyer, Cornil, Lailler, Barthelemy, Perroud, Coupland, and Mahomed, with 
others which might be mentioned, appear to establish its possibility, if not 
its frequency, beyond all reasonable doubt. 
Two varieties of syphilitic nephritis are described, one of which may occur 
early, though it is not at all limited to the early period, while the other is 
more commonly a late symptom. The first is a diffused or interstitial ne- 
phritis, which is followed by some atrophy organs in consequence of 
the contraction of the newly-formed elements. The other, or late form of 
syphilitic nephritis, is due to the formation of gummata. Amyloid degener- 
ation is also among the renal lesions which have been attributed to syphilis, 
though Mahomed thinks that this morbid 
change precedes rather than follows the syph- 
ilitic disease. The symptoms which declare 
these kidney affections differ little from those 
which belong to ordinary Bright’s disease, 
among which are headache, loss of color, 
cedema of ankles and face, nausea, etc. On 
applying the usual test, the urine is found to 
contain albumen, and, examined microscopi- 
cally, shows fatty granular casts. 
Death may take place quite suddenly from 
uraemic symptoms followed by coma. Such 
was the case in a young physician of this 
city whose cirrhosis of the kidneys was trace- 
able to a syphilitic cause. Though the prog- 
nosis is grave, yet if the disease is detected early the patient may be saved 
by specific treatment boldly pushed. 
Pathology.—A section of a renal gumma exhibits a large accumulation 
Fig. 2068. 
Gumma of the kidney, exhibiting the 
accumulation of cells in the intertubular 
connective tissue. 562 
SYPHILIS. 
of small round cells disseminated through the intertubular connective tissue, 
which, together with the hyperplasia of the latter, subject the secreting 
portions of the organ to damaging compression. (Fig. 2068.) 
Syphilis of the Suprarenal Capsule is a condition regarding which very little 
is known. The capsules have been seen enlarged in cases where persons 
have died from the ravages of syphilitic visceral disease. Virchow has no- 
ticed not only fatty degeneration, but distinct nodules, probably of a gummous 
nature, in these organs. Chvostek has recorded the results of a post-moi'tem 
examination which go to establish the liability of these bodies to suffer in 
common with other glands from syphilitic disease. 
Pericardium and Heart.—Only a very limited number of cases of syphilitic 
affections of the pericardium have been studied. Gummata and thickening 
of the pericardium have been described, as well as nodules projecting on 
its inner surface and answering to the usual appearances seen in interstitial 
pericarditis. I am not aware that there are any physical signs which would 
enable the physician to distinguish these lesions from other inflammatory 
affections of the pericardium, and their specific origin would have to be 
assumed from the coexistence of syphilitic manifestations in other parts 
of the body. A sufficient number of cases of cardiac syphilis have been 
studied by Ricord, Yirchow, Lebert, Lancereaux, Wilks, and Mannino to 
supply not only indubitable evidence of the occasional existence of the lesion, 
but also reasonably correct details regarding its pathological features. The 
ventricular portion of the organ and the interventricular septum are the 
parts usually seized upon by the disease: only once in six cases examined 
was the auricle found affected. The two forms of manifestation are inter- 
stitial or diffused and gummy myositis, the only difference consisting (as in 
other similar tissues) in the degree of localization of the neoplastic elements, 
there being in the diffused form a wide-spread collection of small round cells 
about the muscular fasciculi and also in the subendothelial connective tissue, 
while in the gummy form the new elements accumulate within circumscribed 
limits, forming yellowish nodules or tumors. The muscles of the valves, and 
exceptionally the valves themselves, participate in common with other parts 
of the heart in these lesions. 
Cardiac gummata undergo the same pathological mutations as similar 
syphilitic lesions in other muscles. Not only do the new-formed cells become 
granular and undergo fatty degeneration, forming a dry, caseous debris, but 
a similar transformation overtakes the muscular fibres also. Hyperplasia of 
the connective-tissue element of the organ also occurs, forming white, indu- 
rated patches on the ventricles. Independently of those consequences which 
follow structural alteration in the cardiac walls, it is possible for gummy 
neoplasms to encroach on the ventricular cavities of the heart and thus 
become the source of embolism or thrombosis. When the myositis is dif- 
fused or general, it is followed by some enlargement or thickening of the 
walls of the heart, and with dilatation of the affected ventricle, which is not 
the case when the disease is localized, as in gummata. Besides the gummy 
lesions, a lardaceous change at the expense of the muscular tissue has been 
noticed. 
Diagnosis.—There are no pathognomonic symptoms which can he regarded 
as essentially syphilitic. The very frequent exemption of the valves from 
specific lesions would furnish a basis for not confounding rheumatic with 
syphilitic myo-carditis. If, however, during the late period of syphilis, car- 
diac disease of a non-valvular character developed, in which dyspnoea, irregu- 
larity, and feeble contractions of the ventricles were prominent symptoms, 
there would be just ground for ascribing the disease to a sj'philitic causation. 
Prognosis.—While the existence of cardiac syphilis must necessarily be 
SYPHILIS OF THE VASCULAR SYSTEM. SYPHILIS OF THE BLOOD-VESSELS. 
563 
a very grave complication, there is no reason for supposing that, when by 
larger data and more exact clinical study an early diagnosis becomes pos- 
sible, the mortality may not be lessened by prompt resort to vigorous con- 
stitutional treatment. 
Syphilis of the Blood-Vessels.—The blood-vessels possess a remarkable 
power to resist disease, at least until after the meridian of life is passed, and 
they are not very often invaded by syphilitic changes. This is especially 
true in regard to the venous system, not more than two or thi’ee cases of 
syphilitic venous disease having been recorded. 
Syphilitic or gummy arteritis is comparatively rare, though a sufficient 
number of cases have been observed to establish its general recognition. 
Writers are not altogether agreed upon the finer details of the pathological 
changes which take place in these vessels, and there are some who are un- 
willing to admit that there is anything so peculiar or specific in the morbid 
phenomena as to take the disease out of the ordinary category of common 
arteritis. Huebner, after a careful study of syphilitic disease of the blood- 
vessels, insists that the initial part of the process begins on the inner surface 
of the artery by proliferation of the endothelial cells, producing a thicken- 
ing of the tunica intima and a consequent diminution in the lumen of the 
affected vessel. There cannot fail to be a resulting diminution of elasticity, 
and, as the tunica intima is likely to be raised at certain points more than 
at others, by irregularities in the endothelial proliferation, the conditions 
favorable to thrombosis are present. This change in the internal coat of 
the artery is followed by a round-celled infiltration of the external tunics by 
migration from the vasa vasorum, stimulated by syphilitic blood circulating 
in the channels of the latter. 
The difference which is claimed to distinguish syphilitic artei’itis from 
athex’oma is that the former begins in the inner coat of the vessel, and the 
latter simultaneously both in the inner and outer tunics. It may be further 
obseiwed that athei’oma is notably a disease of lai’ge vessels, while syphilis 
more commonly elects the small ai'tei'ies. It also advances with much greater 
rapidity than atheroma. 
The pathological history of syphilitic arteritis may be considered a prob- 
lem as yet unsolved. If the nuti’ition of the arteries depends exclusively 
upon the vasa vasorum, I can discover no reason why syphilitic arteritis 
should not run the usual course of syphilitic disease in other tissues and 
organs. ♦ 
The carotid arteries and their cerebral branches are the ones most com- 
monly affected by syphilis. The obstruction of these bi’anches tends to cause 
frontal headache, with evening exacerbations of great severity. This fron- 
tal disturbance is liable to be followed by localized inflammatory accidents, 
causing softening, apoplexy, unilateral pai'alysis, and various disorders of 
the psychical functions of the bi’ain. 
Another important topic connected with syphilitic disease of the arteries 
is the part which it is supposed to play in the causation of aneurism. While 
not ignorant of the very general opinion entertained by surgeons that syph- 
ilitic arteritis and aneurism are in many instances closely related, I may say 
that nothing in my experience goes to confix-m the belief in any such neces- 
sary connection. 
Diagnosis.—The diagnosis of syphilitic as distinguished from atheroma- 
tous arteritis must be based on several eonsidei’ations, such as, first, the ex- 
istence of generalized syphilis; second, the presence of cei’ebral symptoms, 
assuming that the intracranial branches of the carotid are the ones affected; 
third, the age of the patient, atheroma being a disease of advanced life, while 
the arteritis of syphilis belongs to early life. With all the information at our 
command, however, the subject of diagnosis cannot at present be removed 
from the region of conjecture. 
Prognosis.—The prognosis in syphilitic artei’itis is always gi’ave. 564 
SYPHILIS. 
Syphilis of the Racemose Glands. 
Mammary Gland.—A sufficient number of cases of mammary syphilis have 
been studied to entitle the lesion to a place among late manifestations of the 
disease. It occurs in both sexes, but is said to be more common in women,— 
a conclusion which I am disposed to doubt. 
The two forms which syphilitic mammitis assumes are, first, a general and 
quite uniform inflammatory infiltration of the interlobular and intertubular 
connective tissue of the gland, characterized by swelling and undue sensibility 
on pressure, but without redness or heat. 
The second form is the gummatous, in which there is a localized accumu- 
lation of new elements in the connective-tissue component of the gland, form- 
ing a distinct tumor, with an irregular or broken surface and of various sizes, 
from that of an almond to that of a lemon. The gumma, if allowed to con- 
tinue unchecked, gradually approaches the surface, and will probably ulcerate. 
The diagnosis of mammary gumma is somewhat embarrassing, simulating, 
as it does, carcinoma, adenoma, and cystic disease. If contemporaneous with 
unquestioned syphilitic lesions, the patient should always have the benefit of 
constitutional treatment, improvement under which would furnish additional 
evidence of its syphilitic origin. 
Salivary Glands.—Syphilitic disease of the salivary glands is occasionally 
met. The morbid changes, to the extent observed, have been those of con- 
nective-tissue hyperplasia. No cases of gummata, so far as I am informed, 
have been witnessed in these glands. 
Pancreas.—This gland has in several instances been found at autopsies of 
syphilitic subjects to exhibit traces of syphilitic lesions, especially of cirrhosis. 
Syphilis of the Lymph-Glands. 
Late syphilitic adenopathies are met in cases of visceral syphilis, and occa- 
sionally independent of it. The glands affected are the iliac, the preverte- 
bral, the bronchial, and the inguinal. The morbid changes which have been 
observed are not always alike. Sometimes the gland first enlarges from the 
diffused character of the new elements, but subsequently, as the latter are 
converted into connective tissue, it becomes dense and contracted. Should 
there be a new formation of gland-elements, the gland enlarges, exhibits a 
reddish or a yellow color, and becomes soft and unresisting to pressure. When 
the transformation is of the gummy character, the embryonic cell-infiltration 
communicates an abnormal degree of firmness to the gland, which assumes a 
spherical instead of the natural almond-shape, but afterwards becomes some- 
what flattened and quite soft from the caseous changes which overtake the 
accumulated cell-elements. 
Late syphilitic adenopathies are distinguished from tubercular and scrofu- 
lous diseases of the lymphatic glands by the absence of suppuration, and to 
the same circumstance may be attributed their notable freedom from amyloid 
changes. 
Late lesions of the subcutaneous lymph-glands, when once fairly estab- 
lished, are prone to create a periglandular inflammation, which terminates in 
abscess external to the gland. These lesions ax*e almost invariably multi- 
glandular and bilateral. 
Syphilis of the Liver. 
The liver is the subject both of early and of late syphilitic manifestations. 
The symptoms which in the early period exhibit the effects of the poison on 
the gland are general enlargement, pain, jaundice, and dragging weight, with 
some degree of nausea, headache, and lumbar discomfort. The enlargement 
is not attended with any irregularity of surface. In addition to the icteric SYPHILIS OF THE LIVER. 
565 
condition of the skin and conjunctivEe, the urinary secretion is deeply stained 
by the coloring-matter of the bile. These early hepatic symptoms are in most 
instances associated with erythematous and papular syphiloderms, and also 
with mucous patches of the mouth. 
The pathological condition is believed to be one of inflammatory round-cell 
infiltration into the parenchyma of the organ, the pressure of which on the 
biliary ducts, or that made on the bile-ducts by enlargement of the hepatic 
lymph-glands, causes icterus and induces in some degree an hypertrophy of 
the gland. This view of the morbid condition is more in accordance with 
clinical observations than that of Jullien, who regards the hypertrophy and 
other phenomena as depending on a catarrh of the bile-ducts, which extends 
from the stomach and duodenum. 
The early syphilitic liver disease seldom lasts over three months, disappear- 
ing either spontaneously or under general treatment. 
The late lesions of the liver.—Some writers are not disposed to place 
syphilitic lesions of the liver among the early affections of the gland, 
since the post-mortem examinations which have been made in a few fatal 
cases of supposed early hepatic syphilis have shown the existence of yellow 
atrophy, in which the hepatic cells were destroyed,—a structural change 
not seen in syphilitic disease. However this may be, there is no difference 
of opinion in regard to the later lesions. All agree that these are quite 
common, and that they may manifest themselves in one of three morbid 
conditions. 
First. There is a new formation of embryonic connective-tissue elements, 
which, accompanying the vessels and Glisson’s capsule, separate the liver 
into lobules. As the newly-formed conjugate tissue matures and contracts, 
the surface of the organ is rendered irregular and nodulated. The effect of 
this fibrous contraction is also seen in the deeply-notched free border of the 
liver, as well as in the cicatricial fissures which are sometimes observed 
traversing the surface of the organ. 
The second lesion is gumma. Tumors of this nature are seen, singly or in 
groups, seated in the capsule of Glisson and occupying the bottom of the 
fissures, lying beneath the cicatricial depressions in the liver, and of various 
sizes, from that of a grain of corn to that of a hickory-nut. The appearances 
presented by gummata are peculiar. Each tumor at its centre in Glisson’s 
capsule is of a yellowish-gray color; a little farther out there is a light ring, 
and beyond this the deep-red color 
of the normal hepatic tissue. If a 
section of a gumma is made, and 
examined microscopically under a 
moderate power, the centre of the 
tumor is seen to consist of islands of 
small round cells in various stages 
of degeneration, imbedded in a 
fibrous stroma and surrounded by 
a capsule of connective tissue filled 
with round cells laden with fat- 
granules. These cells play an im- 
portant part in the absorption of 
the caseous products resulting from 
retrograde changes in the gumma 
antecedent to their being emptied 
into the lymph-spaces of the invest- 
ing tissue. (Fig. 2069.) 
Third. After the removal of the 
gummata, it is the hyperplasia 
and subsequent contraction of their 
fibrous envelopes which causes the cicatricial distortions and deformities 
of the liver. Strictly speaking, there is no anatomical difference between 
Fig. 2069. 
Gumma of the liver: a, masses or islands of gumma; 
6, capsule surrounding the gumma with new elements.^ 566 
SYPHILIS. 
interstitial and gummy hepatitis, except in the arrangement of the new 
elements. 
The symptomatic history is comprised in two stages. The first consists in 
hypertrophy of the liver, the result of cell-infiltration, and a new formation 
of connective tissue, during which there are experienced pain and a dragging 
weight in the hypochondriac region, followed by jaundice. In the second 
stage the atrophy and lobulation occur, followed by ascites and gastro- 
intestinal derangements, with loss of flesh and strength. 
Diagnosis.—Syphilitic hepatitis is liable to be confounded with alcoholic 
cirrhosis, carcinoma, and hydatid C37sts. 
In alcoholic cirrhosis of the liver there is also irregularity of the surface, 
but the nodules are close together and uniform in size, each acinus being 
invested separately by the sclerosed capsule of G-lisson, and in this fact we 
have the test that differentiates the drunkard’s from syphilitic cirrhosis. 
In carcinoma of the liver there is also a nodulated surface, which resembles 
in some particulars that from syphilis; but in the former disease the magni- 
tude of the projecting masses, the involvement of both lobes simultaneously, 
and the rapid progress of the growth, with the attending emaciation and loss 
of strength, reveal its malignant character. 
In hydatid cysts the tumor is fluctuating, usually oblong or spherical, 
and develops in the direction of least resistance, or in that of the epigastric 
region. 
Prognosis.—The favorable issue of a case of syphilitic hepatitis will depend 
on its early recognition and the use of judicious treatment before the hyper- 
trophic stage has made any considerable advance. Active general treatment, 
under these circumstances, will frequently ai’rest or cure the disease. If, 
however, the stage of atrophy has been reached, remedies are of little avail. 
A fatal termination is only a matter of time. 
Syphilis of the Spleen. 
Enlargement of the spleen is not uncommon in early syphilis. In the heredi- 
tary disease hypertrophy is the rule. When occurring early, the increase in 
bulk is attributed to active hypersemia, or splenitis; the late hypertrophy is 
referred to an increase of cell-forms in the splenic pulp, with augmentation 
of the connective tissue of the trabeculae, followed by sclerosis and contrac- 
tion, the usual sequels of gummata. 
Amyloid degeneration of the spleen, which has often been observed in 
syphilitic cases, is regarded by some syphilographers as the result of pro- 
tracted exhaustion rather than of any direct action of the syphilitic poison; 
and this is highly probable, since a similar degeneration is not uncommon 
after any protracted suppuration, as, for example, an old case of osseous 
necrosis. 
TREATMENT OF LATE SYPHILIS. 
When we have to deal with the manifestations of late syphilis,—in other 
words, that stage of the disease in which the prevailing lesions are deep and 
of a gummy nature, affecting the skin, bones, and viscera,—the mercurial 
treatment will be found to be far less efficacious than when used for the 
syphilides of the early period. The pathological conditions peculiar to late 
syphilis consist in localized accumulations of devitalized cells, for the removal 
of which the aid of the lymphatic vessels must be called in, and for this 
purpose the iodides now take their proper place in syphilitic therapeutics. 
Almost half a century ago, Wallace, of Dublin, introduced the iodide of 
potassium into syphilitic practice. The remedy very soon acquired universal 
recognition. Although the iodides are employed by many practitioners in 
all stages of syphilis, yet, in consequence of their rapid elimination from the 
system through the various secretions (those of the kidneys, nasal mucous 
membrane, salivary, sweat, lachrymal, and mammary glands), they do not TREATMENT OF LATE SYPHILIS. 
567 
possess the potency necessary to combat successfully the lesions Avhich belong 
to early syphilis, when the disease is acting with its greatest intensity, and 
when we require a drug the action of which will be fatal to the permanency 
of neoplastic formations. I do not wish to be understood as conveying the 
idea that the iodides are utterly powerless in early syphilis. On the con- 
trary, the lesions do disappear under their use; but their disappearance is by 
suppression, not by eradication,—so that on the suspension of the remedy 
the physician will have the mortification of constantly witnessing relapses. 
Of the different compounds of iodine the iodide of potassium is unquestion- 
ably the most efficient. The iodides of sodium and ammonium are next in 
value, and in cases where the potassium salt disagrees with the stomach or 
unpleasantly affects the nasal mucous membrane, one or other of these prepa- 
rations may be substituted. The iodide of potassium can be exhibited either 
in solution or in pill-form. The first is to be preferred, though the latter 
will prove a great convenience to persons who are compelled by their busi- 
ness to travel, and with whom bottles constitute a very undesirable kind of 
impedimenta. The pills will require to be compressed in order to keep the 
salt unchanged. The dose in which the potassium iodide should be given 
will depend altogether upon the seat of the lesion. In cases of ordinary 
superficial syphiloderms, from five to ten grains three times a day will be 
sufficient, but when the surgeon is confronted with impending disease of the 
central nervous system, or with rapidly-increasing ulceration of the larynx 
or fauces, it may be necessary to administer the salt in much larger quanti- 
ties,—giving even as high as one or two drachms in the course of twenty- 
four hours. When exhibited in solution, a very convenient formula is the 
following: 
U Potassii Iodidi, Jij ; 
Aquae Destillatae, f^jvss; 
Syrupi Gaultheriae, f^ss. 
M.—Sig. Dessertspoonful in a wineglassful 
of water three times daily. 
The best time for giving the medicine (which should be largely diluted) is 
about one hour after meals, as it is then less likely to disturb the stomach. 
When the iodide of potassium is administered in pills, each pill, when taken, 
should be followed by half a goblet of water, in order to prevent gastric irri- 
tation. When the administration of the iodide is followed by intestinal pain, 
a small amount of opium or a few drops of laudanum will serve to allay the 
griping; and when it gives rise to nausea or other gastric disturbance, the 
distress may be avoided by taking the remedy in carbonic-acid water. Kejms 
advises in place of this water the use of Yichy water. The irritation of the 
mucous membrane of the nose, the coiyza, and the acneform eruptions of the 
skin produced in many persons by the iodide of potassium will often subside 
spontaneously upon lessening the amount given and persevering in its use. 
Should the eruptions persist, three or four drops of Fowler’s solution of 
arsenic may be taken with each dose, with a reasonable prospect of over- 
coming the annoyance. 
The iodide can be advantageously associated with iron for patients whose 
constitutions have been damaged either by the ravages of the disease or by 
other maladies which deteriorate the blood, causing anaemia or tubercular 
degeneration of the lymph-glands. The formula which I prefer is the fol- 
lowing : 
Potassii Iodidi, 3U 5 
Ferri et Potassae Tartratis, ; 
Aquae Destillatae, f£v; 
Tincturse Anthemis Nobilis, ; 
Syrupi, f^i. 
M.—Sig. Dessertspoonful three times a 
day in a wineglassful of water. 
While the iodides possess a special adaptation to the treatment of late 
syphilis, mercurials are not always contra-indicated; indeed, in many in- 568 
SYPHILIS. 
stances, where the syphilides exhibit unwonted obstinacy, the association of 
the two remedies forms a combination which possesses a magical power to 
conquer that which neither separately could do. The different combinations 
in use are the protiodide of mercury, the strop Gibert (already described), and 
the bichloride of mercury. The latter, in my judgment, generally proves 
the most satisfactory, and can be given either as a pill or in solution, with 
the iodide of potassium: 
Potassii Iodidi, 3>>ij j 
Hydrargyri Bichloridi, gr. iss j 
Aquae Menthae Piperitae, 
Syrupi Aurantii Corticis, fgi. 
M.—Sig. Dessertspoonful in a wineglassful of water 
three times a day one hour after meals. 
Should the pill be preferred from motives of convenience, as is sometimes 
the case, it can be prepared according to the formula below: 
Potassii Iodidi, £v; 
Hydrargyri Bichloridi, gr. iij; 
Pulvis Glycyrrhiza), £>i> 
Syrupi, q. s. 
M.—Ft. pil. (compressatse) no. lx. 
Sig.—One pill half an hour after each meal. 
When the pill disturbs the bowels, the addition of a very little opium will 
correct the evil. 
The protiodide of mercury is usually given in pills, each pill containing 
from a quarter to a half grain, one being taken three times a day. 
Sarsaparilla at one time occupied an important place in syphilitic thera- 
peutics, but at present it is considered by many to be wholly inert. I cer- 
tainly have seen cases of advanced syphilis, which in spite of the usual 
treatment had come to a halt, suddenly begin to improve under the use of 
this remedy, administered in the form of decoction, of which the patient 
drank not less than three half-pints each day. The bichloride of mercury 
may be given in a decoction of sarsaparilla, and, I think, with the effect of 
increasing the salutary operation of the former. 
There are times when it will be necessary to abandon all specific treatment 
for one of a different character. This is particularly true in the case of 
patients who have suffered from frequent relapses, or who have neglected 
early treatment, adding perhaps to the existing evil the damaging conse- 
quences of intemperance and a dissolute life, and in whom the usual syphilitic 
remedies cause gastric and intestinal irritability, with loss of appetite. Such 
persons often lose flesh, strength, and color, become tremulous and feeble 
in their limbs, and suffer from extreme despondency. Under these circum- 
stances, cod-liver oil, iron, quinine, the mineral acids, blood-making wines, 
sea-battiing, change of air and climate, and a carefully-selected diet, will 
prove of the utmost importance. 
Local Treatment of Late Syphilis.—In several of the lesions which belong 
to advanced or late syphilis local measures have a positive value, and may 
be considered under the several manifestations for which topical remedies are 
employed. 
Onychia.—In the dry form of onychia no treatment other than that proper 
for secondary syphilis will be demanded. 
The moist, suppurating, ulcerating variety of the disease is extremely 
obstinate and perplexing. The affected parts should be washed at least twice 
daily with a hot solution of permanganate of potash, and then dusted with 
iodoform or nitrate of lead. Penciling the granulating surface with a solu- 
tion of bichloride of mercury (hydrargyri bichloridi, gr. i-ij, aqu© fontan©, 
f§i) will often serve an excellent purpose in modifying the character of LOCAL TREATMENT OF LATE SYPHILIS. 
569 
the diseased part, and will induce a healthy action. Solutions of nitrate of 
silver and of caustic potash have been extolled. Of the former, twenty 
grains dissolved in one fluidounce of distilled water, and of the latter, one or 
two drachms in an ounce of water, should be applied over the diseased matrix. 
The sulphate of copper constitutes a good stimulating and alterative applica- 
tion. The use of a hot poultice at night will often improve the local condi- 
tions, and prepare the matrix for some of the remedies already mentioned. 
Alopecia, pityriasis, and epithelial accumulations.—The topical applications 
to be used are those which will conduce to cleanliness and favor an active 
capillary circulation. The hair should be clipped short, and the scalp, after 
being cleansed with an alkaline wash, should be washed daily with a stimu- 
lating lotion, consisting of bay-rum, tincture of cantharides, and bichloride of 
mercury (spiritus myrcise Oss, tincturse cantharidis, foij, hydrargyri bichlo- 
ridi, gr. ij). 
Gummata.—In ulcerating gummata, benefit will also be derived from pen- 
ciling the ulceration with dilute nitric acid, or with a solution of thymol in 
glycerin and alcohol,—four grains of the thymol in an ounce each of the 
glycerin and alcohol. 
Laryngeal syphilis with ulceration.—The local remedies which may be em- 
ployed with benefit are iodoform, alum, tannin, iodine, nitrate of silver, 
and chromic acid. They are all best applied after being dissolved in water 
or in glycerin, and can be conducted to the exact seat of the lesions by the 
aid of the laryngoscope and a camel’s-hair brush supported on a long, curved 
handle. The galvano-cautery has also been used in the treatment of grave 
ulcerations of the larynx, and is spoken of favorably. The vapor from the 
tincture of iodine and laudanum, and also that from the compound tincture 
of benzoin or from carbolic acid, may be inhaled, with the effect of allaying 
laryngeal irritability and spasm. 
When an attack of dyspnoea occurs threatening suffocation, tracheotomy 
may be required. In 104 cases of the operation performed by Trelat and by 
Thomson, 80 were successful. 
Iritis.—The same necessity exists for preserving the dilatation of the pupil 
in syphilitic as in non-specific iritis, and for this purpose the instillation of 
atropia becomes exceedingly important. It must be applied once in every 
twenty-four or forty-eight hours until the morbid action is completely broken 
up. 
Lachrymal obstruction, causing the tears to overflow, will be benefited by 
dropping on the eye twice daily a weak solution of the sulphate of zinc 
(zinci sulphatis, gr. i, aquae rosae, fSi). A collyrium of nitrate of silver will 
prove valuable in similar conditions (argenti nitratis, gr. i, aquae destillatae, 
fSi). 
Tubercular or serpiginous ulcerations are benefited by a wash consisting of 
a three per cent, solution of bromine. A new and healthy action will, in 
many indolent ulcerations of a syphilitic origin, be excited by the local use 
of the acid nitrate of mercury or by nitric acid, either of which may be 
applied diluted to the margins of the sore once or twice a week. 
Stricture of the rectum.—When syphilitic stricture of this part of the 
bowel occurs, and the calibre of the intestine becomes so obstructed as seri- 
ously to interfere with the passage of the faeces, it will be necessary to dilate 
the coarctated portion by the use of hard-rubber bougies. These instruments 
should not be employed prematurely, as is often done, since they tend to create 
a great deal of irritation, and thereby engraft an active inflammatory element 
on the disease already existing. Here, as elsewhere, the constitutional treat- 
ment must be chiefly relied upon. 
Bone disease.—In the local management of bone syphilis, it is proper to 
abstain from all meddlesome interference. The pain arising from perios- 
titis will be somewhat palliated by anodyne lotions, as laudanum and lead- 
water, or by painting the surface with a mixture of equal parts of tincture 
of iodine and tincture of belladonna. When the suffering is acute, a 570 
SYPHILIS. 
few leeches applied adjacent to the painful parts will afford marked relief. 
Blisters placed directly over the node will also amelioi’ate the pain. When 
the latter is accompanied with poi*sistent throbbing, a free subcutaneous 
division of the oversti’ained periosteum will greatly lessen the violence of the 
symptoms. 
In all cases of syphilitic neci*osis, the surgeon should wait until the dead 
portion has become well separated from the living part of the bone before 
attempting its extraction. This sepax-ation is easily determined by the 
mobility of the necrosed piece, tested by the pressure of a pi'obe or dii-ector. 
In cai’ies, the circumscription of the osteitis and the detachment of the 
devitalized fi’agments can often be facilitated by touching the parts with 
acid nitrate of mercuxy two or three times a week. 
Sarcocele.—In syphilitic sarcocele, where the disease has x-esulted in ulcera- 
tion, with protruding fungoid and hopeless disorganization of 
the gland, the cui*e will be expedited by promptly removing the x’emnants 
of the testes with the knife. 
INFANTILE, OK HEREDITARY, SYPHILIS. 
The transmission of syphilis from parent to offspring is a subject which 
has greatly perplexed syphilographers. I shall not enter into any argument 
upon this matter. I believe that either parent who is or has been the sub- 
ject of syphilis is capable of communicating the same to the foetus. In most 
instances which have come under my own observation the unfortunate legacy 
has come from the male parent, who not only has impressed his own constitu- 
tional diathesis on the fecundated ovum, but also through the latter has poi- 
soned the mother in a like manner. On the other hand, a syphilitic mother 
will communicate s}rphilis to her child, whether the disease was contracted 
before fecundation or during gestation. The influence of constitutional treat- 
ment in protecting the ovum from infection is very remarkable. I have seen, 
what has frequently been witnessed by others, a mother give birth to a healthy 
child, fecundation having taken place while the father was under treatment, 
and I have seen the same mother abort, and in other instances give birth 
to a syphilitic foetus, when the father had neglected constitutional treat- 
ment. A mother who has once had an infected child will, in order that a 
succeeding pregnancy shall be uncomplicated by syphilis, requii-e, as well 
as the male pai*ent, to have been under general treatment before conception 
takes place. 
A foetus in passing through the matei’nal passages, or an infant at the 
bi-east of a wet-nui’se, may conti’act syphilis,—the former by direct inocula- 
tion from a chanci'e in the vagina or on the neck of the uterus, the latter 
from the secretions of a mucous patch about the nipple touching the lip or 
the buccal cavity. These statements admit of no doubt. There are numer- 
ous instances on l-ecoi’d where a syphilitic child has infected its wet-nurse by 
nui’sing at the bi’east. Should such a child present no exteimal signs of the 
disease at birth, they generally appear very soon after, and in the large pro- 
portion of cases during the first or the third month. In 249 cases of heredi- 
tai*y syphilis analyzed by Lancereaux, 118 developed during the fii'st and 217 
before the termination of the third month. One-thii’d of all syphilitic con- 
ceptions perish before the full period of gestation; and hence the frequent 
aboi’tions which ai*e seen in this class of cases, and which usualty occur about 
the sixth month. These miscaiTiages ai'e often to be attributed to disease 
of the placenta, due either to the pi’esence of circumscribed gummata or to 
diffuse infilti’ation with new elements. 
It does not follow that a child born of syphilitic parents, and presenting 
no appeai’ances of disease for a number of months succeeding birth, will not 
afterwai'ds exhibit signs of the taint. These may be delayed to the eighteenth 
or twentieth year before development. HEREDITARY SYPHILIS. 
571 
Signs of infantile syphilis.—The foetus at birth may exhibit no symptoms of 
the disease; indeed, the child often appears to be strong and well nourished; 
but sooner or later the manifestations of the poison become apparent in the 
development of snuffles, or in a discharge from the nasal cavities. Emaciation 
follows, the skin changes its color, becoming sallow, wrinkled, and shrunken 
over the face, and giving to the infant the appearance of premature age. 
The peculiar hoarse cry and the sore throat which accompany these symp- 
toms indicate also a certain degree of laryngitis and pharyngitis. 
The lesions which occur in the syphilis of infants are the same, in the main, 
as those of adults. First in order are the affections of the skin and mucous 
membranes. 
jErythematous syphilodermata appear generally in two or three weeks suc- 
ceeding birth, have a pink or faint copper color, and may extend over the 
body, nates, genitalia, limbs, and face. 
Mucous patches are the most common of all cutaneous lesions in infantile 
syphilis, appearing very soon after birth, and selecting the cutaneo-mucous 
borders of the various outlets of the body, as at the anus, the nares, and the 
angles of the mouth. They may appear also in the axilla and over different 
parts of the genitalia of either sex. When occupying the lips and anus, after 
healing they leave a series of linear and radiating cicatrices, which give a 
puckered appearance to the parts. These patches at the verge of the anus, 
stimulated by the heat and moisture resulting from contact of the contiguous 
surfaces of the nates, become quite prominent, forming moist papules or con- 
dylomata, which are charged with the syphilitic poison and are therefore 
capable of inoculating others. When seated in the mouth, the nurse may be 
inoculated in giving suck, or other persons in kissing. 
Papular syphilides are not very common, and, when they do appear, consist 
of smooth, flat papules having a dirty red succeeded by a copper color. 
Many coalesce, and in certain regions, as on the palms of the hands, the soles 
of the feet, and the tips of the fingers, they undergo desquamation. 
Vesicular syphiloderms are rarely seen among the lesions entailed by heredi- 
tary syphilis. 
Pustular syphiloderms (impetigo, ecthyma) occur not often earlier than two 
months after birth. They may occupy any portion of the body, but they 
affect particularly the nates, thighs, and face; at length they become covered 
with crusts, beneath which ulcerations form, especially when they are arranged 
in groups. 
Bullae (pemphigus) in hereditary syphilis, either discrete or confluent, oc- 
casionally exist both before and after birth, 'f hese lesions, resembling watery 
blisters, either burst, leaving superficial ulcerations after their contents have 
been discharged, or, if the epidermis does not give way, the contents dry up, 
leaving for some time yellowish or dark crusts. The palms of the hands and 
the soles of the feet are the usual regions selected by syphilitic bullai: indeed, 
the election of these localities by the eruption is one of the marks whereby 
this form of bullse may be distinguished from that which is non-specific in its 
origin. 
Tubercular lesions are even more uncommon than the vesicular syphiloderms, 
and are among the later manifestations of the disease. They consist of small 
spherical indurations in the derm, which break down, leaving ulcers, which 
become covered with dark crusts or scabs. 
Appendages of the Skin.—The nails of infants occasionally become diseased 
and drop off from inflammation of the matrix. The latter may be secondary, 
extending to the nail from pustules which occupy adjacent parts of the finger. 
The nails of both hands and feet may suffer in this manner, and the shedding 
is sometimes repeated a number of times in succession. 
Hair.—The hair may share the same fate as the nails, dropping out not 
only from the scalp, but also from the eyebrows and other parts of the 
body. 572 
SYPHILIS. 
Locomotor System.—Lesions of the bones, articulations, and muscles also 
are among the common manifestations of infantile syphilis. 
Bones.—The bones commonly selected as the seat of hereditary syphilis 
are the radius, ulna, humerus, tibia, femur, metatarsal, metacarpal, and pha- 
langeal bones, the sternum, and the clavicle. 
One of the most remarkable and characteristic lesions of the osseous sys- 
tem, first particularly noticed by Ranvier, and subsequently elucidated by 
Wagner, is delayed ossification and partial or complete disjunction of the 
epiphyses and diaphyses of the long bones, conditions associated with osteo- 
and periosteal chondritis and abnormal thickening of that layer of the epi- 
physeal cartilage in which ossification takes place. The thickening is due to 
unusual vascularity and new formation of cell-elements. The swelling at 
the articular ends of the bones, denoting the changes alluded to, is gener- 
ally of an indolent nature, and, unless the epiphyseal separation becomes 
complete, the movements of the joint are not materially interfered with or 
attended with pain. When the disjunction is complete, the great mobility of 
the limb might be referred to fracture; but the absence of pain and the fact 
that no violence had been realized would be evidence sufficient to exclude the 
idea of an injury of that kind. 
These lesions resemble those of rickets, but differ in certain pai’ticulars, 
such as the early period at which they appear, and the coexistence of cutaneo- 
mucous phenomena. These points, with the wan, stunted, and puny appear- 
ance of the child, will betoken a syphilitic causation. 
Periostitis also may attack the bones of syphilitic children, causing marked 
hypertrophy, and, in the case of those who are beginning to walk, deform- 
ity from curvatures, which are determined by the superincumbent weight of 
the body. The bones of the lower extremities are those which suffer most, 
—including the metatarsal bones and occasionally the phalanges (dactylitis). 
The flat bones are not exempt from similar attacks. Those of the cranium 
may present flattened projections or nodes. 
Atrophic changes in the cranial bones, the result of gelatiniform metamor- 
phosis of the osseous tissue, have also been described by Parrot. 
Necrosis of the cranial bones is also among the late lesions of hereditary 
syphilis. In a lad, twelve years old, who was under my care, numerous ulcer- 
ations opened over the frontal, parietal, and occipital bones, all leading down 
to dead bone. This patient suddenly died in a state of coma. 
Teeth.—Mr. Jonathan Hutchinson has directed attention to certain pecu- 
liarities of the permanent teeth which he deems diagnostic of hereditary 
syphilis. These peculiarities affect principally the incisors of the upper jaw, 
and occasionally the canines. The incisors of the lower jaw are not entirely 
exempt from similar changes. The superior incisors, however, are those 
which, Mr. Hutchinson believes, furnish the unmistakable pathognomonic 
evidences of hereditary syphilis. These teeth are stunted, notched at their 
extremities, narrow or peg-like at their cutting edges, and their enamel is 
often of a dirty brown color. (Fig. 2070.) These dental peculiarities are 
often associated with syphilitic stomatitis 
and a diffuse keratitis, the cornea being cloudy 
from the interstitial infiltration of new ele- 
ments. The extremities of the notched or 
crescentic edges, receiving the greatest press- 
ure, gradually wear away, until in adult life 
the affected teeth become preternaturally 
short and flat on the cutting edge. 
Though the temporary teeth generally escape syphilitic changes, yet it is 
not always so. They sometimes, under the influence of the constitutional 
disease, appear prematurely, are irregular in form, dwarfed, undergo early 
decay, and drop out. 
While there is little room to doubt that the observations of Mr. Hutchinson 
Fig. 2070. 
Syphilitic teeth—Hutchinson. HEREDITARY SYPHILIS. 
573 
are correct in the main, it is certain that many syphilitic children are born 
and grow up without any of the above distinguishing dental peculiarities, and 
not only so, but these vices of conformation are sometimes closely imitated 
by constitutional conditions very different from syphilis, such as rheumatism, 
rickets, and mercury-poisoning. 
Liver.—The liver is peculiarly prone to suffer in hereditary syphilis. 
Its lesions have been particularly described by Gubler. The organ is larger 
than normal; its tissue is preternaturally firm, even to hardness; and its 
investing tunic, the capsule of Glisson, sometimes exhibits points of local 
thickening. Gummata, both diffused and circumscribed, are found in its 
substance. The white granulations which are seen between the acini of 
the organ are composed of collections of embryonic cells (circumscribed 
gummata). 
Spleen.—The spleen is often affected in infantile syphilis, the viscus being 
larger and its substance firmer than normal. It is frequently affected at the 
same time with the liver. According to Dr. Gee, splenic hypertrophy occurs 
in about one-fourth of all cases of hereditary syphilis. 
Suprarenal Capsules.—These bodies appear to be frequently implicated in 
hereditary syphilis. The lesions which have been observed by Virchow and 
others consist in fatty transformation of the gland-tissue, and infiltration of 
the cortical layer by connective-tissue corpuscles (diffused gummata). 
Thymus Gland.—This body does not escape syphilitic invasion, being fre- 
quently the seat of localized collections of embryonic cells or of gummy 
tumors, which undergo softening, resembling in some respects abscesses. 
Lungs.—These organs are not uncommonly affected in syphilitic children, 
the lesions corresponding closely to the diffused and circumscribed gummata 
met with in other organs. The cell-infiltration is often so great about the 
ultimate ramifications of the bronchial passages and vessels as to render the 
pulmonary tissue quite firm, and the infiltration thus opposes the entrance 
of air in many places into the air-cells. 
Nervous System.—Both the brain and its meninges may be attacked by in- 
herited syphilis, the most common lesions being marked by the formation of 
fibrous tissue and gummy neoplasms. To this cause may be ascribed many 
of the cases of epilepsy, chorea, spastic contractions of muscles, paralysis, 
and idiocy which are encountered among young children. 
Eye .—The tunics of the eye which are liable to hereditary syphilis are the 
iris, cornea, and choroid. 
Iritis.—Iritis is first in order of frequency and time. It may occur at va- 
rious periods from six months to fourteen months after birth, and it affects 
both eyes in about one-half of the cases. The subjects of the disease exhibit, 
generally, other manifestations of hereditary syphilis. The danger to the 
pupil is such that the early recognition of the iritis and the adoption of 
active mercurial treatment are matters of great importance. 
Cornea.—Allusion has already been made to keratitis as being frequently 
associated with the crescentic or notched teeth; and just as the latter are 
a peculiarity mainly of the second dentition, so the keratitis is rarely seen 
earlier than the fifth or eighth year. No evidences of active inflammatory 
action may be expected. Small nebulae or gray spots will be seen over dif- 
ferent portions of the cornea, which enlarge and finally coalesce, imparting 
first a hazy appearance and finally a ground-glass opacity to the structure. 
The new elements which are concerned in producing the altered state of 
the cornea are not situated on its surface, but between its laminae, consti- 574 
SYPHILIS. 
tuting, therefore, an interstitial infiltration or keratitis. Yision, at first in- 
distinct, at length becomes so imperfect that the outline only of objects can 
be seen. Children suffering from syphilitic keratitis present other evidences 
of the constitutional vice in the corrugated or wrinkled forehead, sallow 
color of the skin, and radiating cicatrices or fissures at the corners of the 
mouth. 
Notwithstanding the unpromising appearance of the cornea, the prognosis 
in syphilitic keratitis is rather favorable, the cornea usually clearing up under 
mercurial treatment. 
Choroiditis.—Syphilitic choroiditis ordinarily develops in children between 
the ages of seven and ten years. The rational sign of the disease is indis- 
tinctness of vision, which after a time may pass away, the sight improving 
very much. This rather singular succession of phenomena is explained by 
the changes which the new elements undergo. Diffused infiltration in the 
choroid is followed by absorption. The ophthalmoscope alone can reveal 
disease in the choroid. When the eye is examined by this instrument, there 
are seen, in addition to the exudation in the membrane, localized opacities in 
the vitreous humor, and sometimes in the retina and the lens. 
Syphilitic choroiditis is favorably influenced by constitutional treatment. 
Ear.—The organ of hearing must also be numbered among the parts of 
the body which are attacked by hereditary syphilis. It is common for both 
ears to be affected simultaneously, and, as no signs of structural change can 
be discovered in the acoustic apparatus, the lesion must be located either in 
the auditory nerves or in that part of the brain from which these nerves 
arise. Syphilitic deafness arises about the age of puberty. 
The treatment of hereditary syphilis must be determined by circum- 
stances. When there is reason to believe that the mother is laboring under 
the disease, in order to prevent the premature expulsion of the foetus and to 
secure it from participating in the parental vice, the treatment must com- 
mence with or very soon after conception, and be continued throughout 
gestation and lactation. 
Mercurial remedies are to be preferred, and may be introduced into the 
system either by the mouth or by inunctions. When administered by the 
mouth the dose should be small, for fear of provoking miscarriage. The mer- 
curial may be given with advantage in connection with the iodide of potas- 
sium. One-fortieth of a grain of the bichloride of mercury and five grains 
of the iodide of potassium, in solution, exhibited three times a day, will 
usually be well borne by the stomach of the mother; or, if not, one-half 
of the quantity may be prescribed, and the effect increased by rubbing into 
the groins and inside of the thighs, night and morning, one drachm of 
mercurial ointment. Should gastric symptoms follow, it will be necessary 
to rely wholly on inunctions. 
After the child is born, it should be nui'sed from the maternal breast. It 
is scarcely necessary to state that it would be highly improper to consign the 
infant to a non-syphilitic wet-nurse under the circumstances, even if the child 
exhibited no evidences of syphilitic disease. Carelessness or indifference on 
this point has in many instances been instrumental in perpetrating a great 
wrong, by infecting an otherwise healthy person. Should the milk of the 
mother fail, it will be necessary to resort to properly diluted cow’s milk of 
unquestioned purity. 
The treatment proper to a syphilitic child consists in the use of mercurials, 
both internally and by inunction. When administered by the mouth, the 
bichloride of mercury is the remedy to be preferred. The dose should not 
exceed one-three-hundredth part of a grain three times a day. If given. 
TREATMENT OP HEREDITARY SYPHILIS. SYPHILIS AND MARRIAGE. 
575 
with the iodide of potassium, often a valuable combination, a very excellent 
formula is the following: 
Potassii Iodidi, gr. viij; 
Hydrargyri Bichloridi, gr. 
Syrupi Aurantii, f£>ijss; 
Aquae Destillatae, 
M. et ft. sol. 
Of this, half a teaspoonful may be given to an infant six months old, or 
double the amount to one a year old, three times a day. 
The introduction of mercury by inunction can be effected either by rub- 
bing into the groins and inner aspects of the thighs of the child one scruple 
of mild mercurial ointment every evening, or by spreading half a drachm of 
the same over a piece of old linen and securing it over the abdomen by the 
ordinary belly-band. It will be necessary to persist in the treatment for four 
or five months, or until all external evidences of the disease have disappeared. 
Nor is this sufficient: once every year for at least five years the child should 
be subjected to a repetition of constitutional treatment for a period of not 
less than two months. 
When iritis exists, the use of atropia should not be neglected, for only in 
this way can we guard against occlusion of the pupil. 
There are two other methods of securing the constitutional action of mer- 
cury in hereditary syphilis,—namely, by the bath and by fumigation. The 
first is prepared by adding to three or four gallons of warm water eight or 
ten grains of the bichloride of mercury. It is proper to allow the child to 
sit in the bath for fifteen minutes, protecting it well by a blanket wrapped 
around the neck and falling over the tub or other vessel containing the 
medicated liquid. When removed from the bath, the patient should be 
carefully dried and enveloped in flannel. 
Fumigation is to be conducted in the same manner as when employed for 
adults. Other measures calculated to improve the health and strength of 
the infant must not be neglected. Iron, cod-liver oil, food rich in the ele- 
ments of nutrition, all have their place in the general management of the 
patient. 
Mineral Waters enjoy no small reputation in the treatment of syphilis. 
On the continent of Europe the waters which are esteemed of the greatest 
value are those of Bareges, Aix-la-Chapelle, Wiesbaden, Kreuznach, and 
Carlsbad, and in this country the springs of Arkansas, and the various sul- 
phur waters found in Pennsylvania, New York, and Virginia. Thermal 
waters do good by increasing the activity of the glands of the skin and kid- 
neys, thus diluting and favoring the elimination of the products of textural 
waste. It is also true that these waters beget a remarkable tolerance to the 
use of mercurials and potash, allowing either of these remedies to be given 
in much larger doses than under other circumstances, without any incon- 
venience whatever. There is no evidence, however, to show that, aside from 
constitutional remedies, mineral waters exercise any curative power over the 
disease. 
SYPHILIS IN ITS SOCIAL RELATIONS. 
Marriage.—Among the many embarrassing questions which are referred 
to physicians for decision is that in regard to the propriety of persons who 
are or have been the subjects of syphilis entering into the relation of mar- 
riage, and, in some of its aspects, a more delicate or serious subject does not 
come within the province of professional experience. The circumstances 
under which an opinion is sought are not always the same, and in disposing 
of the subject it will be necessary to consider the matter from different stand- 
points. 576 
SYPHILIS. 
First. Would it be proper for an individual while suffering from a recent 
attack of either local or generalized syphilis to marry? To this there can be 
only one answer. To sanction such a union would be criminal in the highest 
degree. 
Second. What counsel touching the subject of matrimony should be given 
to one who has a venereal sore of uncertain nature ? There must always be 
some doubt in regard to the differential diagnosis of chancre and chancroid, 
and therefore it will be proper for the person in question to abstain from 
marriage for a period greater than the longest which has been observed 
between the development of chancre and the occurrence of constitutional 
symptoms,—that is to say, for five or six months,—during which the most 
careful examination should be instituted from time to time by the medical 
attendant, who should carefully scrutinize every region, tissue, and organ 
known to suffer from generalized syphilis. Just here a troublesome com- 
plication may arise. It may be that on the first appearance of the venereal 
sore a mercurial treatment has been instituted, the effect of which, as is 
well known, is to interrupt or to postpone the usual evidences of the gen- 
eralized disease, and of course to enshroud the whole subject in a maze of 
doubt. Under these circumstances, how shall the physician proceed to ob- 
tain information which will enable him to advise safely ? The problem for 
solution is embodied in the question, Was the venereal lesion an infecting 
chancre? To determine this question it will be proper to inquire as to the 
length of time which elapsed between exposure and the appearance of the 
sore or sores, and, if there were more than one, whether they appeared 
simultaneously or followed one another; also as to the presence of indura- 
tion, or of any trace of such induration discoverable at the time of exami- 
nation, etc. 
If it is ascertained that the sore or sores developed a few days after 
intercourse, were multiple, appeared consecutively, and possessed no indura- 
tion, and that the cicatrix exhibited nothing peculiar in density or color, the 
evidence would be against the existence of chancre. But the inquiry should 
not stop here: the observer must push the investigation into another region, 
the glandular. Following the venereal sore, was there any enlargement 
of the inguinal lymph-glands? and, if so, was the enlargement bilateral or 
unilateral, affecting one or several of the glands? painful or hard and pain- 
less? suppurating or non-suppurating? These questions are based on the 
assumption that the venereal sore is seated on some part of the genital 
organs. 
If it is found that the adenitis was unilateral, affecting chiefly a single 
member of the group, and that the swelling was highly sensitive, accom- 
panied with redness of the overlying skin, terminated in suppuration, and 
healed up quickly, there will be additional reasons for believing the original 
sore to have been non-infecting. 
Pursuing the investigation further, it will be proper to inquire if any erup- 
tion was observed upon the skin, and, if so, on what part of the body; was it 
accompanied by itching? and wbat was its appearance? Were any grayish 
patches observed in the mouth? was there any falling of the hair? and, on 
examination, is there any enlargement of the post-occipital glands ? If a 
negative answer is given to all these questions, the testimony is decidedly 
adverse to the theory of a constitutional disease. But as the value of tes- 
timony depends on the knowdedge of the party testifying touching the sub- 
ject in question, it will be far more satisfactory that the information sought 
shall be received from the lips of a physician who has been cognizant of all 
the facts in the case; and when these coincide with the idea of a venereal 
sore being a chancroid, I see no reason why the person who has been on trial 
should not be allowed to marry. 
Suppose, however, the testimony corroborates the theory of the original 
sore having been a chancre, notwithstanding no present evidence of general- 
ized syphilis exists. What is the duty of the physician in the premises? LEGAL REGULATION OF PROSTITUTION. 
577 
Certainly not to advise marriage, because the manifestations of the disease 
are not always governed by the limitations of time. 
A more difficult question to dispose of is whether an individual who has 
once suffered from syphilis, but for several years has been free from any mani- 
festations of the disease, is or is not disqualified for marriage. On this point 
there will be a difference of opinion. That children of parents, one of whom 
has been the subject of syphilis in past years, are born apparently free from 
any constitutional infirmity, cannot be denied. One of the parents, excep- 
tionally strong and vigorous, may impart to offspring a degree of vitality 
which will overmaster the innate weakness of the other, or the generalized 
disease of the parent or parents in such eases may have been of a very mild 
type and promptly attacked by mercurial treatment. The common but un- 
accountable differences in the persistence of syphilis in different persons must 
be a matter of common experience. In one case the symptoms disappear as 
if by magic under the use of proper remedies, while in another case relapses 
are constantly occurring, and new manifestations cropping out at short in- 
tervals, and in a third the disease disappears for many years, only to break 
out again when entirely forgotten. Twice within a short time have I seen 
patients who, after enjoying complete exemption from all visible traces of the 
disease, one for seventeen years, and the other for a longer period, had an 
unmistakable outbreak of the old enemy, which, at least in one of the cases, 
was proved by the prompt subsidence of the symptoms under the mixed 
treatment after other measures had utterly failed. 
In another case in point, which I recall with no pleasant feelings, I reluc- 
tantly gave my consent to the marriage of a man who had enjoyed excel- 
lent health and entire freedom for nearly four years from any symptoms of 
the disease from which he had suffered. Four months succeeding the con- 
summation of the union his wife miscarried, the foetus bearing all the marks 
of hereditary syphilis, and the mother covered with roseola. With this ex- 
perience, I am forced to believe that the capacity to stamp upon offspring 
the evil effects of generalized syphilis in many persons is never wholly lost; 
and entertaining these views, it follows that I cannot conscientiously sanction 
a union the issue of which is liable, during gestation, to poison the mother, 
and, if permitted to reach the full term of intra-uterine life, comes into the 
world laden with the sorrow and curse of parental sin. 
There are those in the profession who make syphilis a Pandora’s box full of 
every evil, present and future, the parent of many of the infirmities which 
appear in descendants under different names. t Struma is among the number 
of diseases referred to this source. Except in the fact that an hereditary 
syphilitic taint may, from the deterioration of tissues which it induces, pre- 
dispose or leave the body vulnerable to those causes which act in developing 
struma, I cannot believe that there is anything in common belonging to the 
two diseases. 
Legal Regulation of Prostitution.—In order to limit the extension of s}Tphi- 
lis, it has been proposed to place prostitution in this country under legal con- 
trol, as is done in several countries abroad. The proposition has met with 
violent opposition from a large and influential portion of the community. It 
is urged, 1 believe, by the objectors that all legislation on this subject is an 
approval of the vice; that it must bear unequally upon the sexes, and that it 
subjects the objects of control to mortification and self-degradation, in conse- 
quence of the personal examinations necessary in carrying out the require- 
ments of regulation acts. In answer to these objections it may be asked, 
Does the making of laws against theft, arson, or fornication in any way imply 
that, by recognizing the existence of these crimes, either the framers of such 
acts or their constituency approve of them? Must one portion of the human 
family, who in the gratification of lust become centres for the dissemination 
of a dreadful disease, be secure against the exactions of law because another 
part, though equally guilty, cannot from the force of circumstances be reached 578 
SYPHILIS. 
by similar provisions? and is the moral nature of a woman who exposes her- 
self for hire to be degraded or shocked by the enforcement of the humane 
provisions of a law which removes her from a den of infamy, places her in a 
temporary home, out of the reach of want or the temptation to sin, and at 
the same time relieves her of the most dreadful disease? It is the duty of 
the state to protect not only the lives and the liberties of its citizens, but 
their health as well. At one time I was disposed to take sides with the 
opponents of prostitution laws; but on a more comprehensive and careful 
study of the subject, and especially of the results which have been reached in 
those countries* where such legal regulations are in operation, I am forced to 
believe that the evil is one which comes legitimately within the province of 
civil law. 
* See an exhaustive address on the subject of the Prevention of Syphilis, by Dr. J. William White, 
Philadelphia Medical Times, January 14, 1882. CHAPTER XXXVI. 
TUMORS. 
GENERAL CONSIDERATIONS. 
The word “tumor” has been employed from time immemorial to designate 
any circumscribed swelling or enlargement, or, as Galen puts it, any disease 
in which certain portions of the body depart from their normal form by an 
unnatural increase in size. At present, however, the term is used in a more 
restricted sense, and is applied only to those new formations of obscure 
origin—usually called neoplasms—which after their appearance remain either 
as permanent or progressive productions. 
This restriction in meaning will exclude from the class of morbid or tumor 
formations all those products of inflammation which give rise to limited 
temporary swellings, as well as all so-called retention cysts and those general 
enlargements of a part which are usually designated as hypertrophies. 
That ordinary inflammatory formations and hypertrophies should not be 
confounded with tumors will appear from the following considerations. The 
products of common inflammation are generally short-lived. As soon as the 
cause which brought them into existence ceases to operate, they undergo a 
retrograde metamorphosis and are reabsorbed and disappear from the tissues 
in which they were formed, their elements manifesting little power of self- 
perpetuation or proliferation. When furnished in order to repair an injury, 
as a broken bone, the supply is rarely much in excess of the demand, and 
when the work is completed all the material which can serve no useful pur- 
pose is taken away, and every inequality or irregularity rounded off and 
smoothed with a completeness which rivals the work of the sculptor’s chisel 
as he gives the last or finishing touches to his figure. Even when under 
repeated irritation an inflammatory new formation acquires extraordinary 
bulk, as sometimes happens when a wound has been unnecessarily tampered 
with, the induration quickly disappears with, perfect rest. It is true that 
ordinary inflammatory transudation is capable of developing into connective 
tissue, as is constantly witnessed in the formation of cicatrices, or into bone, 
as is observed in following the history of a node; yet the developing force 
ceases with the production of the scar or the bone. It does not continue to 
go on piling up increased quantities of fibrous or osseous tissue; and as for 
the higher type of tissue, such as adenoma or myoma, there is no evidence 
to show that it ever has a common inflammatory origin. In addition, common 
inflammatory new formations, when required for purposes of reconstruction 
or repair of structures, exhibit no tendency to supplant or destroy the latter, 
as neoplasms do, but rather become assimilated to them. 
Again, in contrasting morbid growths with hypertrophies a notable differ- 
ence will be observed. The former are localized, involving only a circum- 
scribed portion of a part or of an organ ; the latter are general. The former 
cause alteration in form and symmetry; the latter do not efface or obliterate 
the normal features of a part. A pathological hypertrophy of the uterus, 
for example, will be represented by a tuber, or knob, confined to a small 
part of the uterine tissue, while a physiological hypertrophy affects the 
entire organ. 
The arm of a blacksmith or the leg of a danseuse may, under the stimulus 
of exercise, attain extraordinary dimensions, but in neither instance is the 
symmetry of the extremity destroyed or its function impaired. 580 
TUMORS. 
Physiological hypertrophy is always associated with increased function or 
power; pathological hypertrophy is functionless. 
Classification.—Tumors may be classified both clinically and anatomically. 
Clinical.—The basis of the clinical classification rests on the benign or ma- 
lignant tendency of the morbid growth. A tumor which if allowed to remain 
is capable of doing injury only by its bulk and pressure, or which if removed 
exhibits no tendency to return, is a benign, or non-malignant, growth. A 
tumor which proves destructive to the tissues in which it is located, which 
tends to contaminate adjoining glands or to be disseminated through the 
blood-vessels, inducing changes unfavorable to the proper nutrition of the 
body, which after removal manifests a tendency to recur either at the original 
seat of the disease or in another part of the body, and which is capable of 
eventually destroying life, is termed a malignant growth. Fortunately, the 
number of such formations, as compared with the non-malignant, is small; yet 
I am disposed to believe that there is an increasing frequency of the former 
out of all proportion to the growth of population. 
There is a third class of tumors, which, without being positively malignant, 
manifest a strong though not invariable tendency to reappear, and which from 
this circumstance have been styled recurring tumors (some of the sarcomata). 
Independently of the course and termination of these three classes of tu- 
mors, there is a marked difference in their anatomical constitution. The be- 
nign tumors do not materially differ from the nature of the tissues in which 
they fix their habitation. For example, lipoma, a neoplasm consisting of fat, 
is in most respects identical with the surrounding adipose tissue, and a fibroma 
is only a localized hyperplasia of the connective tissue in the midst of which 
it is lodged : hence the term homologous has been applied to all such neoplasms. 
Malignant tumors, on the contrary, embody in their structure histological 
forms which are altogether unlike the perfected tissues in which they grow, 
and accordingly have been designated heterologous growths. It is proper to 
state in this connection that Virchow uses the term heterologous in a sense 
different from that already defined, applying it to typical neoplasms which 
occupy atypical localities, as when a cartilage tumor appears in the testicle. 
These terms are the equivalents of Broca’s homomorphic and heteromoiphic, 
or the more modern terms homotopia and heterotopia. According to the 
same authority, all neoplasms which in their formation observe an order 
similar to that of the tissues in which they appear, as a lipoma in adipose 
tissue, or a fibroma in conjugate tissue, are embraced under the term hyper- 
plasia, and are equivalent to proliferation, or the building of a tumor by the 
multiplication of cells from those pre-existing in the tissue in which the neo- 
plasm arises; while to morbid growths which are not the derivatives of pro- 
liferation from the cells of the structure furnishing a habitat for the tumor, 
though they may answer to other normal types, the term heteroplasia is 
applied, under which head would come a bony tumor that developed in con- 
nective tissue, such a neoplasm being foreign or abnormal in this situation. 
The terms typical and atypical also have been introduced into the literature 
of neoplasms. By a typical tumor is meant one the structure of which cor- 
responds to or represents a completed or mature tissue, while by an atypical 
growth is meant one which represents in its histoid elements an incomplete 
or embryonic tissue. A lipoma, a fibroma, and an adenoma, answering re- 
spectively to fat, fibrous, and glandular tissue, may be adduced as examples 
illustrative of the typical class of tumors, sarcoma and carcinoma as examples 
of the atypical, representing, as they do, the one embryonic connective tissue 
and the other imperfect epithelial tissue. These terms express ver}r much 
the same ideas as are conveyed by the words homologous and heterologous. 
In the differentiation of malignant and non-malignant tumors the clinician 
gathers the facts which are to form the basis of this broad classification from 
various considerations, among which may be mentioned,— 
1. Number.—Malignant tumors at first are always solitary, and when mul- 
tiple the secondary occur generally at an advanced stage of the disease, and are caused either by infection through the lymphatic system or by dissemi- 
nation through the blood; in other words, are metastatic. There are some 
exceptions to this rule. Carcinoma of the rectum or of the eye is seldom, 
though occasionally, followed by secondary formations of a similar nature. 
2. Recurrence after extirpation is another evidence of malignancy in a 
tumor. Such a history, to be reliable in a diagnostic point of view, must be 
accompanied by an assurance that no part of the original growth had been 
allowed to remain at the time of the operation. Until this has been deter- 
mined, little value can be attached to the circumstance of recurrence, as that 
might happen in the case of a cyst or of a lipoma, should a fragment of the 
first or a few lobules of the second have escaped the knife. 
3. Glandular infection is another sign of the malignant nature of a tumor, 
and one of marked significance; and yet it may not appear until very late in 
the disease, or possibly in some instances may fail to appear at all. Carcinoma 
of a mamma sometimes exists for several years without any involvement of the 
axillary glands. It so existed for nine years in one case which was under my 
observation. Enlargement of lymphatic glands in not a few instances ac- 
companies tumors which are altogether benign, in consequence of propagated 
irritation. 
4. Infiltration, that is, the peripheral extension of cell-forms of the same 
nature as those constituting the primary neoplasm, is another expression of 
malignancy. The value of this sign is somewhat lessened, as it is possible to 
have at the circumference of a harmless tumor an inflammatory infiltration, 
accidental to the growth, from traumatic or other causes, which will closely 
counterfeit the first, and may indeed result in a limiting capsule to the tumor. 
5. Physical qualities, as external configuration, density, and weight, are 
also important factors in the clinical examination. Irregularity or nodula- 
tion, compactness of structure, and weight out of proportion to bulk, are, as 
a rule, at variance with the idea of benignity. There are, however, enchon- 
dromatous and fibrous growths which combine the qualities of density and 
irregularity and yet are non-malignant, and also tumors, both infectious and 
non-infectious, which pass through various changes affecting their form, con- 
sistence, and weight; yet when these are studied in their entire history, their 
true character can usually be ascertained. 
6. Rapid growth of a tumor is another symptom which always should 
awaken a suspicion of malignancy. For while it is true that carcinoma and 
sarcoma may pursue a slow or chronic course, it is equally true that harmless 
neoplasms rarely increase rapidly. • 
7. A tumor followed by a diathesis or cachexia, that is, a change wrought 
in the general system deeply affecting the function of nutrition, altering the 
color and expression of the face, and accompanied by a general loss of flesh, 
is chargeable with malignancy. But even a change so radical as this may 
follow the presence of an ovarian growth, benign in its nature, or, indeed, 
any exhausting malady benign in its course, and therefore cannot be accepted 
as an invariable evidence of metastasis from the primary tumor affecting 
internal organs. 
8. Mobility.—A tumor which shows a disposition to become adherent to 
the skin and adjoining tissues, thus lessening its mobility, exhibits thereby a 
common quality of malignancy. Exceptions to this are seen in some of the sar- 
comata, which exhibit little tendency to become adherent to surrounding parts. 
9. Color.—Neoplasms in which the overlying skin presents a lilac or purple 
color are rarely benign in their character. Keloid may imitate in some 
degree the color alluded to. 
10. Sensibility.—Both benign and malignant growths generally pursue, for 
a time at least, a painless course. This is true of the former at almost every 
period of their history; and when it is otherwise, the suffering is due to the 
bulk of the tumor, causing pressure on the nerves of adjoining parts. In 
malignant neoplasms, however, pain is not proportioned to their size, but is 
equally severe, when it does exist, in the small as in the large, and in charac- 
TUMORS. 
581 582 
TUMORS. 
ter is lancinating, darting, or stabbing. The exceptions to this are found in 
sarcomata, all of which are painless except the alveolar variety. The reason 
that this difference should exist between carcinoma and sarcoma is found 
in the fact that the former is supplied with nerves, while the latter have 
none, save in the case of alveolar sarcoma, the mode of formation of the 
latter being analogous to that of carcinoma. Neuromata, it is true, are ex- 
tremely painful, but the pain is not darting, and it is, moreover, greatly in- 
creased on the application of pressure, which is not true of malignant tumors. 
11. Locality.—The nature of neoplasms is often disclosed by their situations. 
Lipomata, for example, select the back, shoulders, inner part of the thighs, 
and neck; carcinomata the outlets of the body, mammary glands, etc. 
12. Ulceration.—A tendency to integumentary adhesion by a tumor is 
usually followed by ulceration, a result quite uncommon in any other than 
malignant growths. 
When ulceration does occur in benign tumors the ulcer is confined to the 
skin, while in case of malignant growths it involves the structure of the 
tumor as well. 
13. Juices.—Another most important difference between malignant and be- 
nign neoplasms is to be found in the liquid products of the two, the latter 
yielding no juice, while carcinoma furnishes a milky, and sarcoma a blood- 
stained, juice. 
14. Vascularity.—The blood-vessel supply of benign tumors is generally 
meagre, while in malignant growths it is abundant. 
We might in this summary enumerate certain other differential and diag- 
nostic peculiarities of tumors, but sufficient has been written to show that 
while a clinical classification of morbid growths has its value in the routine of 
surgical practice, it yet lacks scientific accuracy, being concerned chiefly in 
solving the problems of malignancy or benignity, and even these particulars 
it is often unable to determine with certainty. 
A histological classification of tumors is made on the basis of physiological 
derivates. The three germinal layers into which cells of the embryo differ- 
entiate play separate and independent parts in the scheme of development. 
They havo no power to interchange offices. At present it is believed that 
this law of special development, which begins as soon as these germ-layers 
have fallen into place, and which renders one layer incapable of producing a 
tissue or organ like that formed by another layer, never becomes inoperative 
as long as the life of the body remains, but continues through all the muta- 
tions which occur in the economy of the tissues. Nor is there any reason to 
believe that this law is suspended or annulled when the physiological growth 
is interrupted or perverted by pathological processes. As in the development 
of the various tissues from the germ-layers, the embryonic always precedes 
the perfected structure, and as between the two there are a number of inter- 
mediate forms, so in the production of all neoplasms or morbid growths, 
however they may differ among themselves, there is not one which can be 
strictly said to be heterologous, or which has not its type in some stage 
between the genesis and complete development of the tissues of the body. 
This observation was first made by Muller, and, together wTith another made 
by Virchow, that the cell-components of every morbid growth are derivates 
from pre-existing cells of the organism, is now generally accepted as a fact by 
pathologists. 
Origin.—On the subject of the origin of morbid growths there is a great 
diversity of opinion among pathologists. In regard to the various theories 
which have at different times been promulgated, not one can be said to rest 
on positive demonstration. Very distinguished names are connected with 
each, and it is not improbable that there may be in each certain grains of 
truth which serve to give them some degree of credibility. 
Lawrence believed that the origin of tumors lay in a point of extravasated 
blood, which, after coagulation, underwent organization, and thus became 
the basis for a new growth. Carswell, in his work on the Elementary Forms TUMORS. 
583 
of Disease, laid down the theory of the fibrinous or plastic origin of all new 
or adventitious formations. Certain tumors, as carcinoma, have also been 
referred to a parasitic causation. This was the theory of Adams, w'ho in 
his treatise on cancer of the breast assumed the presence of h}7datids. 
When the microscope was introduced into the study of anatomy and phys- 
ical pathology by Easpail in 1827, a new era commenced in both normal and 
morbid anatomy, rendered especially notable through the labors of Schwann, 
eleven years later, who, working in the field of vegetable physiology, wrested 
from plants the secret of the cell theory of wood-tissue, the organisms in 
which answered to the vesicles of Easpail. In this discovery of Schwann 
lay the germ or seed-thought of rational pathology; and the same year in 
which the cell doctrine was announced Muller began the study of morbid 
growths with the microscope, the revelations of which are responsible for 
the statement made by this observer that the elementary forms of tumors 
were so analogous that there wTas no foundation for the use of the term 
heterologous. Seven years later, Yogel, laboring in the same field, laid the 
foundation of the typical and atypical differentiation of tumors, observing 
that benign growths conformed in their histological elements to the normal 
tissues of the body, while those that were malignant lacked this corre- 
spondence. 
Coming down to a more recent period, when by means of improved instru- 
ments and more accurate methods of study our knowledge of pathological 
processes has been greatly enlarged, we are met with the theory of a diathesis 
or dyscrasia as accounting for the formation of neoplasms. The earliest 
advocate of the doctrine was Eokitansky, and among those who have 
espoused the theory at the present time are names no less distinguished than 
those of Paget and Billroth. By dyscrasia is understood a peculiarity of 
organization extending not to the blood alone, but to all the solids of the 
body, in consequence of which, when the proper excitant is applied, a new 
formation or morbid growth follows. This general constitutional stamp of 
an individual is capable of being transmitted from father to son, and through 
the latter to the grandson, and so may be perpetuated from generation to 
generation. 
Cohnheim believes in the congenital origin of tumors, and in explanation 
assumes that embryonic cells exist in greater number than is necessary for 
the original construction of the tissues, and that these redundant organisms 
are stored away somewhere in the completed structures, only waiting for the 
application of the proper stimulus or for some disturbing element to be intro- 
duced, during the different stages in the evolution or involution of the tissues, 
to start them into aggressive activity, and by multiplication or proliferation 
to form a tumor. According to this view, every tissue contains a secret 
enemy, which, assassin-like, is ready to threaten its life whenever the proper 
occasion arrives. 
Nervous influence has also been named in explanation of tumor-growths. 
This theory is based on the known influence which the nerves and their cen- 
tres exert over the nutrition of the tissues, the withdrawal of which nutrition 
is believed, in many instances at least, to disturb the harmonious operation 
of that force which gives definite form, size, interchange of elements, and all 
other mutations which we attach to the work of normal nutrition. The leading 
advocates of the nervous theory are Schroeder Van der Kolk and Lang. 
Eindfleisch advocates the theory of the spontaneous origin of tumors, re- 
ferring all neoplasms either to an excessive hyperplasia, especially of connec- 
tive-tissue elements, during the period of active growth, or to those retrogres- 
sive changes which the tissues in advanced life are doomed to undergo, and 
in which a redundancy of epithelial forms is produced. 
Another theory is the inflammatory. Nor is it by any means a modern 
one, but dates back wellnigh to the commencement of the Christian era, or 
at least to the time of Galen. It was maintained by Broussais, by the elder 
Gross, and by leading pathologists, both German and French, among whom 584 
TUMORS. 
may be mentioned Virchow, Samuel, Cornil, llanvier, and others not less 
distinguished. In this country the idea of inflammation being the leading 
factor in the production of morbid growths is evidently gaining strength, and 
chiefly through the exhaustive labors of Dr. Formad, demonstrator of path- 
ological histology in the University of Pennsylvania. 
It would be strange if a field of such attractive interest and a subject of 
such universal study as the one under consideration should escape the keen 
eyes of men who believe in the omnipotence of matter and who worship only 
at the altar of “Force.” Accordingly, we have a dynamic theory to account 
for the increase if not the origin of neoplasms; in other words, as tumors 
have no physiological functions to perform, and therefore no outlet for the 
accumulating force, the latter, it is thought by some, is compelled to expend 
itself in growth. 
Among these various and conflicting doctrines, what one is to be accepted 
as the most plausible ? for it is doing no injustice to say that not one has been 
demonstrated to be true. 
There are, in my judgment, three conditions necessary to the development 
of a morbid growth,—namely, structural peculiarity, a specific irritant, and in- 
flammation. The first confers a susceptibility to be impressed in a particular 
manner by external or internal agencies; the second offers the particular 
stimulus which calls out the specific impressibility; and the third is the 
constructing or architectural force immediately concerned in causing the 
localized accumulation of neoplastic elements. The absence of any one of 
these factors will be fatal to the active manifestations of the remaining two. 
In illustration of predisposing organization, take a dozen farmers each of 
whom, in sowing his fields, throws across his shoulder a bag half filled with 
grain. They continue their labors for dajTs together. In a short time one 
discovers a fatty tumor originating exactly over that portion of the shoulder 
upon which the weight of the bag rested, while the other eleven go free. The 
pressure in each case was the same in kind, weight, place, and time, yet only 
in one did the irritant meet that susceptibility in the adipose and fibrous 
tissues of the neck which was required to awaken the neoplastic inflammation. 
A number of persons receive contusions of the arm or shoulder, all of equal 
severity, but in one alone is developed a sarcoma at the seat of injury. Leav- 
ing out the idea of tissue-predisposition to tumor-formations, how explain the 
neoplastic growth ? 
The influence of functional force as a factor in the development of certain 
kinds of tumors cannot escape observation. Cysts of new formation are 
most common during early life, when from the activity and force of the cir- 
culation exudations and extravasations are most likely to occur, accidents 
which are prominently concerned in the production of such growths. It is 
during the child-bearing period, when the sexual functions are at full tide, 
that neoplasms allied in structure to the higher tissues appear as myomata 
or fibro-myomata. It is in the young girl who has passed the period of 
puberty and entered fairly upon that of womanhood that we find mammary 
adenomata. Osteomata and chondromata in their growth are to a great 
degree influenced by that of the bone with which they are connected, the 
rate of increase being greatest during the stages which precede osseous ma- 
turity; they often become stationary or even undergo a sensible atrophy when 
that maturity is passed. It is the knowledge of this fact which induces the 
prudent surgeon to postpone or counsel against early operative interference 
in cases of bony tumors or of uterine myomata, as with the cessation of 
growth in the skeleton or the completion of the menopause these neoplasms 
cease to grow. While the above observations apply to the history of benign 
tumors, it is otherwise with certain ones of a malignant nature, notably car- 
cinomata, which find in this period of tissue-involution, characterized by the 
suspension or decline of function, a soil congenial for their development. CYSTS. 
585 
Tumors may be divided into cysts and neoplasms. Cystic tumors are of 
two kinds, retention cysts and neoplastic cysts. 
Retention cysts consist in a dilatation of the ducts or secreting cavities of 
glands, the contents of which are the normal secretions more or less altered 
by retention. These cysts may be arranged as follows: 
Classification of Tumors. 
Sebaceous. 
Mucous. 
Salivary. 
Seminal. 
Oily. 
Lactiferous. 
Synovial. 
Blood, or venous. 
Retention cysts. 
Neoplastic cysts are tumors of new formation, and may be classified as 
below: 
Extravasation, or san- 
guineous. 
Exudation. 
Softening. 
Hydatid. 
Dentigerous. 
Dermoid. 
Proliferous. 
Neoplastic cysts. 
Congenital. 
I do not recognize the exudation cyst of Yirchow, who applies the term to 
the accumulation of a fluid in a closed cavity,—for example, hydrocele,—as 
belonging to the category of cysts, being properly dropsies. If such are to 
be regarded as tumors, it will be necessary to place among the latter ascites, 
hydrothorax, hydrops articuli, etc. 
The classification of non-cystic tumors (neoplasms) is based on their phy- 
siological derivates. They may be grouped under the two general divisions 
of typical and atypical. 
Lipoma. 
Fibroma. 
Rhabdomyoma. 
Leiomyoma. 
Chondroma. 
Osteoma. 
Lymphoma. 
Myxoma. 
Neuroma. 
Angeioma. 
Lymphangeioma. 
Typical neoplasms. 
Corns. 
Warts. 
Horns. 
Papilloma. 
Adenoma. 
Free, or surface 
epithelium. 
Epithelioma, benign. 
Glandular epithelium 
Glioma. 
Sarcoma. 
Hard. 
Soft. 
Melanotic. 
Colloid. 
Telangiectasic. 
Endothelioma. 
Carcinoma. 
Atypical neoplasms. 
Epithelioma, malig- 
nant. 
Cylindroma. 
Squamous. 
Cylindrical. 
Cysts.—Tumors under the above head are divided into retention cysts and 
neoplastic cysts. They consist of a sac containing liquid, ropy, or pultaceous 
matter. The distinction between retention cysts and neoplastic cysts, or 
Benign Tumors. 586 
TUMORS. 
cystomata, consists in the single fact that the first are constructed out of 
normally existing materials, while the second are new formations. Thus, a 
sebaceous tumor must be regarded as a cyst, while a bursal tumor, which is 
the result of pressure, will rank as a neoplastic cyst, or a cystoma. 
These formations when primarily cystic are usually benign in their char- 
acter, but when developed secondarily in pre-existing neoplasms are often 
expressions of malignancy. 
Cysts may also be divided into simple and complex. 
In simple cysts the contents are generally secreted from the interior of 
the encapsulating wall, while in those belonging to the complex division 
the contents consist of different, organized substances. 
Form.—Cysts vary greatly in form, being round, oblong, cylindrical, and 
lobulated, differences due for the most part to the resistance of contiguous 
or adjacent structures. They are also unilocular, consisting of a single sac; 
or multilocular, made up of several distinct compartments. They are also 
described as proliferous, embracing endogenous and exogenous, or secondary 
growths, developing from the interior of the primary sac, and growing in- 
ward in the first, and in the second growing outward. 
Manner of formation.—1. Some cysts are formed by dilatation of the acini, 
or the excretory ducts of glands, and hence are called retention cysts, the 
contents being the normal secretion more or less altered. Such are the 
sebaceous tumors so often seen on the scalp, and the mucous cysts originating 
in the mucous follicles of the lips or mouth. In like manner are formed serous, 
salivary, lactiferous, seminal, and oil cysts. 
2. Cysts may be formed by the presence of some fluid or solid body dis- 
placing the connective tissue of a part, crowding together its fibres, and 
obliterating the interspaces, thus constituting a membrane or wall. Such 
are sanguineous or extravasating cysts. 
3. Cysts may originate in serous or synovial membranes which are de- 
void of any excretory ducts (exudation cysts), either by an expansion of 
the entire membrane or by a pullulation or yielding of a circumscribed por- 
tion of the same; for example, in spina bifida and in the bursse or ganglions 
which form on the front and the back of the wrist, over the olecranon process 
of the ulna, or over the patella. 
Similar cysts (neoplasms) often arise de novo altogether independent of any 
pi’e-existing serous or synovial membrane, examples of the most typical 
character being witnessed in cases of talipes, in which large, fleshy, callous 
cushions form on the sides and dorsum of the foot, and are filled with a ropy 
secretion. 
4. Cysts may arise also, it is believed, by a prolific new formation and 
aggregation of cells, or nuclei, into groups imbedded in an intercellular sub- 
stance which gradually is developed into connective tissue. The best exam- 
ples of such are seen in the chorion, kidney, and thyroid gland. They have 
been carefully studied by Kokitansky, Frerichs, and Simon. 
5. Another mode in which cysts originate is by the union or coalescence 
of the contiguous papillee of dendritic growths, leaving a cavity in the midst. 
The connection which exists between the wall of a cyst and the parts in the 
midst of which it is imbedded consists of connective tissue, which frequently 
is laminated, and is often mistaken for the wall or shell of the cyst itself. 
This connection is generally loose, allowing the superincumbent structures to 
move freely over the cyst. The two may become closely united by the occur- 
rence of inflammation, which renders removal more difficult, as this condition 
is unfavorable to enucleation. 
The walls of cysts vaiy greatly in thickness and strength, being in some 
instances very thin and almost transparent, and in others quite thick, almost 
cartilaginous in consistence, and opaque. Occasionally the cyst-wall becomes 
calcified. 
Most cysts have a white, gray, or pearl color. 
Vascularity.—In the simple variety of cystomata numerous small vessels CYSTS. 
587 
reach the sac from different sources, all passing through the loose connective 
tissue on its periphery. Sometimes a considerable trunk passes to the cyst- 
wall at a particular point, and afterwards spreads a net-work of very fine 
branches over its surface. In the complex cysts, such, for example, as origi- 
nate in the ovary, the blood-vessel supply is derived wholly from the seat of 
origin. 
Etiology.—The causes which operate to produce the development of cysts, 
though quite different in their nature, are all based on the presence of some 
irritant. In the retention cysts it is generally inspissated secretion, in the 
serous and synovial it is chronic inflammation ; and the same is true during 
the initial stage of such as arise from exudation or extravasation into parts 
without any preformed sac. 
Nature sometimes improvises a cyst in order to eject from the body certain 
offending substances. The following is a very remarkable example of this 
kind. A lady, sixty-five years of age, had suffered from an enlarged liver. 
The organ had extended wellnigh into the right iliac fossa, during which 
time the gall-bladder became adherent to the iliac fascia. She stated that 
for several months after the acute symptoms had passed over she was unable 
to straighten her body, every attempt to do so being accompanied by a feel- 
ing as though something was put upon the stretch and would break. Finally 
a swelling made its appearance over the right buttock, and it grew steadily 
until I was consulted, at which time the tumor or cyst measured eighteen 
inches across and had become so cumbersome that it could no longer be en- 
dured. Removal was advised and acceded to. After uncovering the C3Tst, 
which was of enormous extent and 
was filled with a straw-colored se- 
rum, I found the sac had a long pro- 
cess, or neck, which extended over 
the crest of the ilium and dipped 
into the iliac fossa. In passing a 
finger into its cavity, I discov- 
ered, at the bottom of the cyst, a 
nest of hard bodies, eight in num- 
ber, which w7ere removed by means 
of a long-bladed forceps, and proved 
to be biliary calculi (Fig. 2071), 
which had evidently been in the 
gall-bladder at the time the latter 
became adherent to the iliac fascia, 
and which had, by ulceration, es- 
caped into the iliac fossa, and subsequently created the irritation which 
resulted in the formation of a cyst. 
Under the head of simple retention cysts are the sebaceous, serous, 
mucous, salivary, seminal, oily, lactiferous, and synovial. 
Fig. 2071, 
Three specimens of biliary calculi taken from the pelvis 
through the neck of a cyst. 
Sebaceous Cysts.— These cysts may be acquired or congenital, simple or 
proliferous. The simple forms are commonly met with on the hairy scalp 
and the face, and frequently are present in large numbers. They are more 
common in females than in males. These cysts are formed by the secretion of a 
sebaceous or a hair follicle becoming inspissated and accumulating in the gland, 
which gradually undergoes enlargement until a tumor is formed. That the 
changed state of the secretion, consisting of epithelium, steatomatous matter, 
and often cholesterin crystals, is not due to obstruction of the excretory duct 
of the follicle, is evident from the fact that frequently by making pressure on 
the enlargement the contents of the glands can be extruded in the form of a 
paste-like cylinder. 
The orifice of the duct leading into an enlarged follicle is frequently marked 
by a dark point, caused by foreign matters or dirt becoming adherent to the 
sebum. 588 
TUMORS. 
F, |The simplo sebaceous tumors are the millet-grains, the comedones, and the 
steatomata, or wens. 
1. Millet-grains.—These usually appear at the inner canthus of the eye, on 
the upper eyelid, and immediately beneath 
the lower eyelid. They are most common 
in women, and especially in women over 
fifty years of age, and are readily recog- 
nized as minute white masses rising from a 
brown, discolored skin. (Fig. 2072.) 
Treatment.—Though incapable of doing 
harm, yet, as the discoloration tends to 
spread and become a source of annoyance, 
it often proves necessary to resort to sur- 
gical treatment, which consists in excision. 
The operator should be careful to take away 
with the small white masses the dark skin 
on which they rest, and should bring the 
sides of the wound together with fine silk 
sutures previously treated in carbolated oil. 
2. Comedones, or acne, differ from other 
sebaceous tumors in an extra-follicular in- 
flammation excited by the retained sebum, 
which causes a deposition of l}'mph in the 
connective tissue around the gland, forming 
a hard knob, and not unfrequently giving rise to the formation of a little 
pus. These tumors are very common on the face, forehead, and neck of the 
young of both sexes, recurring some time after puberty. The dark point 
already alluded to is present and marks the orifice of the duct of the follicle. 
These follicles ai’e easily emptied by pressure, the sebum being moulded, 
as it escapes from tho ducts, into the shape of worms, whence the name. 
Treatment.—Tumors of acne do not demand the use of the knife. In 
time they disappear without either medical or surgical interference; but, in- 
asmuch as their presence upon the face is disfiguring, few persons are satis- 
fied to leave the cure to natui’al processes. In such cases the treatment 
must be both constitutional and local. The former consists in regulating 
the bowels, correcting any disturbance of the digestion, and insisting on the 
use of a plain, simple, and unirritating diet, avoiding all fatty substances, 
using meat sparingly, and subsisting largely on milk and farinaceous articles 
of food. 
The local measures to be employed should be such as are calculated to 
remove the pasty accumulations from the follicles, restore their healthy se- 
cretion, and resolve the exterior indurations, to effect which great advan- 
tage will be derived from steaming the face with the vapor of hot water 
every night before retiring, and sleeping in a mask wet with a solution of 
the bichloride of mercury (gr. i of the salt to fgiv of water). In employing 
the steam, the simplest plan is to fill a teapot with boiling water, and, holding 
the face over the same, cover the head and vessel with a large handkerchief. 
The mask is made of patent lint, which, after being cut into the form of the 
face, with openings for the eyes, nose, and mouth, is covered on the smooth 
side with oiled silk to prevent evaporation of the moisture. Being wetted 
on the opposite side with the liquid, it is secured to the face by pieces of 
tape attached on each of the upper and lower parts of the oval. The steam 
and the medicated water tend to soften the sebum, thus favoring its escape 
from the glands, and at the same time removing by their alterative action 
tho plastic deposit around the follicles. This removal is also facilitated by 
the use of iodide of lead ointment diluted somewhat by the addition of a 
little vaseline, and rubbed into the diseased parts every evening. 
3. Steatomata, or wens.—These differ chiefly from the preceding variety of 
sebaceous tumors in the size to which they grow, varying from the bulk of a 
Fig. 2072. 
Millet-graius. CYSTS. 
589 
pea to that of a pullet’s egg. When allowed to attain a large size, these 
growths are liable to become inflamed, ulcerate, and suppurate. The escape 
of the vitiated secretion, mingled with pus, does not, however, cure the 
tumor. The sac will refill and again discharge, continuing the process 
indefinitely. Sometimes a vascular growth will be developed and protrude 
through the ulcerated opening of the cyst, spreading over the borders of the 
latter like a mushroom. That wThieh was commonly regarded as the sac of 
these tumors, until otherwise shown by Werner, and still later by Mr. Hewitt, 
is only a dense capsule constructed from laminse of glandular epithelium and 
sebum compactly pressed into a dense, membrane-like structure, within 
which lies a softer sebaceous material, either of a syrupy or a. pasty con- 
sistence. The true cyst-wall is formed from the connective tissue exterior to 
the sebaceous capsule. Fig. 2073, represent- 
ing a section of a sebaceous cyst, will explain 
the arrangement of its components. 
The hereditary origin of these cysts is a 
subject of common observation with sur- 
geons. 
These sebaceous or epidermal cysts differ 
in regard to the dark or depressed point 
which in many of the tumors marks the 
opening of the excretory duct. 
Frequently this orifice cannot be discov- 
ered, on which account it has been supposed 
by Paget and others that the tumor origi- 
nated as an ordinary cyst. To my own mind 
it does not seem improbable that many se- 
baceous glands exist in which there is a congenital absence of the excretory 
orifice. 
Treatment.—The cure of these sebaceous growths consists in removing 
the cyst entire. This can be effected in two ways,—by excision and by 
caustics. 
The former is to be preferred, and is accomplished most conveniently and ex- 
peditiously—after shaving the hair from the part and a little distance around— 
by making an incision through the integument over the cyst until the latter is 
exposed, when it can be turned out entire by insinuating between the skin and 
the tumor the curette extremity of a director and separating the easily-lacera- 
ble adhesions; or the primary incision may be made directly through the skin 
and into the cyst, and, after pressing out the* contents, dragging out the sac 
with a pair of forceps. After the removal, the edges of the wound should 
be laid together and maintained in place by one or two narrow strips of ad- 
hesive plaster, and covered with a small pledget of lint moistened with car- 
bolated oil. In females, who dislike to have the hair removed, the closure 
can be made by separating one or two strands on each side of the wound and 
passing them through a perforated shot, which can be clamped by a pair of 
compressing forceps. 
Though the operation is very simple, and is generally regarded as free 
from danger, yet it is not always so. Erysipelas may set in, and, as has 
happened, prove fatal. A lady once walked into my office, sat down, and 
had quite a large cyst removed from the scalp, after which she returned to 
her house and to her family duties without experiencing any inconvenience 
whatever. On the same day, 1 believe, I visited a gentleman at his residence 
and removed from his head a cyst of the same character, and though remain- 
ing in the room after the operation, yet he was attacked with erysipelas, and 
for six weeks lay in the most critical condition, but finally recovered. 
When a caustic is used, the surface of the cyst is destroyed by caustic 
potassa, its contents are discharged, and the sac is either pulled away or 
eradicated by a second application of the caustic applied to the interior of 
the cyst. 
Fig. 2073. 
Section of sebaceous cyst: 1, connective-tis- 
sue cells of cyst-wall; 2, epithelial cells of 
gland; 3, dense, horny celis; 4, cells of sebum. 590 
TUMORS. 
In cases where persons who are out of health are the subjects of sebaceous 
cysts, the prudent surgeon will decline any interference. 
Mucous Cysts.—Mucous cysts may appear anywhere on a mucous surface 
where muciparous glands exist. They are usually seen on the inner surface 
of the lips, particularly the lower lip, on the inner surface of the cheek, be- 
neath the tongue, in the ducts of Rivinus, at the root of the tongue, in the 
larynx, pharynx, and oesophagus, in the antrum maxillare, in the rectum, 
labia, and vagina, and in the glands of Naboth and Cowper. They are found 
in the kidney, at the extremity of the papillee of the Malpighian cones, caus- 
ing dilatation of the uriniferous tubes, also in the capsule of the glomerules 
of the cortical portion of the organ ; in nasal polypi and other growths. 
These cysts generally are tense, globular swellings, occasioning little or no 
pain, the contents of which are viscid or ropy, with mucous corpuscles and 
epithelial debris, in color resembling generally the white of an egg, some- 
times cotfee-grounds, and occasionally, as I have seen, looking like Indian 
meal and water. Mr. Paget has witnessed instances in which the contents 
resembled the ink of the cuttle-fish in color. These cysts, when originating 
in the glands of the cervix uteri, frequently project through the os, and have 
been mistaken for polypi. They are met with from the size of a pea to 
that of an orange. 
Treatment.—The radical cure of mucous cysts requires the obliteration of 
the sac, or cyst-wall, just as in sebaceous cysts. This is effected by excision, 
the seton, and caustics. Excision is generally to be preferred. When situ- 
ated on the lips, the growth should be included between two semi-elliptical 
incisions and dissected away, the parts being afterwards brought together by 
fine silk-thread interrupted sutures. In other accessible localities it will be 
sufficient to cut away the cyst and allow the surface to heal by open granu- 
lation. In sublingual cj'sts it is only necessary to remove the front wall of 
the cyst with the scissors or a bistoury, and destroy the posterior part of 
the sac by cauterization with the nitrate of silver. 
Salivary Cysts are met with in connection with the ducts of the salivary 
glands, appearing under the tongue as ranula, also in the cheek. In the 
first the obstruction is either in one or more of the sublingual ducts or in the 
duct of Wharton, probably also in the ducts of Rivinus; and in the last 
location the tumor is formed by distention of the parotid duct, resulting 
from some obstacle preventing the escape of the salivary secretion into the 
mouth, and often caused by the presence of a calculus. These cysts generally 
contain a ropy, glairy fluid. 
Treatment.—The sublingual cysts are most satisfactorily treated by ex- 
cising an oval piece from the sac, and after the escape of its contents cauter- 
izing the cavity of the cyst with nitrate of silver and packing it for a short 
time with a dossil of lint. 
The parotid cyst should bo opened from the inside of the cheek, in order 
to avoid a salivary fistula, which would most probably follow were the sac 
opened externally. 
Seminal Cysts have been treated of under the head of Diseases of the 
Genito-Urinary Organs, vol. ii. page 593. 
Oil Cysts, a very uncommon variety, are found in the mammary gland, also 
in and about the orbits. Quite recently I removed a cyst of this nature from 
the breast of a lady. In addition to containing the proximate principles of 
fat, margarin, stearin, and crystals of palmitin, epithelium and sebaceous 
matters are found. A tumor the contents of which are similar to the above, 
and which occurs in the temporal bone, in the ovary, and in the cerebellum, 
has been described by the Germans under the name of the pearly tumor. 
Treatment.—These cysts ai’e to be dissected out when accessible. EXUDATION CYSTS. 
591 
Lactiferous Cysts are considered along with diseases of the mammary 
gland. 
Synovial Cysts.—The consideration of these cysts will be found under the 
head of Diseases and Injuries of the Muscular System. 
Blood or Venous Cysts have an entirely different origin from extravasation 
or hemorrhagic cysts. They commence by the wall of a vein yielding at a 
particular spot until at length a pouch, or diverticulum, is formed, which by 
the continuance of the original cause becomes pedunculated, its cavity being 
finally closed off from that of the main vein. Twice I have removed such 
cysts,—once from the neck of a young girl, where the cyst was connected 
with the wall of the internal jugular, and once from the thigh of an elderly 
man, the cyst being attached to the saphena magna. 
For the diagnosis of blood cysts the exploring-needle will usually be found 
necessary, though a soft, fluctuating tumor, which when tested by light is 
found to be opaque, and which has no history of abscess, may generally be 
assumed to contain blood. 
Treatment.—Except in the case of hematocele, hemorrhagic and vascular 
cysts are cured only by excision, in which the sac is removed with its con- 
tents. When the cyst is connected with the wall of a vein, a thread or liga- 
ture should always be placed on each side of the pedicle before the growth 
is detached. 
Exudation Cysts.—As the name implies, they contain a thin, serous, albu- 
minous, and watery fluid, sometimes clear as spring-water, at other times 
dark, and often undergoing spontaneous coagulation. Their existence, how- 
ever, does not depend exclusively on some connection with a serous membrane. 
They occur in the kidney, particularly where it is granular; in the ovary, 
mammary gland, thyroid gland, and testicle; in hones, even in cartilage, and 
often in the subcutaneous connective tissue of the neck (Fig. 2074) and other 
parts of the bod}r, and also in that which is 
deeper and binds together the components 
of various structures and organs. In one 
instance I removed a cyst the size of an 
orange which had developed in the centre 
of the median nerve of the arm. 
A favorite region for the formation of 
these cysts is the neck, in which locality 
they are seen above the clavicle, in the sub- 
clavian region, along the edge of the tra- 
pezius muscle, beneath the jaw, and in the 
space between the angle of the latter and 
the sterno-cleido-mastoid muscle. They are 
sometimes termed hygromata, or hydroceles 
of the neck. When seated over the middle 
of the neck, or along the side of the trachea 
or larynx, they are likely to be confounded 
with cysts of the thyroid or with bursal 
cysts, which frequently are found in connec- 
tion with the cartilages of the larynx. In- 
deed, it has been surmised by some writers 
that they may have originated in one of these forms, and that in the course 
of their growth they have been gradually detached from and become inde- 
pendent of their original connections. (Fig. 2075.) There is no evidence, 
however, of such a genesis; indeed, the contents of cysts which are truly 
thyroid or bursal are entirely unlike the contents of those under considera- 
tion. The former are ropy or viscid, while the latter are more like serum or 
water in consistence. 
Fig. 2074. 
Cyst from the neck of a female removed with- 
out opening the cyst-wall. 592 
TUMORS. 
Cysts of the neck are not confined to any age, occurring, as they do, during 
intra-uterine life, in infancy, and in adults. They are, however, more common 
in adults between twenty and thirty, 
and perhaps more frequent in females 
than in males. They may grow to a very 
large size,—for example, as large as a 
child’s head,—and are usually painless. 
In shape they are spherical, oblong, or 
multilobular. The form is measurably 
determined by the resistance of adjacent 
structures. The construction of strong 
bands of dense fascia, which lie in dif- 
ferent directions over the sac of a cyst, 
will cause a single cyst to assume in 
time the appearance of one which is 
multilobular. The deep surface of a 
cyst of the neck has a remarkable tend- 
ency to extend into the intermuscular 
spaces and other recesses of the region ; 
for example, under the clavicle, under 
the trapezius muscle, and beneath the 
scapula. The walls of such a cyst are generally quite thin, and loosely con- 
nected with the surrounding parts, and its interior lined a pavement 
epithelium. The contents are sometimes limpid and watery, and at other 
times straw-colored or brown ; the fluid being usually coagulated by heat. 
It is produced through the agency of the cells which line the interior of the 
cyst-wall, and also by transudation. 
Etiology.—Serous cysts in the neck and other parts of the body are both 
congenital and acquired. 
The determining cause is not the same in all cases. The acquired cyst, I 
believe, sometimes receives its start in local inflammation of a subacute 
character, causing some degree of softening in the cells of the connective 
tissue, which results in the formation of a little cavity, into which a transu- 
dation takes place. The peripheral pressure of this exuded serum enlarges 
the boundaries of the cavity by displacing and condensing the surrounding 
connective tissue and closing up the interspaces between its fibres, thus 
walling in the cyst. The rupture of an overstrained vessel, followed by a 
slight blood-extravasation, may also be the initial cause of a serous cyst. A 
circumscribed cell-infiltration, it is not unreasonable to believe, will also de- 
termine a cyst, much in the same manner as a similar infiltrate will produce 
an abscess. The ii*ritation caused by a morbid growth in the connective 
tissue of a part will constitute a potential cause for creating a cyst. I re- 
moved from the side of a young man a cyst which had been gradually form- 
ing for seventeen years, and which contained the remains of an angeioma. 
The interpretation which I gave to this neoplasm was not that of a cystic 
degeneration of the ntevus, but rather an atrophy of the latter by an en- 
croachment of the cystic fluid on its vessels. 
Diagnosis.—The growths with which serous cysts, when deeply situated, 
are liable to be confounded are cold abscesses, lipomata, blood-swellings, 
sai’comata, and parasitic cysts. Fluctuation, which is common both to cysts 
and to abscesses, and is realized by palpation, is not exactly alike in the two. 
The contents of a cyst convey to the touch the sensation of a much thinner 
liquid than that which belongs to an abscess. In abscess, moreover, the 
whole mass of the swelling is more fixed, and, if acute, in the course of its 
progress the constitutional phenomena of rigors and febrile exacerbations 
will have been experienced. 
In lipomata the tumor is soft and doughy to the touch, instead of elastic 
and fluctuating, as in cysts, and when the former are compressed between 
the thumb and fingers the surface is thrown into dimples and fissures, and 
Fig. 2075. 
Congenital hydrocele of the neck of an infant. EXTRA VASA TION OR SANGUINEOUS CYSTS. 
593 
the lobular character of the mass becomes apparent, none of which peculi- 
arities can be discovered in cysts. 
The differentiation of these cysts from sarcomata must be based on the 
more rapid increase of the latter, the enlarged net-work of veins which often 
cover the surface of these neoplasms, and the absence of tension when pressure 
is made with the finger upon the surface of such a growth. Very frequently, 
especially in superficial cysts, the tumor, in a proper light, will be found to 
be translucent. In any case, should a doubt remain as to the differential 
diagnosis between cysts and the tumors or abscesses above enumerated, we 
have in the exploring-needle a ready and sure method of clearing up all 
obscurity and establishing the distinction beyond peradventure. 
Treatment.—There are two ways in which to treat exudation cysts,— 
namely, by extirpation and by inflammatory irritation. The first is, with few 
exceptions, to be preferred. The dangers which, according to certain writers, 
attach to excision of cervical cysts I have never witnessed. I have removed 
very many, and in some instances very large, growths of the kind from this 
region, and have never experienced any evil results whatever. 
Before undertaking such an operation, the surgeon should know that the 
patient is free from any constitutional indisposition, and that there is not a 
general prevalence, at the time, of erysipelas. 
In removing the cyst, the incision over its surface should be free, and the 
superincumbent tissues, after cutting through the skin, are to be cautiously 
raised and divided on a grooved director, taking care not to cut into the sac. 
If this is done and the sac is thoroughly uncovered of all its cellular in- 
vestments, the enucleation of the tumor is greatly simplified, requiring for the 
most part only the use of the handle of the scalpel, the end of the director, or 
the fingers, with occasionally a touch of the knife, to separate all surround- 
ing adhesions and turn out the cyst entire. If the sac is opened, the fluid 
contents will escape and its walls will collapse, rendering it often difficult to 
distinguish it from the adjacent connective tissue. 
The treatment by inflammatory irritation consists in the use of injections 
and setons, and in stuffing the interior of the sac with lint, the object in each 
procedure being to establish suppuration, and in this way secure the atrophy 
of the cyst-wall. 
Among the injections, that of carbolic acid is strongly recommended by 
Dr. Levis, of this city. The crystals are dissolved in glycerin and injected 
into the cyst. 
Extravasation or Sanguineous Cysts are of1 two kinds, hemorrhagic, or ex- 
travasated, and vascular. 
Hemorrhagic cysts may originate in three waj’S. 1. The spontaneous 
or traumatic rupture of a number of vessels, chiefly venous, results in an 
extravasation of blood, which clears for itself a space in the midst of the 
connective tissue of a part, exactly in the same manner as has been de- 
scribed in the formation of a serous cyst. The fibres of the areolar tissue 
are crowded together closely, and the normal spaces sealed up by an active 
cell-proliferation and by the transudation of lymph, thus constituting a wall 
or sac. The blood so inclosed remains in a liquid state for a long time. The 
blood tumor seen on the scalp of new-born infants, and caused by the long- 
continued pressure of the foetal head against the walls of the pelvis, or by 
the blades of the obstetric forceps, belongs to the above variety of sanguineous 
cysts. 
Doubtless these collections of blood will be denied a place among cysts by 
most writers, inasmuch as they are of temporary duration and spontaneously 
disappear. But if a collection of fluid more or less consistent and isolated 
from all surrounding parts by an encapsulating wall constitutes a cystoma, 
there is no good reason for excluding from the list the blood-swelling described, 
on the ground of its temporary existence. 594 
TUMORS. 
These cysts generally undergo a spontaneous cure, either by absorption of 
their contents, or, as sometimes happens, by suppuration. 
Except in the latter termination, when the swelling should be laid open as 
an ordinary abscess, these sanguineous collections require no other treatment 
than the local application of stimulating remedies, as alcohol, solutions of 
muriate of ammonia, or tincture of iodine. 
2. The second variety of extravasation cyst is one in which the wall or sac 
has been preformed, or one in which the hemorrhage takes place into a serous 
cavity. In illustration of the former, an ordinary exudation cyst has been 
tapped, and the peripheral vessels, suddenly losing the resistance of the ab- 
stracted fluid, give way and fill the sac with blood; or the same result may 
take place in an exudation cyst which has been rudely handled or has been 
injured by a blow, much in the same manner as hydrocele is sometimes con- 
verted into ha3matocele by accidental violence. In both of these varieties 
the contained blood is usually coagulated. 
In the third mode in which extravasation cysts are formed, their origin is 
probably due to nsevoid degeneration, in which the walls of an angeioma 
become absorbed, allowing the blood to find its way into the surrounding 
parts, or to the gradual expansion of a portion of these walls into a limit- 
ing sac. 
At all events, blood cysts of long standing which admit of no explana- 
tion more reasonable than the above are occasionally encountered. They 
are not confined to any special locality, but have been seen in the neck, on 
the side of the chest, along the posterior border of the scapula, and over the 
parotid gland. In such cysts the blood is dark and sometimes mixed with 
granular matter; at times it is mingled with serum and contains crystals 
of cholesterin. 
Hydatid or Parasitic Cysts may without any great impropriety be consid- 
ered under the head of cysts. They are found in almost every part of the 
body, in the liver, uterus, ovary, kidney, testicle, lungs, bones, eye, brain, etc. 
These cysts vary in size from that of a mustard-seed to that of the foetal 
head. They are usually spherical in form, though they are sometimes 
cylindrical. 
Two varieties are found in man, the cysticercus cellulosae and the echinococ- 
cus,—the former being derived from the hog, and the latter from the dog. 
Both are species of the tsenia. 
The taenia solium, which is frequently met with .in the human intestine, 
springs from the use of measly pork, on the livers of which are frequently 
seen little bladders, or cysticerci, which contain the parasite. On entering 
the stomach and passing into the intestine of man, this parasite is developed 
into the tape-worm, which possesses a head and a flat or ribbon-shaped 
body, composed of a number of joints or segments, in all many yards long. 
The head is very small, scarcely exceeding a grain of fine bird-shot in size, 
with a proboscis, around the base of which are arranged a double row of 
hooklets, and farther back are four suckers. The segments or joints of the 
parasite embody both the male and the female organs of generation, and are 
filled with ova. The ova, after fecundation, contain the embryo worm, 
armed with the hooklets by which the animal is able to anchor itself in the 
intestines and resist expulsion. One or more of the joints of the taenia con- 
taining fecundated ova are expelled with the human dejections, which fre- 
quently are eaten by unclean animals, and in this way reach their intestine, 
where the ovum is hatched, the embryo disrobing itself of the membrane in 
which it is enveloped. Thus liberated, it gradually penetrates the intestine 
and makes its way into various parts of the body, and at length becomes 
encysted in a membrane of delicate connective tissue, forming the tumor 
designated cysticercus cellulosse. In dissecting this cysticercus, it will be 
found to have an exterior envelope, consisting of a vascular fibrous mem- 
brane, which is always wanting when the cysticercus occupies a cavity, and HYDATID OR PARASITIC CYSTS. 
595 
which appears to be the direct product of parasitic irritation, as in the case 
of a bullet, which, when buried in the tissues, often becomes encysted. Within 
this envelope is contained a transparent spherical vesicle filled with fluid, which 
enfolds the parasite. 
Echinococci resemble in most respects the ttenia solium, already described, 
save in the number of joints, which are much fewer. They have the two rows 
of hooklets at the base of the proboscis, and also the suckers. 
The ova of the echinococcus, after entering the intestine, lose the inclosing 
membranes, and the embryos, thus liberated, make their way through the 
body. Unlike the teenia solium, the echinococcus is found in colonies, large 
numbers occupying a single cyst. This cyst, like that of the cysticercus 
cellulosse, is formed from connective tissue, and supplied with blood-vessels, 
the contained vesicles being sometimes single and at other times multiple, one 
being inclosed within another, like the concentric layers of some vegetable 
bulbs. The cyst-membrane has a pulpy consistence, and is composed of 
numerous superimposed lamime or leaflets, each exhibiting finer layers when 
examined under the microscope, while on the innermost layer are seen, 
studding its surface like grains of millet-seed, numerous vesicles of the 
echinococcus, each measuring about one-tenth of a millimetre in size. The 
fluid contained in the transparent vesicle is clear, has a saline taste, and is 
not albuminous, being affected neither by heat nor by nitric acid. 
Diagnosis.—The diagnosis of hydatid cysts must necessarily be a matter 
of great uncertainty. The peculiar trembling or fremitus which is felt on 
lightly percussing or compressing the tumor between the fingers cannot, of 
course, be elicited when the cyst is seated in internal organs and inaccessible 
to manipulation. Where the contents of a cyst are aspirated, and fragments 
of the parasite, as hooklets and other debris, are discovered by the microscope 
in the fluid removed, the nature of the tumor will be revealed. By the same 
mode of examination the presence of an hydatid may be predicated in the 
kidney or in the lung by detecting portions of the animal in the urine or in 
the matters expectorated. 
Hydatids are prone to undergo destructive changes. The contents of the 
sac may perish and its walls shrivel up or become calcified. Suppuration in 
some instances is excited by the presence of the hydatid, or, in consequence 
of degenerative changes in the vesicle, the disorganized pai'asites may be 
ejected from the body along with secretions of the organ in which they have 
found a habitat. Fatal peritonitis has followed the presence of hydatids in 
the liver. 
A male patient, having an elastic, fluctu-* 
ating tumor, which I regarded as a cyst, on 
the side of the thorax, presented himself at 
the clinic of the University of Pennsylvania. 
On turning off the superincumbent tissues, 
three transparent cysts, cylindrical in shape, 
and marked at several points by constric- 
tions, were exposed (Fig. 2076), which 
proved to be hydatids. 
A variety of echinococcus is described by 
authors in which a large number of minute 
cavities, filled by gelatinous bodies made up 
of echinococci, hooklets, etc., are imbedded 
in a stroma more or less firm. 
Hydatids are much more common abroad 
than in this country. In those Northern regions where the dog is the 
close companion of man, as in Iceland, it is stated, on the authority of 
Eschricht, that a very large proportion of the population suffer from the 
parasite. 
Treatment.—When accessible, the proper remedy for hydatid cysts is 
excision. In more inaccessible cases, as when the tumor occupies the liver 
Fig. 2076. 
Hydatid cyst removed from side of thorax. 596 
TUMORS. 
or kidney, its destruction may be attempted by tapping and afterwards 
injecting into the sac the tincture of iodine. 
Dentigerous Cysts have been treated of under the head of Diseases of the 
Jaws, vol. ii. p. 938. 
Cutaneous or Dermoid Cysts.—1. These cysts are not sebaceous, nor are 
they necossarijy confined to the skin, but may arise in the deeper structures, 
and generally appear at or near the outer extremity of the eyebrow. They 
are congenital. The limiting wall or sac of such growths is never dense and 
thick, neither are the contents so consistent, dark-colored, or offensive as 
those of the ordinary wen. They differ in another important particular from 
the latter, in their tendency to cause an absorption of the bone contiguous to 
which they are located. In this manner such tumors have destroyed the 
tables of the skull and entered the cranium. In one instance I removed 
from over the outer angle of the frontal bone of a lady a cyst of this 
kind, which had opened the frontal sinus by producing absorption of its 
wall. 
In a number of instances a meningocele has been mistaken for one of these 
cysts, and, unfortunately, these errors have been followed by fatal results. 
The possibility of committing such a mistake should make the surgeon care- 
ful in every case of congenital cutaneous cyst to strengthen his diagnosis by 
such tests as are capable of removing any which may exist. Cys- 
toceles or meningoceles are generally reducible by pressure. They become 
tense by placing the head in a dependent position, and when firmly pressed 
are apt to excite some brain-symptoms of an unpleasant nature. 
2. A second variety exists in which the cyst, unlike the ordinary sebaceous 
one, is unprovided with an excretory duct. The skin with all its components 
in their physiological perfection may be present in the cyst, as the glands 
with their sebaceous matter and hair, and the papillfe giving rise to warty 
and horny growths. 
3. A third variety, most remai’kable of all and most difficult of explana- 
tion, is met with, in which are found, in addition to sebaceous matter, tissues 
diverse in structure, as skin, muscle, and nerves, also teeth, bone, and carti- 
lage, all thrown together in the most disorderly manner. The most common 
seats of these cysts are the ovary and the testicle. (See vol. ii. pp. 598, 813.) 
They are occasionally observed in the kidnej7, brain, lungs, and other organs 
of the body. Dr. Irvine* exhibited before the London Pathological Society 
a remarkable example of dermoid cyst from the brain of a child. 
Treatment.—The radical cure of these cysts can be effected only by extir- 
pation, and this when the tumor is accessible and an opei’ation is not contra- 
indicated by other conditions. 
Proliferous Cysts are those on the walls of which other cysts and organized 
structures grow. These secondary productions sometimes assume the char- 
acter of vascular or papillomatous growths, which may become so exuberant 
as to break through the surrounding wall and form an exterior fungoid mass 
of granulations, closely imitating in appearance malignant disease. It is 
these secondary productions which make those cysts, originally retention, 
neoplastic cysts. (See Cysts of the Mammary Gland.) The ovary, the 
thyroid body, and the mammae are frequently the seats of these neoplasms. 
In other cases the parent cyst becomes the seat of other cysts, some de- 
veloping inwardly (endogenous) and others growing outwardly (exoge- 
nous). These cysts are usually seen in the ovary and in the chorion. The 
mole or hydatid mole of obstetric writers is an example of this variety 
of cyst. Those cysts which arise in the ovaiy commence, most probably, in 
the Graafian follicles, although on this point pathologists do not agree. The 
secondary cysts which appear in such amazing numbers on the walls of the 
* British Medical Journal, November 30, 1878, p. 802. LIPOMA. 
597 
parent cyst may be considered as the product of cells resident in the latter. 
Often these secondary cysts grow in such numbers and crowd so closely to- 
gether that absorption of the walls in contact with one another occurs, and 
in this way they form a multilocular tumor, the loculi of which communicate. 
Owing to their prodigious proliferating capacity, these tumors often attain 
enormous dimensions. Their walls gradually increase in thickness, and their 
contents exhibit the greatest diversity, having all degrees of consistence, from 
a liquid as thin as water to one as thick as molasses, or semi-solid, like jelly 
or glue. Nor does the color of the contents vary less than their consistence, 
being sometimes straw-colored, at other times brown or of a chocolate hue, 
and occasionally containing blood. In some of these cysts which originate 
in the ovary the remains of foetal structures are found, mingled with seba- 
ceous matters. 
The diagnosis of these cysts has been considered at length under the head 
of Ovarian Tumors. (See vol. ii. p. 795.) 
The treatment consists in excision. 
The broad ligament also becomes the seat of cysts, but these differ from 
the ovarian in that the contents are as clear and limpid as spring-water, 
coagulate spontaneously, and frequently disappear spontaneously after one 
or more tappings. 
TYPICAL TUMOPvS, OR BENIGN NEOPLASMS, WHICH CONFORM IN 
THEIR HISTOLOGICAL ELEMENTS TO CONNECTIVE TISSUE. 
Lipomata, or fatty tumors, are among the most common neoplasms met 
with by the surgeon. No part of the body is exempt from these growths, 
though they exhibit a special predilection for certain regions, as the back of 
the neck, the shoulders, the posterior portion of the trunk, the inside of the 
arm and thigh, and the nates. More rarely these tumors are seen on the 
front of the abdomen, in the epigastric region, in the temporal region, upon 
the scalp, in the labia majora, in the plantar surface of the foot, in the omen- 
tum, stomach, intestines, and among the fasciculi of muscles. From a female, 
the patient of Dr. Lodge, of this city, I removed a large lipoma, which occu- 
pied the left temporal region, having its origin between the two layers of the 
temporal aponeurosis. In another patient, operated on in the clinic of the 
University, a fatty tumor was excised from the sole of the foot. Lipomata 
wrhich grow from the nucha often attain enormous dimensions, reaching in some 
instances to the hips, and by their weight becoming pedunculated. Occasion- 
ally they are seen of great bulk springing from the side of the neck. In a 
patient sent to me for operation from Conshohccken by Dr. Reed, the base of 
the tumor occupied almost the entire side of this region, extending outward 
until it rested upon the corresponding shoulder. (Fig. 2077.) In walking, this 
body or great globular mass of fat floated in mid-air like a distended bladder. 
Adipose tumors frequently are multiple, appearing sometimes in different 
portions of the same region or extremity and at other times over different 
and distant parts of the body. When existing in numbers they seldom attain 
any great size, rarely exceeding a hickory-nut or walnut in bulk. These 
tumors often have an hereditary origin, and sometimes are congenital. The 
period of life when they are most common is that between thirty and sixty 
years. Lipomata, it is said, occur most frequently in thin or lean persons, 
yet, according to my observation, thin and fat subjects furnish about an equal 
number of cases. It has been frequently noticed that in persons having fatty 
Lipoma.* 
* It is proper for me to state that the cuts introduced under the chapter on tumors to illustrate the 
microscopic appearance of morbid growths have been taken from a “ Manual of Microscopic Diag- 
nosis,” by Dr. H. F. Formad, Lecturer and Demonstrator of Morbid Anatomy in the University of 
Pennsylvania, and illustrated by Dr. I. W. Blackburn, that they were all prepared, under Dr. Formad’s 
direction, in the Pathological Laboratory of the University of Pennsylvania, and that most of them 
were drawn from specimens furnished from my own operations. 598 
growths who undergo emaciation the tumors do not participate in the general 
wasting of the adipose tissue; on the contrary, they rather increase in size. 
Lipomata, when allowed to 
remain undisturbed, will find 
their way into every recess 
and adjacent fissure, in conse- 
quence of which a very imper- 
fect idea of the magnitude of 
the neoplasm is obtained an- 
terior to an operation. 
TUMORS. 
Fig. 2077. 
Fig. 2078. 
Lipoma of the neck. 
Fat-tumor, or lipoma. 
Fatty tumors differ in form, being sometimes ovoidal, sometimes spherical, 
and at other times flattened. The shape depends largely on the anatomical 
peculiarities of the surrounding structures, the growth enlarging in the direc- 
tion of least resistance. The surface presents a lobulated appearance, the 
lobes being somewhat separated from one another by depressions made by 
prolongations of connective tissue derived from an investing capsule of the 
same material, which, penetrating into the interior, serves by its divisions to 
separate the tumor into lobes, lobules, and even granules. (Fig. 2078.) It 
is this connective tissue which gives also to fatty tumors their notched bor- 
ders. Crossing a lipoma in different directions, it is in some places seen to be 
gathered into strong bands, often almost completely detaching some one or 
more of the lobes from the main body of the tumor. The perfection of the 
capsule of a lipoma depends on the amount of loose connective tissue which 
may be present in the locality occupied by the growth. The more abundant 
this is, the more complete will be the fibrous capsule, and, for the same reason, 
the more easily will the neoplasm be shelled out. On the posterior part of 
the neck or on the back little or no capsule is possessed by lipomata, and con- 
sequently greater difficulty is experienced in their removal, as a dissection 
rather than an enucleation is required to separate them from their connection 
with the surrounding parts. It is seldom that a lipoma in these regions is 
distinctly lobulated, the fat being in small masses and held together by a 
large amount of dense, fibrous tissue, which penetrates the mass in all direc- 
tions. So large an amount of connective tissue is sometimes mingled with 
the adipose material that the tumor is termed mixed, or a fibro-lipoma, the 
fibrous and fatty components being present in nearly an equal degree. 
Lipomata are also found in combination with angeiomata, usually of congen- 
ital origin, the vascular portion being chiefly venous, and often giving to the 
tumor a bluish appearance similar to that of neevoid growths. In cases of this 
nature the vascular part of the tumor sometimes atrophies, leaving in its 
place a reticulation of dark-colored connective tissue, in the interspaces of 
which lie granules of fat. In addition to the above combination others occur, 
as sarcoma and myxoma. The former sometimes follows the removal of a 
lipoma, appearing in the very place from which the latter was extirpated. 
Lipomata are not very well supplied with blood-vessels, and those which LIPOMA. 
599 
are present follow in their distribution the connective tissue which consti- 
tutes the trabeculae or frame-work of the neoplasm. No nerves exist in this 
class of tumors, and this fact, taken in connection with the absence of any 
large blood-vessels, will explain their want of sensibility and the slight degree 
of hemorrhage which follows their excision. 
Lipomata differ from ordinary adipose tissue in having larger vesicles, 
smaller vessels, no nerves, and probably few, if any, lymph-vessels. The dis- 
tinction will be seen by contrasting Fig. 2079 and Fig. 2080. 
Fig. 2079. 
Normal adipose tissue. Fat vesicles and lobules small; nerve-trunk and open spaces, above which are blood-vessels, 
both divided transversely. The frame-work of connective tissue strong, and branched. X 
Lipomata rarely, though they do occasionally, undergo retrogressive 
changes, as calcification and ossification; also fibroid, mucoid, and cystic 
degeneration. These transformations are generally limited to portions of 
the growth. The contents of these lipomatous cysts are made up of the 
proximate constituents of fat, and also of mucoid matters. 
Diagnosis.—The diagnosis of fatty tumors generally is not difficult. They 
have a soft, doughy feel, a lobulated surface, are quite movable, insensible to 
pressure, and tardy in their growth. A very characteristic feature of lipomata 
is the dimpled appearance presented by the overlying integument when the 
tumor is firmly compressed between the thumb and fingers. The numerous 
depressions which appear on employing this test indicate the place where 
the capsule of the tumor sends in the fibrous prolongations which divide the 
mass into lobes and lobules. 
Causes.—In many instances lipomata arise without anj’- apparent cause. 
In other cases the development of the tumor appears to have been deter- 
mined by inflammation. The fact that those portions of the body most ex- 
posed to irritation are generally the parts elected by these neoplasms would 
seem to point strongly to an inflammatory causation. 
Owing to pressure or to the great weight which they sometimes attain, 
lipomata are liable to ulceration, the resulting sore and the discharges being 
foul and unhealthy. 
Treatment.—The treatment of lipomata consists in removal. When the 600 
TUMORS. 
tumor is large, the redundant integument should be included between two 
elliptical incisions. As soon as the capsule is exposed and divided, the growth 
Fig. 2080. 
Lipoma taken from the thigh. Fat vesicles and lobules large; some bands of connective tissue traversiug the 
tumor. X 40. 
can generally be enucleated with the fingers, though here and there, perhaps, 
a tough band of fibrous tissue will require the edge of the knife. When the 
capsule is absent, the dissection of the tumor from the surrounding parts 
will often be tedious. Seldom will it be necessary to tie more than one or 
two vessels. After all bleeding is arrested, it only remains to introduce a 
drainage-tube, or a number of threads of catgut, close the wound accurately 
with a few interrupted sutures, and apply the antiseptic dressing, making 
the same secure with a carbolated or sublimate roller. Healing usually 
takes place promptly, and no return of the tumor may be expected. 
Fibromata. 
Fibrous tumors take their name from being made up chiefly of connective 
or fibrous tissue, and accordingly may appear in any locality where material 
having this physiological type exists. Though particularly partial to the 
uterus, where they often attain a great size, fibromata occur also in the skin, 
in the fascia, in the subserous and submucous connective tissue, among the 
fasciculi of muscles and nerves, in and about the articulations, in the perios- 
teum, ovary, testicle, mammary gland, labia majora, and various other regions 
of the body. Elephantiasis may be regarded as a wide-spread fibroma. 
Fibromata vary in size from that of a grain of shot to that of a foetal 
head. In one instance I removed from a patient in the Pennsylvania Hospital 
a fibrous growth from the summit of the uterus equal in bulk to a large head 
of cabbage, to which, indeed, it bore a very striking resemblance. Though 
differing in form, these neoplasms ordinarily are spherical, ovoidal, or lobu- 
lated. Their connection with the parts from which they grow is sometimes 
broad or sessile, at other times pedunculated, and not uncommonly they lie 
imbedded in, without any close connection with, the tissues. Though gener- 
ally devoid of a capsule, they may often be readily shelled out of their bed HARD FIBROMA. 
601 
by enucleation on dividing the superincumbent structures. In the case of a 
female, who for a long time had carried a growth of this nature on the back, 
a short distance to one side of the lumbar spine, the tumor was spontaneously 
ejected through a break in the overlying skin caused by a fall. 
Fibromata may be single or multiple. Multiple fibromata of the soft 
variety answer to the leontiasis of Virchow. Fibromata may exist in such 
numbers, when seated in the midst of muscular tissue, as almost to replace 
the latter. In a lady from whom I removed the uterus, including the foetus, 
delivery being impossible by the natural passages, very little of the muscular 
uterine tissue existed, in consequence of an immense number of fibroids; so 
little, indeed, that the power of contraction in the organ was almost entirely 
lost. 
Fibromata are sparsely supplied by blood-vessels. These vessels some- 
times are without any muscular walls, and are so united to the substance of 
the neoplasm that when divided they remain with gaping mouths unable to 
retract, thus favoring hemorrhage. 
The period at which fibrous growths generally occur is during middle life, 
or between thirty-five and fifty-five years. They are seen more frequently 
in women than in men. Though capable of destroying life by pressure or by 
the hemorrhage which they induce, particularly when seated in the uterine 
walls, yet in other respects fibromata are entirely benign, and possess no power 
to infect the general system, unless they embody sarcomatous elements which 
may appear metastatically in some internal organ, especially the lungs. 
The general appearance of fibromata varies somewhat. Generally, they 
have a glistening white, a yellowish, or a slightly red color, and are firm and 
elastic to the touch. Their density varies according to the compactness with 
which the connective-tissue fibres lie or are interwoven. On this physical 
property is based a division into hard and soft fibromata. 
Fibroid growths may undergo ulceration, generally the result of pressure. 
In these cases the ulcer is limited to the overlying integument, and under 
proper management will heal. 
Hard Fibroma.—This variety is characterized by closely-packed fibres 
of connective tissue, which 
run in various and appar- 
ently confused directions, so 
that when a section is made 
some of the fibres of the tu- 
mor are divided longitudi- 
nally and others transverse- 
ly. (Fig. 2081.) At certain 
points, where a blood- 
vessel exists, there is often 
seen a singularly method- 
ical arrangement of the ana- 
tomical elements, the fibres 
being arranged in a series 
of concentric layers, very 
similar in appearance to 
that presented by the Ha- 
versian canals in bone. 
In other instances the 
fibres of connective tissue 
are less closely packed to- 
gether, and, instead of being 
straight, present a wavy 
appearance. A very excel- 
lent example of this variety 
of fibroma is seen in the illustration (Fig. 2082), exhibiting the microscopic 
Fig. 2081. 
Microscopic section of a hard fibroma taken from the thumb of one 
of my patients, and exhibiting the connective tissue running in longi- 
tudinal and transverse directions. At the upper part a vessel with con- 
centric disposition of the surrounding fibres; at the middle the ends 
of fibres cut transversely. X 300. TUMORS. 
appearance of a fibrous tumor which I removed from the mammary gland of 
a middle-aged woman. 
Another form of fibro- 
ma is met with, of a less 
dense consistence than 
those already described, 
in which the bundles of 
fibrillar conjugate tissue 
are arranged in seg- 
ments, giving to the tu- 
mor a somewhat alveo- 
lated appearance, with 
numerous young cells 
(endothelial) scattered 
about the fibrils and in 
an active state of prolif- 
eration. In Fig. 2083, 
taken from a fibroma of 
the scrotum which I 
removed from a patient 
in the University Hos- 
pital, this disposition 
of the anatomical ele- 
ments of the neoplasm 
is accurately repre- 
sented. 
Fig. 2082. 
Fibroma of the mamnue. The wavy disposition of the connective tissue is 
seen, and at the left upper corner a number of the fibres cut transversely. 
The irregular cavity to the right is a milk-duct cut across and partially filled 
by proliferating epithelium. X 300. 
Soft Fibroma. — Al- 
though fibrous growths 
are generally hard and 
firm to pressure, this is not always the case. In not a few instances they 
Fig. 2083. 
Fibroma of the scrotum. Around the fibrillar bundles of connective tissue are seen many young endo- 
thelial cells in a state of active proliferation. 
will be found quite compressible, and have been called soft fibromata. The CAVERNOUS FIBROMA. 
603 
physical property from the presence of which such neoplasms receive their 
name results from the predominance of cell-forms in various stages of devel- 
opment,—round, fusiform, and stellate, some collected into groups, others 
scattered, and all mingled with delicate reticulated connective-tissue filaments. 
(Fig. 2084.) The uterus furnishes a favorable soil for the production of soft 
fibromata. 
Fig. 2084. 
Intramural fibroma of the uterus. The connective tissue is chiefly of the reticulated variety, 
and contains large numbers of young cells collected in groups, between which is a delicate fibril- 
lar tissue formed by the union of stellate cells. 
Cavernous Fibroma.—Last, we have another variety of fibroma, to which 
the name cavernous is given. In its elements and their arrangement it does 
not differ from cavernous angeioma. Like soft fibroma, its common seat is the 
uterus. The tumor consists of apartments gr alveoli of different size and 
form, their walls being formed of fibrillar connective tissue, originally lymph- 
spaces, which have been enlarged or distended by an accumulation of red blood- 
corpuscles. (Fig. 2085.) These neoplasms are spongy or compressible, and 
are subject to alterations in size, determined by varying amounts of blood 
contained in the alveoli. 
Under the head of fibromata will also come those fibrous tumors of the 
derm which are named keloid. These neoplasms frequently arise in cicatrices, 
appearing as a ridged or a flat tumor, have a bluish or deep lilac color, and 
are extremely dense and hard to the touch. Keloid is made up of fibrillar 
connective tissue, w’hich in its development replaces all the components of 
the normal skin, including glands, nerves, papillary elevations, etc. Fig. 
2086 exhibits the microscopic structure of a keloid, drawn from a small 
growth of the kind which was removed from the shoulder of a young woman, 
over the posterior border of the scapula. When keloid forms in a cicatrix, 
no blood-vessels enter its structure. 
Fibromata are sometimes associated or mixed with other neoplasms, as 
lipoma, myxoma, sarcoma (particularly when growing from periosteum), 
myoma, chondroma, and, as seen in Fig. 2085, with angeioma. 
The degenerative changes of a benign character which fibromata undergo 
are mucoid, adipose, calcareous, and cavernous. Cavities are not unfrequently 
seen in the substance of fibroids, containing clear or cloudy serum. 604 
TUMORS. 
Fig. 2085. 
Cavernous fibroma from the uterus, consisting of a frame-work of fibrillar connective tissue arranged 
in alveoli and the latter filled with red blood-corpuscles. X 300. 
Fig. 2086. 
Keloid of the skin. Very fine filaments of fibrillar connective tissue forming dense 
bundles, which are indistinctly seen. An arterial blood-vessel, with branches, is seen 
in the midst of connective tissue, the tunica adventitia of which is seen infiltrated with 
proliferating cells. MYOMATA. 
605 
Diagnosis.—The diagnosis of a fibroma will be formed on the following con- 
siderations,—namely, slowness of growth, hardness of structure, increasing 
fixedness, regularity of surface, absence of pain, except when by growth the 
tumor encroaches upon adjacent nerves, no tendency to become adherent to 
the integument, when subcutaneous, and no enlarged veins over its surface. 
Treatment.—Operative measures for the removal of fibromata should not 
be undertaken prematurely, as the active life-history of growths is closely 
related in many cases with the functional activity of the part or organ with 
which they are connected. When located in the uterus, their growth often 
ceases with the menopause, and if connected with bone, their increase may 
stop with the perfected nutrition of the skeleton, and, as the increase of a 
fibroma is ordinarily very slow, it is a good rule to abstain from all inter- 
ference until at least the patient has reached those vital crises with which 
the body is destined to cope, when, if no halt is made in the growth of the 
tumor, the question of its removal may be entertained. 
When seated in the uterus, the feasibility of extirpation will be determined 
by location. Intra-uterine and extra-uterine fibroids are amenable to surgical 
methods, which have been described under the head of Diseases of the 
Female Genital Organs, vol. ii. page 766, while those which are intramural 
offer, often, insurmountable difficulties to removal. 
In all accessible localities, under the conditions already prescribed, fibrp- 
mata should be extirpated either by the ecraseur or by the knife. 
Tumors consisting exclusively of muscular tissue, if they ever exist, must 
be exceedingly rare. 
Myomata. 
Fig. 2087. 
Rhabdomyoma from the kidney of a foetus. The striated fibres are seen both in longi- 
tudinal and in transverse section, with the intermediate connective tissue. X 300. 
The two varieties of this new formation are the rhabdomyoma and the 606 
TUMORS. 
leiomyoma, terms used by Lenlcer to designate the derivatives of this neo- 
plasm. 
Rhabdomyoma is congenital, and for the most part met with in some por- 
tion of the genito-urinary apparatus, as the kidney, testicle, uterus, or 
vagina, and also may be found in combination with sarcoma and carcinoma. 
Rhabdomyoma is allied in its histological elements to striated muscle. (Fig. 
2087.) The fibre-cells are very much smaller than those of ordinary mus- 
cular tissue. 
Leiomyoma (Fig. 2088) belongs to smooth muscular tissue,—is, indeed, a 
Fig. 2088. 
Leiomyoma from the cervix uteri. The muscular cells are seen divided transversely and 
longitudinally, running in various directions, concentrically arranged about a cut blood- 
vessel, and are mingled with connective tissue. The angular appearance of the cells will 
also be noticed. X 300. 
hyperplasia of that tissue,—and, being associated with a preponderance of 
connective tissue, resembles a fibroma rather than a myoma: hence it is not 
improperly termed fibro-myoma, or myo-fibroma. The muscle-cells are seen 
isolated or gathered in bundles, and run in various directions. 
The peculiarities of the two forms of myoma, as contrasted with normal 
muscular tissue, will be more fully appreciated by comparing the former 
with Fig. 2089, in which is shown a view of normal smooth muscular tissue of 
the uterus, the cells of which are considerably larger, and the nuclei smaller, 
than in the neoplasms, and the elements arranged in a manner to imitate in 
many respects the alveoli of carcinoma. 
Leiomyoma, unlike rhabdomyoma, is not congenital. It occurs in the 
uterus, vagina, bladder, testicle, prostate, scrotum, oesophagus, stomach, and 
intestines. The tumor is firm in consistence, has few blood-vessels, resembles 
in form oi’dinaiy uterine fibroids, being spherical or pyriform, has a white or 
flesh-colored appearance when laid open, and may attain to the size of the 
foetal head. 
Myomata often are multiple, and often possess a distinct capsule, from which 
they may be safely enucleated when in the walls of the uterus. ENCUONDR OMA TA. 
607 
The growth is one peculiar to mature or advanced life, increases slowly, 
is benign in character, but may give rise to serious trouble from pressure or 
Fig. 2089. 
Smooth muscular tissue from the uterus. Muscular fasciculi cut transversely and longitudinally. 
A longitudinal section of a small artery in the upper part of the figure. 
from profuse hemorrhage from the uterus, both of which not unfrequently 
attend its presence. In many instances myomata become stationary, es- 
pecially after the menopause, or undergo calcareous or mucoid degeneration. 
Treatment.—The growth of myomata is occasionally arrested, and in 
some cases the tumors materially diminish, by the use of ergot, employed 
hypodermically. The physiological action of this drug in inducing muscular 
contraction, and thus depriving or lessening the supply of blood to the tumor, 
will explain its beneficial effect. For the same reason, myomata often become 
passive or atrophy after the subsidence of the menstrual function, when, of 
course, periodical congestions of the uterus and its appendages cease. 
Where myomata continue to be progressive, and where from pressure or 
repeated bleedings the health and life of the patient are jeopardized, it will 
be proper, whenever feasible, to extirpate the tumor, either through the 
natural passages when the growth is intramural, or through an abdominal 
incision when it is otherwise located, as in or on the walls of the uterus. 
Enchondromata. 
Enchondromata are tumors composed of cartilage. Muller was the first 
to describe these neoplasms as enchondromata. 
The common sites for enchondromata are on the phalanges and metacarpal 
bones, where they generally are multiple. (Fig. 2090.) The next in fre- 
quency are the bones of the pelvis and the femora, and then follow the ribs, 
the scapula, and the bones of the face, especially the inferior maxilla. Nor 
are such tumors confined to the bones: they may originate in the joints 
or cartilages, as those of the air-passages, and in glands, particularly the 
parotid, the testes, the ovary, and the salivary and mammary glands. They 608 
TUMORS. 
occur also in the sheaths of tendons and in the lungs. When originating in 
bones, these growths often attain enormous dimensions, especially when 
connected with the scapula, fem- 
ora, or ribs. In an elderly man, 
brought to me from the western 
part of Pennsylvania, the tumor, 
which was attached to the ribs 
of the right side (Fig. 2091), was 
almost equal in bulk to the 
body of the patient. The largest 
growth of this nature recorded 
is that mentioned by Sir Philip 
Crampton, in which the tumor, 
attached to the femur, measured 
in its circumference six feet and 
a half. 
Enehondromata are generally 
round, abruptly-defined tumors, 
sometimes quite smooth on the 
exterior surface, or made up of 
numerous nodules closely massed 
together. These masses or knobs may be blended or separated by distinct 
partitions of other material, and then vary much in their density and i-esist- 
ance. Though usually firm and resistant to the touch, they sometimes are 
elastic and compressible. The 
consistence of cartilage neo- 
plasms is not alike; they vary 
not only at different periods of 
the growth, but in different por- 
tions of the same tumor. When 
cut into, the knife will encounter 
great resistance at one point, 
and at another very little. The 
firmer portions exhibit on sec- 
tion a grayish-wThite or faintly 
blue color. The softer parts are 
frequently the products of retro- 
gressive changes, having the con- 
sistence and appearance of gelat- 
inous, gummy, or horn-like ma- 
terial. The progress or growth 
of enehondromata may be either 
slow or rapid, and, as they are 
usually benign, it is attended in 
either case by little or no incon- 
venience, and by no pain except 
that which may result from bulk 
and pressure. 
When situated in soft tissue, 
enehondromata are surrounded 
by a capsule of condensed con- 
nective tissue. 
Cartilage tumors are peculiar to young subjects, appearing before or about 
the period of puberty. Rarely do they affect persons of mature or advanced 
life. Occasionally they occur congenitally, and, according to Weber, they 
are sometimes hereditary. It would seem that the case mentioned by Paget,* 
in which Mr. Martineau removed an enchondroma from the radius of a boy 
whose father had a similar growth on the pelvis, was of this kind. 
Fig. 2090. 
Enchondroma of the fingers. 
Fig. 2091. 
Enchondroma arising from the ribs. 
* Paget’s Surgical Pathology, page 459. ENCHONDROMA TA. 
609 
In structure enchondromata consist of one of three forms of cartilage,— 
hyaline, fibrous or reticular, and mucoid; or all three varieties may be 
combined in the same tumor, though the last-named is quite rare. 
The connection of enchondromata with the bones may be peripheral, be- 
tween the periosteum and the bone, or central; sometimes it is both. When 
developing in the shaft of long bones, near the middle, their origin is gen- 
erally both internal and external. When affecting the phalanges of the 
fingers, they are usually internal, the external wall of bone becoming ex- 
panded, as the tumor grows, into a thin shell, which crackles under press- 
ure. The articulating ends of the bones are for the most part exempt from 
enchondromata. 
The cell-forms which are present in enchondromata differ in number and 
in form, being numerous when the vitreous or hyaline matrix predominates, 
and fewer when the fibrillated connective tissue prevails. In form the cells 
are round, oval, oblong, fusiform, and stellate. The latter variety are denied 
a place among cell-forms by some pathologists, who look upon them as 
cavities existing in the matrix. The vessels are few in all varieties of en- 
chondromata, particularly in the hyaline. Enchondromata may embody so 
large a proportion of fibrous tissue as to resemble fibromata. 
The microscopic characters, therefore, which differentiate pathological 
from normal cartilage are the disposition in the former of the hyaline matrix 
into very delicate interlacing fibres, between which are seen the cartilage- 
cells, either scattered or grouped, a softer condition of the matrix, and the 
presence of blood-vessels. 
According to Cohnheim, the growth of enchondromata proceeds exclusively 
from certain particles of cartilage, which, like embryonic cells elsewhere, have 
not been used in the development of cartilage-tissue, but remain over. This 
Fig. 2092. 
Enchondroma (from testicle). The gradual—almost insensible—transition from ordinary fibrillated connective 
tissue, seen on the right side, into cartilage-tissue, seen on the left, is quite striking. X 300. 
theory—for it is only a theory—would exclude from all participation in the 
formation of pathological cartilage the cells of cartilages already existingiin 
definite form. The arrangement of elements in enchondromata differs according to the 
prevailing type assumed. In the hyaline variety, the cartilage-cells are 
imbedded in a finely-fibrillated matrix (Fig. 2092), so delicate, indeed, that it 
may readily be taken for a homogeneous, structureless material. 
In other cases of enchondromata the intercellular material or matrix is 
made up of fibrillar tissue so arranged as to form more or less perfect alveoli, 
610 
TUMORS. 
Fig. 2093. 
Enchondroma from the knee-joint, exhibiting the alveolated arrangement of the fibrillated matrix inclosing 
groups of cartilage-cells. X 300. 
inclosing groups of cartilage-cells (Fig. 2093), and imitating in some respects 
the interior frame-work of carcinoma. 
Fro. 2094. 
Enohondroma cartilage-cells imbedded in a fibrillated matrix o, and in a granular matrix 6. 
Enchondromata, as already stated, are usually benign, though they are 
sometimes combined with malignant neoplasms, for example, with sarcoma, 
carcinoma, or myxoma (Fig. 2095); and when generalization or secondary 
deposits are observed in cases of enchondromata, the baneful effects must be 
charged, not to the cartilage element of the growth, but to some other neo- ENCHONDROMA TA. 
611 
plasm with which it is associated, and which has established its residence in 
the former. 
The degenerative or retrograde changes which sometimes overtake en- 
Fig. 2095. 
Myxomatous enchondroma from thyroid body. The myxomatous and cartilaginous elements are mingled together, 
and in the left upper corner a plexus of capillary vessels is seen. X 300. 
chondromata are the mucoid, the fatty, and the cystic, and they are occa- 
sionally subject to calcification or ossification. These changes explain the 
occasional appearance of large cavities filled with yellow, gelatinous, colloid- 
looking materials, and also of the white, cretaceous masses into which the 
tumor is sometimes partially transformed. 
Diagnosis.—The diagnosis of enchondromatous tumors is not generally 
a matter of difficulty. Their hard, slightly-compressible feel, their knobbed 
or irregular surface, their painless progress, and, usually, their connection 
with cartilage or bone, serve to indicate their true character. 
Prognosis.—The combinations and degenerations met with in enchondro- 
mata will suggest the wisdom of giving a very guarded prognosis, as some 
of these neoplasms which wear a very harmless exterior often conceal a 
deadly foe. 
Treatment.—Enchondromata may cease to grow with the completion of 
the skeleton, or when the epiphyses and diaphysesof the bone become solidly 
united by osseous material. The possibility of this will suggest the pro- 
priety of not being too precipitate in surgical interference as long as the 
growth exhibits a tendency to follow a chronic or slow course. The same rule 
should be observed when cartilage-growths occupy the fingers : it is better 
to leave them undisturbed so long as there is no interference with the move- 
ments of the digits. When, on the other hand, the tumor progresses rapidly, 
it should be removed, when this is feasible. Operations for this purpose must 
necessarily differ according to the location and duration of the disease. An 
enchondroma which occupies the surface of a bone, after having been un- 
covered, can, in its early stage, sometimes be cut away with the saw or chisel 
without sacrificing the bone on which it rests. In most cases, however, these 
tumors are so incorporated with the deep portions of the bones in which they 612 
TUMORS. 
develop that the removal of the latter along with the growth becomes neces- 
sary. An enchondroma of the femur may have been allowed to attain such 
magnitude before application is made for surgical advice that nothing will 
meet the demands of the case short of the extirpation of the limb at the 
coxo-femoral articulation. Yery large enchondromata growing from the bones 
of the pelvis should be left without interference. 
Osteomata. 
Osteomata, commonly described as exostoses, are masses of bone or out- 
growths from different portions of the skeleton. These tumors belong to early 
life, and are sometimes congenital. Though they may appear in almost every 
hone, they have an evident predilection for certain parts of the skeleton, 
as the femur, the maxillfe, the cranium, the orbit, the cementum of the teeth, 
the ulna, and the last phalanx of the great toe. In rare instances an osteoma 
may arise in the soft parts. These tumors agree in structure and chemical 
composition with either the compact or the spongy tissue of normal bone. 
Bony masses which occur in other tumors, even in those most closely allied 
to osseous tissue, as enchondromata, are not included among osteomata, being 
secondary or accidental productions, belonging to the retrograde metamor- 
phosis of neoplastic life. Osseous nodules are met with in the ovary, testicle, 
lung, and several other internal organs. Masses of osseous tissue are found 
in various parts of the body where fibrous tissue exists. The ligaments of 
the spine occasionally undergo this metamorphosis, as well as the cartilages 
of the ribs, of the larynx, and of the trachea, the bronchi, and sometimes 
the tendinous insertions of muscles. These changes, however, represent a 
calcification rather than an ossification. 
Similar transformations are seen to occur in the sclerotic and choroid 
tunics of the eye, in the pericardium, in the heart, and in the membranes of the 
brain. Some of these transformations are purely senile, as the calcification of 
the cartilages of the larynx and of the ribs; others, as those which occur in 
the cartilages and in the folds of the synovial membrane of the joints, arise 
from rheumatoid disease; and others, again, from long-continued irritation, 
as may be seen in the bony plates, referred to by Rokitansky, which form in 
the biceps muscle of the soldier from the effects of the rifle-drill, or in the 
adductor muscles of the cavalryman from the pressure on the saddle by 
the thighs. 
All those accumulations of redundant callus, which are produced by in- 
flammation, and sometimes acquire considerable bulk, but which are unstable 
in their duration, disappearing almost entirely with the subsidence of the 
irritation that called them into existence, are very properly excluded from 
osteomata. 
Osteomata very often are multiple, and appear on different bones of the 
skeleton, indicating thereby the presence of some general cause or diathesis 
determining their formation. These growths, when connected with bone 
(exostoses), are not always limited to the periosteal surface, but may occur 
within the bone, or in the medullary cavity (enostoses). 
In form, bone tumors are not uniform, being sometimes lobulated, some- 
times spherical, and at other times spinous or spiculated. Their attachments 
may be either pedunculated or sessile. Though generally benign in their 
character, osteomata are occasionally combined with sarcoma (osteo-sarcoma). 
Osteomata are, with few exceptions, of slow growth, and vary from the 
size of a grain of coffee to that of a cocoanut. Except when the tumor attains 
considerable magnitude, little inconvenience is experienced by the patient, 
and when disability or pain occurs it is generally to be attributed to interfer- 
ence with the movements of tendons or to pressure on adjacent nerves. Yery 
often the increase of an osteoma ceases when the skeleton has attained its 
full growth. In dissecting-rooms it is quite common to see on the bones 
of old persons outgrowths of this nature, which evidently had remained OSTEOMATA. 
613 
stationary after reaching a certain size, and had in no way been inconsistent 
with perfect health. 
In some instances exostoses appear to arise from a law of necessity. Thus, 
I have seen a bony arch thrown over a blood-vessel to protect it from the 
pressure of a tendon which had been thrown out of its place by an acquired 
deformity in the limb. 
Three varieties of osteoma are recognized,—namely, 1, the eburnated, or 
ivory-like (osteoma eburnatum); 2, the compact, or hard (osteoma dura); and, 
3, the spongy (osteoma spongiosum). 
1. Eburnated osteoma.—The chief physical property of this tumor is its 
great hardness or density, the result of the large amount of lime-salts, princi- 
pally phosphates and carbonates, Avhich enter in to its composition. It is made 
up wholly of compact bone, and is without blood-vessels. The lamellae of these 
tumors are arranged concentrically and parallel with their surface, and the 
canaliculi of the bone-corpuscles run towards the periphery of the tumor. 
These growths are round or hemispherical, and their surface is smooth or 
slightly tuberculated. They form on either table of the bones of the head, 
on the bones of the face, on the cementum of the teeth (odontomata), on 
the scapulae, pelvis, and great toe, and they rarely exceed in size the bulk 
of a hickory-nut or a walnut. 
2. Compact or hard osteoma.—This variety of osteoma in density of struc- 
ture occupies a position between the ivory and spongy forms of osseous neo- 
plasms, corresponding in many respects to the tissue seen in the diaphyses of 
bones, exhibiting the same concentrig disposition of the lamellae around the 
Haversian canals, and the same lacunae with the canaliculi, differing only in 
the minute structure from the bone-corpuscles of normal osseous tissue (in 
which the canals of Havers are parallel) by running in different directions. 
(Fig. 2096.) I am disposed to believe that not unfrequently this variety of 
Fig. 2096. 
Osteoma from the femur. The varying directions of the canals of Havers are seen. X 200. 
osteoma is an early stage of‘ the eburnated form, which, by a new disposi- 
tion of bone-salts, gradually undergoes solidification until at length it attains 
to the extreme hardness of ivory, and consequently the obliteration of blood- 614 
TUMORS. 
vessels. The structural unity of osteomata arising from the epiphyses of 
bones, from the cranium or elsewhere, though apparently real, when sub- 
jected to a critical examination by a section carried through both will be 
found to be distinct, the Haversian canals being perpendicular in the new 
and horizontal in the old bone. These exostoses, especially when located 
on the bones of the cranium, have in many instances a syphilitic origin. 
3. Spongy osteomata in almost all cases are confined either to or near to (Fig. 
2097) the epiphyses of the long bones, and occur in young persons. They 
Fig. 2097. 
Spongy osteoma from the ulna of a young girl. Structure shown in the section. 
are sometimes connected with the bones by a broad base, and they are 
often pedunculated. They are round, angular, or stalactite-like in form, and 
have an irregular or knotty surface. Commencing in the cartilage of the 
epiphyses, these tumors are not only invested with a capsule of hyaline car- 
tilage, but at first are loosely attached to the bone, and consequently mova- 
ble, becoming after a time more fixed as the growth is unified with the can- 
cellated tissue of the epiphyses. These tumors belong to the ossifying 
enchondromata of Virchow. 
Diagnosis.—The extreme hardness of osteomata and their very firm con- 
nection with the bone on which or in which they grow render it almost 
impossible to mistake their true nature. 
Prognosis.—Osteomata seldom endanger life, as they are slow of growth 
and benign in character, and rarely attain to any great magnitude, besides 
which they have a tendency to become stationary with the perfection of the 
skeleton. 
Treatment.—Prom what has been said it will be inferred that the neces- 
sity for operative interference in cases of osteoma does not often arise; 
indeed, operations for removal are dangerous when these tumors are epi- 
physeal, as the joint is liable to be opened. When burs® exist over these 
growths, they are believed in many cases to communicate with the synovial 
membrane of the articulation, and consequently to add to the risks of oper- 
ation. Twice have I seen death from pyiemia follow the extirpation of small 
osteomata. It may be accepted, then, as sound surgical practice that, unless 
serious disability exists or is likely to occur from the presence of bony 
tumors, it is best to refrain from any operative measures. Instances are on 
record where large osteomata have undergone a spontaneous cure, either by 
sloughing or by being attacked with caries. Examples of both have been 
given by Paget.* 
When an operation becomes necessary, the tumor should be uncovered and 
detached at its base by the saw. Even when pedunculated, and when a 
portion of the stump is left, the base shows no disposition to grow. 
* Paget’s Surgical Pathology, p. 478. SOFT LYMPHOMA. 
615 
Lymphoma. 
A tumor designated by the term lymphoma occupies a somewhat uncertain 
position in neoplastic literature. By some writers these new formations are 
considered only in the light of an idiopathic hyperplasia of pre-existing 
gland-tissue, while others would not restrict the pathology of the growth 
within such narrow limits, but include in the term changes that obviously are 
of an inflammatory character. There are, however, certain differences be- 
tween the two processes and their results, to which reference will be made, 
that require a distinction to be maintained between glandular hypertrophies 
having an idiopathic and those having an inflammatory, strumous, or tuber- 
cular origin. When occurring in young adults of good constitutions, with few 
exceptions, the tumors possess little sensibility, and are free from any signs 
of inflammation. Lymphoma exhibits a preference for the glands of the 
axillfe, neck, mediastina, and groins. In the cervical region the glands of one 
or both sides may be attacked at the same time, those of other regions par- 
ticipating at a later period in the disease. In a who was under my 
professional care, the glandular involvement began in the neck, first on one 
side and shortly after on the opposite side, followed in the course of a few 
months by enlargement of the glands of the axillae, and a little later of those 
of the inguinal region ; finally the mediastinal glands became implicated, as 
was shown by the occurrence of dyspnoea, which continued until her death. 
Lymphoma appears under two varieties, the soft and the hard. 
Soft Lymphoma.—In this neoplasm all the cells of the lymph-gland are 
Fig. 2098. 
Soft lymphoma. The cut exhibits the structure of an enlarged cervical lymph-gland, one of a number which 
were present on the right side of the neck. On the right side are seen connective-tissue trabeculae, with the lymph- 
path outlined; on the left side, an artery divided longitudinally for some distance, and also transversely; and to the 
right of this, near the upper border, appears a capillary, cur transversely, and its lumen filled with blood-corpuscles. 
greatly increased in number and in size, whilst the connective-tissue frame- 
work of the follicles disappears in a great measure, leaving only a delicate 616 
TUMORS. 
stroma, or reticulum. (Fig. 2098.) The blood-vessels which accompany the 
latter have their walls abnormally thickened. 
In comparing lymphoma either with leukaemic hypertrophy (Fig. 2099) or 
with normal lymph-gland tissue, very little, if any, difference will be seen to 
Fig. 2099. 
Leuksemio lymph-gland. Structure answering to normal lymph-gland tissue. Lymph-spaces along the trabecul® 
have been readily freed of their lymphoid cells by brushing. 
exist, except in the amount of connective tissue, which is more abundant in 
the latter, and in the facility with which the tymphoid cells can be brushed 
out from the lymph-spaces, which is not the case in preparations made from 
lymphomatous glands. 
Hard Lymphoma.—The characters which distinguish hai’d lymphoma from 
the soft variety are the preponderance in the former of connective tissue, 
and diminished number of lymphoid cells. The trabeculae have a somewhat 
alveolated disposition. (Fig. 2100.) The increased firmness of the tumor, 
its slower growth, and its benign character constitute the leading clinical 
characters of the neoplasm. 
In lymphoma the affected glands preserve their lenticular or kidney shape, 
and can be distinguished as separate bodies, never becoming fused into a 
mass of indistinguishable parts. Nor do the tumors, even when acquiring 
considerable bulk, become adherent to the sin-rounding parts by inflamma- 
tory adhesions: they can be moved about freely in the subcutaneous tissue 
without causing the least pain. Their consistence depends upon whether 
the tumor is soft or hard, being slightly elastic in the former and more firm 
or less compressible in the latter. 
There is greater rapidity of growth in the soft than in the hard neoplasm. 
The soft lymphoma is, moreover, prone to become associated with a sar- 
comatous element, in which case the tumor will become generalized by 
secondary deposits in the various internal organs, as the lungs, liver, kidney, HARD LYMPHOMA. 
617 
brain, and mediastinal, post-peritoneal, and intestinal glands (sometimes even 
in the bones), which profoundly affect the functions of those organs, and 
Fig. 2100. 
Hard lymphoma. Alveolated arrangement of the trabecula;, with inclosed lymph-cells. At the left-hand lower 
corner a vessel is cut across. 
soon cause death from exhaustion. It is scarcely possible to mistake the 
period when the disease ceases to be local; the disordered nutrition, loss of 
flesh, increasing anaemia, and dyspnoea all certify to constitutional infection. 
Whether the leucocythaemia which often accompanies lymphoma is due to 
the morbid changes in the affected lymph-glands has not been determined: so 
radical are the pathological alterations wrought by the disease in the impli- 
cated glands that it is scarcely probable that the physiological functions of 
the latter can be, under the morbid alterations existing, carried on to any 
considerable extent. 
The diagnosis of lymphoma from inflammatory, tubercular, or strumous 
hypertrophies of these organs must be based on the following consider- 
ations : 
First, lymphoma occurs in young adults of good constitution, affecting 
usually a whole chain of glands of a limited area of one side of the body. 
Second, lymphoma shows no tendency towards suppuration or caseous 
change, the tumors being free from any inflammatory symptoms. 
Third, the disease is limited within the wall of connective tissue which 
encapsulates the affected glands, and is without any tendency to excite in- 
flammation in the surrounding tissues. 
Fourth, lymphoma may be complicated by sarcoma, or undergo sarcoma- 
tous change; in such case, as a rule, affecting only one single gland, and 
possessing a tendency to generalization, or to the establishing of secondary 
deposits in internal organs. 
Prognosis.—A lymphoma, under any circumstances, gives just cause for 
apprehension. It is a dangerous tumor, and notably so when the growth of 618 
TUMORS. 
the neoplasm is rapid, when the disease exhibits a tendenc}7 to attack several 
glands, and when the patient is under twenty years of age. 
Whenever the signs of constitutional contamination appear, the case is as 
hopeless as one of general carcinoma. 
Treatment.—The remedies which appear to exert some controlling power 
over lymphoma are iodine, arsenic, and iodoform. The first two are em- 
ployed both internally and externally. From eight to twelve drops of the 
compound solution of iodine, or from three to twelve drops of Fowler’s 
solution of arsenic, may be administered three times a day, one hour after 
meals. The topical application of these remedies is made by injection. Ten 
minims of the tincture of iodine, or three drops of Fowler’s solution of 
arsenic, introduced into the parenchyma of the gland, the former every third 
day and the latter every day, can be used with a prospect of effecting some 
benefit. All frictions of the diseased glands are positively injurious. I 
have seen violent inflammation created by the practice. In my own hands 
the employment of iodoform and iron has been followed by good results. 
(Iodoform, gr. ii-iij, ferri redacti, gr. i, exhibited in pill-form, three times 
daily.) 
The use of the knife for the extirpation of lymphomatous glands has 
usually been attended by results so unsatisfactory that it can only be safely 
recommended in cases where it is necessary to relieve pressure which 
threatens the safety of the patient, or possibly when the disease is confined 
to a single group of glands, is actively growing, but perfectly movable, and 
free from adhesion to the skin. Under any circumstances, however, recur- 
rence may be anticipated. 
Lymphangiomata. 
Lymphangioma is a congenital, rarely an acquired, tumor or swelling, con- 
sisting of a net-work of delicate lymph-vessels and lymph-spaces. Wegner* 
makes three varieties of this neoplasm,—the simple, the cavernous, and the 
cystic. 
The simple form of the disease consists of an intricate net-work of delicate 
lymph-vessels, supported by connective tissue. 
The cavernous variety is made up of elements resembling in their arrange- 
ment the cavernous or spongy portions of the penis ; that is, of communi- 
cating meshes or compartments, bounded by trabeculae of fibrous tissue lined 
by an epithelium and filled with lymph. 
The cystic lymphangioma is a transformation from the cavernous, in which 
the connections between one or more of the compartments become closed, and 
the spaces are distended or developed into a cyst-cavity containing liquid 
and coagulated lymph. 
formations are met with in different localities of the 
body, the most common being the neck, posterior part of the thigh, nates 
(see Fig. 1313, vol. ii. page 525), axillae, groin, penis, tongue, cheeks, and lips. 
It also occurs in certain internal organs, as the liver and the kidney. 
The simple and cavernous varieties occur generally in the tongue (macro- 
glossia), lips (macrochilia), and cheeks (macromelia). When the tongue is the 
seat of the disease the organ is enlarged, may protrude from the mouth, is 
quite firm or semi-elastic to the feel, and presents on its under surface rows of 
thick vesicles separated by constrictions, giving a beaded appearance, due to 
the dilated lymph-vessels and spaces. A section of this tumor presents an 
excellent portrait of the interior of the cavernous bodies of the penis. 
When lymphangiomatous neoplasms appear on the cutaneous surface of 
the body the tumor varies from the size of a cherry to that of a foetal head. 
Reichel and Gjorgjewic record the case of a child, a year and a half old, who 
had a congenital growth of the kind which occupied the perineum, and which 
attained the bulk of an infant’s head. When examined, this tumor was found 
to consist of skin, masses of fat, and connective tissue, the latter being dilated 
* Archiv fur Klinische Chirurgie, 1877. MYXOMA TA. 
619 
into numerous cysts or lymph-cavities. In another case, that of Hecker, the 
growth weighed thirty-two pounds. 
The lymphangiomatous tongue has been seen connected with congenital 
cystic hygroma on the front of the neck, the communication between the two 
growths taking place between the muscles of the neck. Some of the German 
writers, as Billroth, Koster, Klebs, and others, regard all congenital cystic 
hygromas of the cervical region, whether front or back, as cavernous lymph- 
angiomas. These new formations on the neck are spherical or bilobed tumors, 
their surface being somewhat rugose, and beneath the overlying skin having 
numerous communicating cysts formed by dilatation of the connective-tissue 
meshes or lymph-spaces, and lined by lymphatic endothelium. To the touch 
sometimes the tumor feels like a series of tangled cords. 
The diagnosis of these neoplasms cannot always be determined by external 
appearances. The soft, doughy, or spongy feel and painless character of a 
lymphangioma may be interpreted as indicating a lipoma, a myxoma, or an 
angeioma,—the latter more especially when the neoplasm admits of being 
emptied to some extent by pressure and again refills, as is sometimes the 
case,—or if the cystic feature is prominent the growth may be mistaken for 
a chronic abscess. The use of the exploring-needle, however, will establish 
the true nature of the tumor by disclosing the presence of a clear fluid, rich 
in saline and albuminous matters. 
Lymphangioma is a benign tumor, never exhibiting any tendency either 
to be transformed into other growths or to undergo retrograde changes. 
Treatment.—The different plans of treatment for the cure of lymphangio- 
matous tumors are by puncture, with and without injection, by excision, and 
by ligature of large arterial vessels; rarely by amputation. Puncture and 
injection with tincture of iodine in small cystoid forms of the disease should 
precede the use of the knife. When excision is practiced, it will often be 
found necessary to tie many vessels, especially veins. 
Myxorryi is the name given by Virchow to a tumor consisting largely of 
mucous tissue. This substance exists normally in certain parts of the foetus, 
as in the subcutaneous tissue and in the umbilical cord. 
In the adult the vitreous humor constitutes the nearest approach to mucous 
tissue. 
These neoplasms correspond to the eellulo;fibrous, soft, or elastic tumors of 
the English,* or the connective-tissue tumorsf and the gelatinous sarcomaj 
of the Germans. 
Myxomata, when laid open, exhibit a yellow or a gray color, with a faint 
tinge of red, presenting a trembling gelatinous mass. 
The anatomical elements of this neoplasm are an intercellular, homogene- 
ous, partially liquid matrix, in which are imbedded cells of different forms,— 
round, spindle-shaped, and sometimes stellate,—their branches joining, and, 
together with a few intersecting threads or bands of connective tissue, ac- 
companied by straggling blood-vessels, giving a somewhat reticulated appear- 
ance to the neoplasm. (Fig. 2101.) The prevailing form of the cell-elements 
in these growths is determined to some extent by the age of the neoplasm, 
being round or irregular in its recent stage, and becoming more elongated or 
radiated as the tumor grows older. 
In chemical composition myxomata yield both mucine and albuminous 
material. 
Myxomata occur in the connective tissue underlying the skin, or in that 
connecting the fibres of muscles, also in conjugate tissue of internal organs. 
The favorite sites for these tumors are the back, thighs, lips, cheeks, labia, 
Myxomata. 
* Medical Gazette, vol. xxi.; also Paget’s Surgical Pathology, 
f Muller on Carcinoma. 
j Rokitansky’s Pathological Anatomy, vol. i. p. 336. 620 
TUMORS. 
clitoris, prepuce, scrotum, axillae, nerve-sheaths, the medullary tissue of 
bones, the nose, the ear, the uterus, the mammary gland, the parotid gland, 
Fig. 2101. 
Myxoma from the peritoneum, exhibiting the various forms of cells, many with their branches or processes,and 
all lying in the mucous matrix, which is represented by a granular appearance of the background. A few bands 
of fibrous tissue are also seen, and a blood-vessel containing a small number of blood-corpuscles. X 300. 
the peritoneum, etc. The soft, gelatinoid polypi constitute good examples 
of myxomata. 
The vitality of myxomata is quite low; possessing, as they do, but few 
blood-vessels, their growth is influenced much by the prevailing cell-elements, 
being usually slow when these are spindle-shaped or stellate, and more rapid 
when they are round or embryonic. 
Myxomata usually do not grow to any great size. In one instance I re- 
moved a typical tumor of this kind, the size of a hen’s egg, from the midst 
of the muscles of the forearm of a young woman. These growths in certain 
localities, as in the nasal fossse, frequently enlarge and after a time diminish 
in size, owing to oedematous infiltration and subsequent exosmosis. A few 
examples have been recorded in which tumors of the above class have grown 
to the size of the head, and in one case, that of M. Lesauvage, weighing over 
forty pounds. 
Myxomata have a soft, elastic, fluctuating consistence, and a roundish or a 
tabulated form. In some of their physical aspects they simulate adipose 
tumors, fluctuating on palpation, and wrinkling on being compressed. When 
seated on the lips, in the nasal cavities, or in any accessible part of a mu- 
cous membrane, a diagnosis is not difficult, as the translucency of the slimy 
contents of the tumor may be detected through its covering or capsule. 
When any doubt remains as to the diagnosis, it will be solved by the use of 
the grooved needle. 
Myxoma occurs both in foetal life and in adults. 
When essentially made up of mucous tissue, myxomata are benign tumors, 
and if carefully removed do not recur. In two instances in which I excised 
these growths from the lower lip there was a return, but, as they did not 
recur after a second operation, I was disposed to believe that some of the 
growth had escaped the knife. When reappearing after careful extirpation, ANGEIOMATA. 
621 
it will be found that the growth is associated with another, probably a sar- 
comatous, element. 
Myxoma is frequently found mingled with other neoplasms, as sarcoma, 
enchondroma (see Fig. 2095), fibroma, and lipoma. These combinations may 
be the result of a simultaneous development of neoplasms of different physi- 
ological derivatives, or they may be only one of the metamorphoses of pre- 
existing tumors which contain elementary fibrous tissue. 
The degenerations which sometimes overtake myxomata are the fibrous, 
by hyperplasia of the connective-tissue element; lipomatous, from infiltration 
of the cells with fat; and telangiectasis, by new formation of vessels. 
Treatment.—Extirpation alone constitutes the proper treatment in cases 
of myxomata, no local or constitutional remedies having any curative influence 
whatever. 
Angeiomata. 
An angeioma is a tumor composed of hlood-vessels supported by con- 
nective tissue, and is known under various names, as erectile tissue, mother’s 
mark, naevus maternus, aneurism by anastomosis (J. Bell), telangiectasis (of 
the Germans). (See vol. i. page 506, Diseases of the Blood-Vessels, where 
angeioma is treated of at length.) The subjoined cut (Fig. 2102), taken from 
Fig. 2102. 
Angeioma from the tongue, exhibiting muscular fibres and a cavernous tissue with oblong cavities, bounded by 
connective-tissue trabeculae. Blood-corpuscles are also seen massed together in some of the spaces. 
a cavernous angeioma of the tongue of a young lad, which I removed while 
these pages were passing through the press, furnishes a good illustration of 
the microscopic appearance of this form of neoplasm. 622 
TUMORS. 
Neuromata. 
Strictly speaking, a true neuroma is a tumor composed of a new formation 
of nerve-elements. The term, however, has been used in a broad sense, and 
was applied by Odier, of Geneva, to all tumors met with on nerves. The 
latter are now designated as false neuromata. 
There are two varieties of true neuroma, ordinarily recognized by writers 
as the myelinic and the amyelinic of Virchow, the former consisting of medul- 
lated nerve-fibres, or nerves of double contour, and the latter of non-medul- 
lated fibres, or fibres of Bemak. 
The clinical distinction between the two is not an easy matter. Only by 
the microscope can their anatomical elements be properly distinguished, and 
both may exist in the same tumor. 
Ganglionic neuromas are also included among those new formations, com- 
posed of ganglionic cells, neuroglia, and blood-vessels. They possess com- 
paratively little interest for the surgeon, being rare and located in the brain 
or spinal marrow, sites entirely inaccessible to operative measures. They 
have been met with also in dermoid cysts. 
The painful neuroma, or subcutaneous tubercle, first described by Mr. 
Wood, has also been improperly classed among nerve-tumors. 
Neuromata occur either in the course of a nerve-trunk or at its cut 
extremity, as is often observed after amputation. 
The tumor described by Verneuil as plexiform cylindrical neuroma, though 
properly speaking not a neuroma, as it does not contain a new formation 
of nerve-fibrils, may, without doing any violence to surgical nomenclature, 
be accepted as a nerve-tumor (a fibroma), consisting as it does of a great in- 
crease of intertubular connective tissue, by which the nerve is increased in 
size, and is composed of twisted or convoluted cords, with sacculated-looking 
enlargements resembling in many respects the lobules of a gland. (Fig. 
2103.) This tumor, which is quite rare, and, so far as has been observed, 
Fig. 2103. 
Plexiform neuroma. 
always congenital, is peripheral, occurring in the subcutaneous connective 
tissue, especially in the region of the neck or near the orbit of the ejTe, 
and, except on rude pressure, is not painful. The overlying skin is also 
somewhat thickened and indurated. 
The medullated myelinic or true neuroma is composed of a new forma- 
tion of nerve-elements. (Fig. 2104.) In addition to the nervous matter 
which forms the major part of a medullated neuroma, there is a consider- 
able amount of wavy connective tissue, which runs in bands or trabeculae 
through the growth, forming alveoli, and inclosing two or more bundles of 
nerve-tubes, each bundle being surrounded by fibrillated connective tissue. 
In the non-medullated or amyelinic neuroma, double-contour or time med- 
ullary fibres are either entirely absent or are present only to a very limited 
extent, the tumor resembling a fibroma and consisting chiefly of fibres of NEUROMATA. 
623 
Fig. 2104. 
Medullated neuroma from the extremity of the sciatic nerve in a stump after amputation of the thigh. The 
nerve-fibres are seen in great numbers, or in bundles, some cut longitudinally and some transversely, and supported 
by connective tissue. X 300. 
Fig. 2105. 
Non-medullated neuroma; the tumor consisting almost wholly of non-medullated 
nerve-fibres; the latter are seen in both transverse and longitudinal section. Inter- 
stitial connective tissue very scanty, and seen most distinctly among the bundles 
of transversely-cut fibres. 624 
TUMORS. 
Remak, with their lateral nuelei. These growths often are multiple. Ben- 
nett refers to pathological specimens in which almost every nerve of the 
body had swellings, which were in all probability false neuromata; and 
Smith mentions cases in which as many as eight and even ten thousand 
similar growths had been counted in one person. The amyelinic form of 
neuroma corresponds in its elements to Duhring’s neuroma cutis (Fig. 2105), 
or nerve-tumor of the skin. 
The painful subcutaneous tubercle lies immediately beneath the skin, is 
rarely larger than the size of a pea. is exceedingly pain- 
ful to the touch, and, though it contains no demon- 
strated nerve-elements, being composed only of fat 
and connective tissue (Fig. 2106), it undoubtedly has 
some relation to adjacent nerves, or it may be that 
some of the supposed connective-tissue fibres are 
amyelinic nerve-fibres. Women are generally the 
subjects of this tumor. 
Neuromatous tumors vary little in shape, being 
spherical, ovoidal, oblong, or bulbous, as when seated 
on the cut end of a nerve in a stump. They admit 
only of lateral movements or of those made trans- 
versely to the course of the nerve. The superin- 
cumbent skin is little, if any, changed in appearance 
from the adjacent integument. In consistence these 
tumors are usually firm to the touch, are extremely 
sensitive to pressure, and increase with little rapidity. 
I removed from the arm of an aged woman a false 
neuroma which had developed in the median nerve 
and grown to the size of a hen’s egg. Smith, of 
Dublin, excised from the sciatic nerve of a man a neuroma measuring ten 
by eleven inches. 
Multiple neuromata are attended with very much less pain than is present 
when the tumor is solitary; indeed, when numerous, the growths may create 
no pain whatever. The pain of neuroma arises at different times: at first fre- 
quently only paroxysmal, it becomes after a time almost constant, with exacer- 
bations of violent, often almost unendurable, suffering, the attacks being pro- 
voked by accidental pressure of the growth, by excitement, both physical and 
mental, even by a draught of cold air passing over the affected part, or from 
atmospheric changes. On these occasions and at other times the pain shoots 
with sudden and startling severity, sometimes upward, as when the neuroma 
is found at the cut end of a nerve, or downward, or in both directions, when 
the new formation has arisen independent of a traumatic origin. The reflex 
spasms which are often caused by neuromata are pai’ticularly distressing in 
consequence of the constant twitching or jumping of the affected muscles. 
Among the evil effects which sometimes follow neuromata are epilepsy and 
paralysis. 
Neuromata have both an idiopathic and a traumatic origin. The latter 
generally belong to the false or those of fibrous character. They may also 
be hereditary. 
Though it is thought that neuromata are most common in males, yet in 
my own experience the idiopathic variety has been met with almost ex- 
clusively in females. They are rarely seen before the middle period of life. 
The suffering which accompanies the examination of a neuroma can be 
materially lessened by adopting the plan proposed by Brown-Sequard, of 
compressing at the time the nerve-trunlc above the tumor between the 
thumb and finger. 
Neuromata are benign tumors, but are sometimes associated with myxoma 
and glioma. They may undergo mucoid softening, and thus closely simulate 
cystic degeneration. 
Treatment.—Constitutional remedies have no curative power whatever 
Fig. 2106. 
Structure of subcutaneous 
painful tubercle. PAPILLOMA. 
625 
over neuromata. The severity of the pain can be lessened by the local 
application of veratria ointment or the tincture of aconite, and it may be 
necessary during the paroxysms of suffering to employ morphia hypodermi- 
cally or by the mouth. 
Excision alone promises permanent relief. When the tumor involves the 
trunk of a nerve, being so mingled with the elements of the latter as to pre- 
clude enucleation, the diseased portion of the cord must be cut away ; and, 
as paralysis must follow this operation in all parts to 
which the ultimate distributions of the divided nerve 
extend, the ends of the latter, when feasible, should be 
united by suture, in order to establish at the earliest 
period the line of communication between the centre and 
the periphery. 
When, as in fibroma or amyelinic neuroma, the growth 
in developing simply spreads the nerve-fibres over its sur- 
face (Fig. 2107), the neoplasm can generally be separated 
by careful dissection or by a kind of enucleation from the 
nerve without seriously interfering either with the struc- 
ture or the function of the latter. 
Plexiform neuroma must be treated by excision, and in 
like manner the painful subcutaneous tubercle, observing 
to include in the extirpation the overlying integument. 
In cases of multiple neuromata, when the tumors are 
very numerous, no surgical interference is desirable; but 
when they are few in number, and some of them are be- 
coming painful, those from which the patient suffers most 
may be excised. 
In neuroma cutis the principal trunks related to the growths have been 
excised with some degree of relief, but with little permanent benefit. Our 
chief reliance in cases of the above character must be upon morphia, given 
in doses to render the suffering at least tolerable. 
Fig. 2107. 
A leash of nerve-fibres 
covering a fibroma. 
Papilloma. 
Cutaneous and mucous membranes are constituted essentially of the same 
histological elements,—that is to say, of papillae or villi, containing vessels, 
nerves, and connective tissue, clothed with epithelium. All papillomata, 
therefore, have their physiological derivatives in these bodies. They are di- 
vided into hard and soft papillomata, a division based on the physical property 
of density or firmness, or, what may be regarded as of more scientific impor- 
tance, on the preponderance of the epithelial or the vascular and connective- 
tissue components of the tumor. Thus, in the hard variety the epithelial 
elements prevail, while in the soft neoplasm the connective and vascular pre- 
dominate. 
Hard Papillomata consist of epithelial hypertroph}r, and include warts, 
corns, horns, thickened nail-tissue, and cutaneous scales. They occur on the 
hands, feet, face, head, the genital organs, and other parts of the skin. These 
growths have been considered in the chapter on Diseases of the Skin and 
its Appendages. 
Soft Papillomata.—Neoplasms belonging to this variety are the products of 
mucous membranes, and are found in the mouth, larynx, pharynx, nose, blad- 
der, vagina, uterus, large intestine, female urethra, inner surface of the eye- 
lids, and, indeed, on any part of a mucous membrane. In venereal conditions 
of the system they are frequently met with in the vulva and vagina, on the 
glans penis and prepuce, at the verge of the anus, and on the perineum. 
Papillary growths are not entirely peculiar to the skin and mucous mem- 626 
TUMORS. 
Fig. 2108. 
Hard papilloma from a wart on the prepuce, exhibiting the fungous, dendritic, or coral-like appearance. 
Low magnifying power. 
Fig. 2109. 
A bud from one of the vegetations represented in the preceding figure, seen under a high power, exhibiting 
the central papilla, with its secondary outgrowths, eminences, its connective tissue, and the investing cells obloDg, 
cylindrical, and finally flattened at the surface. SOFT PAPILLOMATA. 
627 
branes. They are occasionally seen on the serous and synovial membranes, 
as the arachnoid of the brain, and in the joints. The Pacchionian bodies are 
regarded by Luschka as papillomata. 
Papillary neoplasms appear both in the form of solitary and multiple eleva- 
tions, and are therefore simple and compound. The latter form prevails in most 
instances, and arises from hypertrophy, multiplication, or budding of the pa- 
pillae, forming sometimes lengthy and distinct processes, giving a brush-like 
surface to the tumor, as a wart, or by numerous branches, or vegetations of 
varying size, constituting a dendritic, cauliflower, or coral-like mass. (Fig. 
2108.) The different forms observed are the result of a new formation of blood- 
vessel loops. The study of one of these papillary buds will explain the others, 
as the secondary and tertiary outgrowths are only repetitions of the same ele- 
ments. The skeleton of the papilla is a minute eminence composed of loops 
of blood-vessels, with a certain amount of supporting connective tissue, and 
defined by a limiting or basement membrane, on the surface of which rest layers 
of epithelium of different forms, corresponding to those which normally belong 
to the part, the deepest cells being round, and becoming more flattened as they 
approach the surface. (Fig. 2109.) Sometimes the vegetations, however numer- 
Fig. 2110. 
Soft papilloma from the female bladder. Low magnifying power. 
ous, are all inclosed in unbroken layers of epithelium, so that the surface 
of the growth exhibits no irregularities, villi, or branches. In certain situa- 628 
TUMORS. 
tions, as on the interior of the bladder, the nature of the tumor may be 
entirely masked by a calcareous incrustation deposited from the salts of the 
urine. Such an investment in a papilloma of the bladder in one instance 
led me to diagnose a vesical calculus, from the sound communicated through 
the exploratory instrument. The deception was still more complete when, 
by introducing a finger into the bladder of the lady, the hard exterior of the 
mass could be distinctly felt, and not until the saline crust gave way was the 
true nature of the neoplasm recognized. There is a marked difference in 
different cases of papilloma in the amount of epithelium present, it being 
sometimes very scanty, leaving the papillary eminences almost naked, and 
in other instances forming a deep layer composed of numerous laminae. The 
same may be said of the amount of connective tissue in the papillae, it being in 
some cases very scanty and not developed beyond the embryonic stage, and 
in others very abundant, conditions which have much to do with the soft- 
ness (Figs. 2110, 2111) or hardness of the neoplasm. What is true of the 
connective tissue is also true, though in a less degree, of the vascular element, 
some papillomata being much richer in vessels than others. The hemor- 
rhage from these growths is sometimes very profuse, reducing greatly the 
strength of the patient. 
Fig. 2111. 
A fragment of the specimen represented in Fig. 2110. Epithelium columnar 
and forming a single layer. X^OO. 
Papillomata do not depend wholly for their existence on the presence of 
mucous papillae, as in one of the localities where these growths are often 
encountered—namely, the ventricles of the larynx—no eminences of the 
kind exist. It is possible to confound a papilloma with an epithelioma. The 
microscope will generally enable the surgeon to establish the distinction by ADENOMA. 
629 
carefully noting, in the sections subjected to examination, that the cell- 
elements which lie between the papillae in papillomata never extend deeper 
than do those belonging to the normal papillae,—that'is, only to the bases of 
the latter,—whereas the cells of epithelioma penetrate into the subcutaneous 
or the submucous tissue. Another distinction will be found to exist in the 
absence of ducts, of glands, or of anything like the alveolated arrangement 
of the frame-work of the tumor so as to inclose groups of cell-forms, as in 
epithelial carcinoma. 
Papillomata sometimes, by a fusion of their buds or vegetations, embrace 
within their structure a cystic element. (Fig. 2112.) 
Fig. 2112. 
Cystic papilloma developed on the mucous membrane of the uterus. 
Prognosis.—Though papillomata are benign growths, yet, in consequence 
of the difficulty in their complete removal, on account of the very inaccessible 
localities in which they often appear, as, for example, in the bladder, recur- 
rence often follows, and the irritation and inflammation which these neo- 
plasms produce when so situated will often destroy life. 
Treatment.—Extirpation should always be practiced whenever the 
growth is accessible. 
Adenoma. 
Adenoma is the name given by Broca to a tumor composed of glandular 
elements, a new formation or development of gland-tissue. This neoplasm 
has been described under different names. It corresponds to the glandular 630 
TUMORS. 
hypertrophy of Lebert, to the adenoid of Yelpeau, to the chronic mammary 
tumor of Cooper, and to the corps fibreux of Cruveilhier. 
As adenomatous growths occur only in connection with the different 
glands, their neoplastic classification does not differ from the anatomical one, 
—namely, into acinous or racemose, and tubular adenomata. They are met 
with in the mammary, prostate, thyroid, parotid, sudoriparous (Verneuil), 
and mucous glands; also in the mucous glands of the lips and buccal cavities, 
especially those on the inside of the cheeks and in the soft palate; also in 
the nose, vulva, vagina, uterus, female urethra, ovary, colon, rectum, etc. 
Congenital adenomata in the region of the axilla are occasionally met with 
in young women, developing at puberty, simultaneously with the mammae. 
Liicke holds the view that they originate from mammary gland-tissue mis- 
placed in embryonal life. 
Adenomata are by no means common formations, many of the tumors so 
designated from a clinical point of view having turned out to be fibromata. 
The histological elements of adenoma consist of acini, or tubes, filled with 
Fig. 2113. 
Adenoma mammae. Ducts are seen in transverse and longitudinal section, united by connective 
tissue, many of them filled by proliferating epithelium. X 300. 
columnar or flattened epithelium, resting on a basement-membrane, and united 
by a vascularized connective tissue (Fig. 2113), and differing little, if at all, TUBULAR OR FOLLICULAR ADENOMATA. 
631 
from normal gland-tissue. These tumors never become generalized, and 
consequently are benign in character. The chief inconvenience resulting 
from their presence is that arising from pressure. 
The acinous variety generally develops in the mammary gland and in the 
parotid, and when located in the former they have a firm, rather hard, 
inelastic consistence, a lobulated shape, and a light-gray or slightly yellow 
color, and are movable in the midst of the gland-tissue in which they lie in- 
trenched, surrounded by a distinct investing membrane or capsule formed at 
the expense of the connective tissue of the part. 
These tumors are generally single, seldom attain any great size, scarcely 
exceeding that of a cherry or a walnut, except when located in the breast, 
when they may become very large. 
In the mammary gland adenomata seldom appear earlier than puberty or 
later than the age of twenty-five or thirty years. They are often sensitive, 
even, painful, and are frequently associated wTith derangements of the digestive 
or the menstrual functions, the subjects being pale, thin, and easily fatigued 
by any unusual exertion. So commonly is this the case that it is not im- 
probable that the tumor is the effect of general rather than of local causes. 
In the thyroid body the appeai’ance of adenomata after fifteen years of 
age is quite uncommon; and the same may be said of similar growths in the 
mucous glands of the buccal cavities. 
Tubular or Follicular Adenomata are developed in the ducts or follicles of 
mucous and cutaneous glands. The tumors are unlike those of the acinous 
or racemose variety, being soft, frequently pedunculated, having the color of 
the membrane in which they appear, often grayish-white, translucent, and 
possessing some vascularity, the epithelium being cylindrical, or correspond- 
ing in form to that normally belonging to the locality in which they appear. 
This variety includes the soft or gelatinous polypi of the nose, though the 
latter vary in structure, sometimes containing very few, if any, gland-ele- 
ments, being made up chiefly of a delicate connective-tissue stroma filled with 
a mucous fluid and containing some cylindrical cells. In other cases these 
nasal polypi, and in many instances those adenomata which occur in the 
tubular glands of the large intestine and the uterus (uterine polypi), consist 
of a new formation of gland-tissue. 
In the formation of adenomata belonging to mucous membranes the 
normal tube-glands are materially changed from their original form. The 
accumulations of the proliferating cells press jout from the sides of the ducts 
little processes, or buds, some of which have a cylindrical and others a sac- 
culated form, and all so closely packed together as to exhibit very little in- 
terstitial or connective-tissue stroma. The cells, which quite fill the lumen 
of the ducts, though of the usual cylindrical form, are very much larger than 
those which normally belong to the gland. Under certain circumstances the 
epithelium of an adenoma which has its origin in the glands of mucous 
membranes may assume different forms: thus, an adenoma of the rectum 
(rectal polypus), as long as it remains within the bowel, will retain its cylin- 
drical epithelium ; but should it prolapse and remain for some time external 
to the lower sphincter, its epithelium will become squamous or flattened ; 
and in like manner a uterine adenoma which in the uterus is invested with 
a cylindrical epithelium will, should it protrude into the vagina, become 
covered with a pavement epithelium. Indeed, it is only necessary for an 
adenoma of any mucous cavity to protrude from its original habitat and be 
placed under conditions similar to the skin for its epithelium to be grad- 
ually transformed into that of the latter, under the operation of a law of 
necessity which prevails throughout the human organism. 
The sudoriferous glands of the axillae and the sebaceous glands may 
undergo similar changes, though growths from these sources are rarely 
encountered. 
Diagnosis.—Though it is not difficult to diagnose adenomata of mucous 632 
TUMORS. 
membranes when accessible to the eye, their nature being revealed by the 
qualities of softness and translucency, and by a gray or faintly-red color, yet 
in the acinous variety the surgeon is compelled to be reserved, as the clinical 
signs are altogether negative. It is well known that glandular enlargement 
of a part or of the whole of a gland may follow the presence of any neoplasm 
which develops in the interstitial element of its structure; but this change, 
being only an amplification or dilatation of the normal ducts and their acini 
and an increased proliferation of epithelium, constitutes an hypertrophy, and 
not a new formation of gland-tissue. When a tumor, for example, is removed 
from the mammary gland under the supposition of being an adenoma, and 
returns, and, after extirpation a second time, is examined without any gland- 
element being discovered, it is prima facie evidence that its predecessor was 
not an adenoma, as like can only beget like. 
Adenoma arising from epithelial elements bears a very strong resemblance 
to carcinoma, and carelessly examined microscopically may readily be con- 
founded with the latter; but the error will be avoided by observing that in 
adenoma the cells lining the cavities of the gland rest on a well-defined 
basement-membrane, which is not the case in carcinoma. The epithelial 
cells also of an adenoma differ somewhat from those of carcinoma, being 
more regular and smaller, and have generally single nuclei. It is not im- 
probable, however, that in certain localities the former may be transformed 
into the latter. 
The glands which have thus far been considered as the soil for the develop- 
ment of adenomata are those furnished with ducts, but these tumors occur 
also in glands without excretory ducts, for example, the thyroid body, some 
forms of goitre being due to a new formation of gland-tissue; indeed, in most 
cases of cystic goitre there is reason to believe that the latter is the product 
of a degenerating adenoma. 
Adenomata are benign tumors, exhibiting no tendency to return when 
thoroughly removed, and not capable of generalization. 
These growths are sometimes observed combined with other neoplasms, as 
fibroma, sarcoma, and carcinoma. 
They frequently undergo cystic (Fig. 2114), mucoid, fatty, or colloid 
degenerations. 
In cystic degenerations of adenomata, the cysts, especially those which 
occur in the nasal fossro (polypi), are usually filled with mucoid substance. 
In a large mammary cystic adenoma which I removed from a patient in 
the Pennsylvania Hospital, the interior of the cyst-wall was studded with 
papillary vegetations. 
The causes which give rise to adenoma are not always appreciable, but it 
may be assumed that, whatever they may be, they are of the nature of a 
local irritant. Thus, when developed in the nasal fossae, the particular ex- 
citant is catarrhal inflammation; when in the uterus, it is cervicitis, or en- 
dometritis ; and when in the mammary gland, its sudden evolution with 
the attendant afflux of blood incident to the stage of puberty, and the active 
nutritive processes which are in operation during the first twelve or fifteen 
years of womanhood, are, no doubt, concerned in the production of the 
neoplasm under consideration. 
Prognosis.—Uncomplicated adenoma is a benign growth, powerless to 
implicate the general system by secondary deposits or infection. Slow in 
growth, the tumor may at length attain considerable magnitude, and from 
the effects of pressure cause serious inconvenience to the patient. 
Treatment.—Internal remedies seldom make any satisfactor}T impression 
on adenomata. The agents which have been employed for the purpose of 
arresting or removing growths of this nature are the different preparations 
of iodine, iodide of potassium, iodoform, and the bichloride of mercury, also 
the local use of electricity, and injections of tincture of iodine into the 
tumor. In the very early stage of such new formations these remedies do 
sometimes retard or even arrest the growth of the tumor, but such are ex- SARCOMATA. 
633 
ceptional cases. Excision is the only certain method of getting rid of an 
adenoma, and if thoroughly done, and the disease is not combined with some 
Fig. 2114. 
Adenoma of the mammary gland which has undergone cystic-colloid degeneration. X 100. 
malignant element, the operation will probably effect a radical cure. When 
these tumors do recur after the use of the knife, some portion of the growth 
has escaped the scalpel, and in repeating the operation greater care must be 
observed to seek for any trace of the disease. 
Sarcoma, from <ra/>$, “flesh,” is a name originally given to a class of tumors 
sections of which presented somewhat the appearance of flesh. This name 
figured in the crude nomenclature of Abernethy. Schuh at one time applied 
the term to myomata, or tumors of muscular tissue. Muller designated these 
growths fibro-albuminoid. 
The term sarcoma may be said to have been introduced into modern 
pathology by Virchow, and is designed to include a class of exceedingly in- 
teresting morbid growths, which appear to occupy a middle ground or to 
constitute a connecting link between benign neoplasms and carcinoma. Not- 
withstanding the neutral position accorded to these tumors in their progress, 
their extension, and the arrangement of their histoid elements, they are by no 
means free from malignancy. They infiltrate and replace the tissues in which 
they grow; they are followed by secondary deposits in distant organs and 
parts of the body; they ulcerate and send out offensive fungosities of granu- 
Sarcomata. 634 
TUMORS. 
lation-tissue; they produce a general cachexia in time; they recur after having 
been removed ; and, finally, they destroy life. 
Sarcoma makes its appearance ordinarily before the thirty-fifth year, 
although it may develop at any period of life. The occurrence in different 
organs or parts of the body has a certain relation to age: thus, in sarcoma 
of the testis the disease is most common either near to puberty or after 
thirty years, while both in subperiosteal sarcomata and in those growing from 
the central part of bones seven-tenths, as shown by Mr. Butlin, occur after 
sixteen, or between the last-named period and forty. In the eye sarcoma is 
commonly a disease of infancy. Sarcomata developing in bone exhibit also 
a notable preference for certain portions of it. Mr. Eve, of St. Bartholomew’s 
Hospital, in an analysis of Butlin’s tables, has shown that in the femur it is 
the lower epiphysis and in the tibia and humerus the upper epiphyses which 
are generally attacked. The above facts would seem to indicate a certain 
relation existing between the physiological activity of a part and the devel- 
opment of sarcoma. 
It is difficult to determine the relative frequency of sarcoma in the differ- 
ent organs of the body, though there is reason to believe that bone and its 
periosteum are most commonly attacked, particularly the femur, humerus, 
and inferior maxilla, and next in frequency the testicle. The lymph-glands, 
though not entirely exempt, enjoy a marked immunity, and the same may be 
said of most of the other glands, except the mammary, which frequently 
suffers from the disease. 
No tumor can be less complex than a sarcoma. Its physiological type is 
embryonic connective tissue. Arising in some member of this series, it is 
found to partake of the histological characteristics of the tissue in which 
it appears: thus, originating in the periosteum or in the endosteum of 
bone, they undergo calcification or ossification; commencing in the skin, 
the cells become filled with pigment-granules, or, if developed from dense 
fascia or the aponeurotic expansion of muscles, the cells of the growth re- 
semble the spindle-shaped forms of connective tissue. In addition to the 
embryonic cells of the connective-tissue series as the prototypes of sarcoma, 
Billroth regards those of muscles and nerves, and Rindfleisch the different 
stages of inflammatory neoplasia. Pathologists generally are agreed that 
the cell-elements of sarcoma never advance beyond the stage of embryonic 
tissue. That mature or perfected connective tissue is often seen in these 
growths is true, but it is believed to be derived from the parts in which the 
tumor appears. While it is true that there is an original unity of origin in 
sarcomata, it does not follow that the embryonic cells which enter into the 
construction of these neoplasia are alike; on the contrary, they present 
different sizes and different forms, as spherical, spindle-shaped, flat, irregular, 
radiate; and on this diversity are founded the several varieties of sarcomata. 
These forms are the round, the spindle, or fusiform, and the giant cell. 
It is not invariably the case that a single form constitutes the entire bulk 
of a sarcoma. Round, spindle, and giant cells all may exist in the same 
tumor, but it will always be found that one form predominates, and on this 
fact will the growth be classed in accordance with the prevailing histoid ele- 
ments. The intercellular substance, or matrix, also varies. It is sometimes 
homogeneous, structureless, or hyaline, and very scanty, sometimes gelatinoid 
or striated, at other times appears as a reticulated net-work of adenoid tissue, 
and is occasionally differentiated into alveoli. 
The cells resembling those of granulation-tissue are either mono- or multinu- 
cleated, without a cell-wall. The giant or myeloid cells contain the greatest 
number of nuclei. The numerous granules which are often seen scattered 
through the matrix of these neoplasite ai*e due to the extreme fragility of the 
cells, which are prone to rupture and thus allow a brood of nuclei to escape. 
Sarcomata are rich in blood, but the walls of the vessels are wholly formed 
by the surrounding cells, so that the blood-channels are nothing more than a 
series of branching or anastomosing canals grooved out in the midst of the SARCOMATA. 
635 
closely-packed elements of the tumor. Herein lies the explanation of the 
apoplectic clots and loculi filled with blood so commonly met with in this class 
of morbid growths. The vas- 
cularity may be so great as to 
impart to the tumor the prop- 
erties of an erectile growth, 
constituting the telangiectoid 
sarcoma of Yirchow. In some 
instances the neoplasm, in 
virtue of the size and number 
of its blood-channels, pulsates 
like an aneurism and yields 
to the ear a similar blowing 
sound. 
Sarcomata form rapidly and 
often attain a great size. Their 
prevailing forms are round, 
ovoid, or oblong; sometimes 
they are nodulated or multiple. 
(Fig. 2115.) Generally, in the 
early stages they possess a cap- 
sule formed from the tissue in 
which they grow, and which, 
so long as it remains entire, 
resists, but does not entirely 
prevent, infiltration and the 
diffusion of the disease, as the 
latter may extend along the 
line of the vessels which enter 
and leave the growth. They 
may arise in any locality 
where there is connective tissue, as in the skin, in the subcutaneous, sub- 
Fig. 2115. 
Multiple sarcoma of the arm following a contusion. 
Fig. 2116. 
Sarcoma of the shoulder and arm, which began in the deltoid muscle. 
mucous, and subserous tissue, in the midst of muscular fasciculi (Fig. 2116), 636 
TUMORS. 
in the sheaths of nerves and blood-vessels, in the periosteum (Fig. 2117) 
and the endosteum, or marrow of the bones, in the eye and lymph-glands 
Fig. 2117. 
Periosteal sarcoma which began at the femur. 
(Fig. 2118), in the meninges of the cerebro-spinal centres, in the choroid 
plexus of the brain, and in the connective tissue of other growths. 
Fig. 2118. 
Sarcoma beginning in the axillary lymph-glands and extending eight inches below the axilla. 
Sex exercises no influence on the disease, males and females suffering alike. 
Metastatic or secondary deposits in internal organs, as the liver and lungs, ROUND-CELLED OR GRANULATION SARCOMA. 
637 
follow the primary or local tumor,—the diffusion of the disease being effected 
through the vascular, not the lymphatic system of vessels. Local recurrence 
after excision is also a notable characteristic of these neoplasiae. There are, 
however, exceptions to this rule. I have, after the removal of a sarcomatous 
testicle, seen the disease return, not in the seat of operation, but in the skin 
over the upper part of the shoulder. In fine, sarcomata, save the myeloid 
variety, are in every sense malignant and incurable, and therefore the prog- 
nosis must always be exceedingly unfavorable. 
Round-Celled or Granulation Sarcoma.—This tumor, the embryoplastic of 
the French, grows very rapidly, and is followed by secondary deposits in 
other parts and organs. With the exception of the alveolar sarcoma, it is 
the most malignant of all these neoplasiae. Its seat most generally is in the 
bones, muscles, subcutaneous tissue, neuroglia of the brain, spinal marrow, 
and retina, and in the mammary gland of the female and the testicle of the 
male. 
A section of this variety of sarcoma displays in the interior a slightly 
yellow, gray, or brick-dust hue, its histological elements resembling granu- 
lation-tissue. (Fig. 2119.) Examined microscopically, the cells are for the 
Fig. 2119. 
Granulation-tissue from the edge of an ulcerating lipoma. Above, the cells are purely em- 
bryonic ; below, they are changed into a riper tissue; wall-less blood-channels are seen in trans- 
verse and longitudinal section. 
most part round, containing large nuclei with one or more nucleoli. The 
intercellular substance is exceedingly scanty, the small cells being closely 
packed together. These growths contain a large amount of blood, the walls 
of the vessels being the cells and matrix which form the neoplasm. These 
tumors are quite soft in consistence, and furnish, when recent, a considerable 
amount of juice. (Fig. 2120.) 638 
TUMORS. 
Fig. 2120. 
Kound-celled sarcoma of the testicle, showing embryonic cells closely packed with 
little intercellular material. Blood-channels, without walls, cut longitudinally and 
transversely; at the bottom of the figure two seminiferous ducts cut transversely 
and filled with epithelial elements. 
Alveolar Sarcoma.—Another variety of the round-celled sarcoma, and one 
which is quite rare, is the alveolar. The cells, which are round, lie grouped 
together in an alveolated stroma formed by delicate connective tissue and 
spindle-shaped cells. (Fig. 2121.) The cell-components of the growth are 
Fig. 2121. 
Alveolar or round-celled sarcoma from the foot, the alveoli bounded by a delicate connective 
tissue containing spindle-shaped cells. 
somewhat irregular in outline. They possess both single and multiple nuclei 
and nucleoli, which exhibit a shining appearance. The alveoli vary in size 
and shape, and from their walls are given off delicate threads of connective LYMPHADENOID SARCOMA. 
639 
tissue, which intersect the spaces occupied by the cells. The cells, conse- 
quently, are separated or detached from the stroma with great difficulty, a 
fact of some importance as distinguishing these neoplasms from carcinomata, 
in which the separation of the two is effected without difficulty. Rindfleisch 
regards this sarcoma as a carcinomatous degeneration. There are parts of 
the tumor in which the alveolar arrangement is absent and the histoid ele- 
ments are disposed as in the simplest variety, or that in which the cells are 
crowded together with little, if any, matrix. 
Alveolar sarcomata are very vascular, occur in the eye, bones, muscles, 
and skin, and possess the pulsation and bruit of aneurism, with which they 
have often been confounded. 
Lymphadenoid Sarcoma.—This tumor consists of round cells, with large 
oval nuclei and nucleoli. The matrix is formed of an intercellular net-work 
resembling the reticulum of the lymph-follicles or of fungoid granulation- 
tissue. (Fig. 2122.) The vessels of this neoplasm have very delicate walls, 
Fig. 2122. 
Lymphadenoid round-celled sarcoma. Cells in certain portions of the section are inclosed in a 
delicate reticulum, and when the latter is absent it is due to pressure from proliferating cells. 
Blood-vessels cut longitudinally and transversely. 
with a large lumen. It is also soft in its consistence, quite succulent, and on 
section presents a dull red color. 
This tumor originates in the subcutaneous cellular tissue, and also in the 
intermuscular tissue. It is most commonly seen in the lymphatic glands and 
in the thigh, growing from the medullary canal or from the periosteum. It 
exhibits a marked degree of malignancy. When the cells composing the 
growth are large, its softness is correspondingly great, and it answers to 
what at one time passed under the name of medullary cancer. 
Large Round-Celled Sarcoma.—Another variety is that in which the cells 
of the neoplasm, though retaining their round form, are distinguished for 
their great size, equaling those of cartilage. These cells, instead of being 
imbedded in a homogeneous or structureless matrix, are supported in an 
intercellular net-work. (Fig. 2123.) The growth is soft and brain-like in 640 
TUMORS. 
appearance and consistence. This variety of sarcoma has been named car- 
cinomatous sarcoma, also endothelial cancer, and is that which so often 
Fig. 2123. 
Large round-celled sarcoma of the breast. 
becomes the subject of fatty and myxomatous metamorphosis. The favorite 
seat of this neoplasm is in the loose connective tissue underlying the peri- 
toneum and in other parts of the body. 
Spindle-Celled Sarcoma.—This growth answers to the fibro-plastic tumor 
of Lebert and to the recur- 
ring fibroid of Paget. It con- 
sists of spindle-shaped cells, 
with oval nuclei closely- 
packed together and in pai'al- 
lel and crossed lines. The 
compact character of the neo- 
plasm is measurably deter- 
mined by the arrangement 
of its elements, as the little 
interspaces between the ends 
of the cells are filled in by 
the extremities of others. 
(Fig. 2124.) They possess 
very little intercellular ma- 
trix, and often none at all 
is discoverable. These cells, 
though resembling in their 
form those of young connec- 
tive tissue, are, nevertheless, 
only an advanced stage of 
embryonic forms, as they 
never attain to a perfected tissue. In consistence this variety of sarcoma 
Fig. 2124. 
Small spindle-celled sarcoma of the tibia. GIANT-CELLED SARCOMA. - 
641 
is quite firm to pressure, and exhibits on section a fibrous aspect and a white 
or gray color. 
The favorite habitat for this neoplasm is the connective tissue underlying 
the skin and the mucous membrane, also in the sheaths of the vessels and 
nerves, in the mammary gland, the aponeurosis of muscles, the testicle, and 
the marrow and periosteum of the bones. 
When removed, recurrence is the rule; metastasis, however, is very rare. 
Large Spindle-Celled Sarcoma.—There is a variety of the spindle-celled sar- 
coma which is remarkable for the great size of its cells, which have a large 
ovoidal nucleus with multi- 
ple shining nucleoli and with 
a fine granular protoplasm. 
These cells—many of them at 
least—possess two and some- 
times three processes, giving 
to them a radiate or stellate 
form. (Fig- 2125.) These 
cells arrange themselves in 
different ways, so as some- 
times to exhibit a stellate ap- 
pearance, at other times a 
leaf-like figure, and at other 
times, again, crossing one an- 
other in different directions. 
It is in consequence of such 
a disposition of these spindle- 
forms that Kindfleisch has 
founded his radiary, foliated, 
and trabecular varieties of the 
neoplasm. 
The large spindle-celled sar- 
coma originates in the fasciae and other fibrous membranes, and is less marked 
by malignancy than most of the other forms of the disease, metastasis having 
never been recorded. 
Fia. 2125. 
Large spindle-celled sarcoma (tunica vaginalis testis). 
Giant-Celled Sarcoma.—This tumor is chiefly distinguished for the magni- 
tude of some of its cell-elements (two-hundnedths of an inch in diameter), 
of different forms, and often supplied with branches or outgrowths of proto- 
plasm which communicate with one another. (Fig. 2126.) Resembling, as 
they do, the cells in the medullary tissue of bones, this neoplasm was desig- 
nated by Paget myeloid. The cells inclose a large number of oval nuclei, 
amounting to twenty-five or thirty, the nuclei being shining. The giant- 
cells are found not unfrequently in the spindle-celled, but rarely in the 
round-celled sarcoma. This neoplasm is soft, having less consistence than 
the spindle-celled variety, and presents, when laid open, a variety of colors, 
sometimes gray or white, and at other times brown-red or mottled. It may 
attain a large size, is highly vascular, and is destructive to the tissues in 
which it grows, though the least malignant of the different varieties of sar- 
coma. This morbid growth is largely confined to the bones, and is generally 
incapsulated by a bony shell. It is frequently met with in the maxillie, com- 
mencing either in the periosteum (epulis) or in the cancellated structure 
of the bones. It may be multiple, particularly in the young. No cases of 
metastasis, I believe, have ever been observed. 
Melanotic Sarcoma.—In some instances granules of pigment infiltrate the 
embryonic cells, and even their nuclei, but rarely the matrix, imparting a 
dark or black color to the neoplasm. This constitutes the melanotic sarcoma. 
The spindle-celled and the alveolar varieties are those in which this pigmen- 642 
tation most generally occurs. The forms of the cells are round (Fig. 2127) 
and fusiform (Fig. 2128). 
TUMORS. 
Fig. 2126. 
Giant-celled sarcoma from the thigh. The giant-cells (five in number) lie in the midst of spindle-cells; two 
blood-channels filled with blood-corpuscles. 
Fig. 2127. 
Fig. 2128. 
Melanotic round-celled sarcoma (eye). 
Melanotic spindle-celled sarcoma (eye). 
The seat of melanotic sarcoma is the skin of the hand, foot, neck, the cho- OSTEOID SARCOMA. 
643 
roid coat of the eye, and on the front of the abdomen. It is often multiple, 
and exhibits a decided tendency to the formation of secondary deposits in 
distant parts and organs. 
Sarcomata are found combined with myxoma, lipoma, osteoma, angeioma, 
glioma, and lymphoma. 
Calcification is among the metamorphoses of these neoplasms. 
Myxo-Sarcoma is a form of the disease in which the cells of the neoplasm 
are destroyed in different parts of the tumor, leaving in their places a num- 
ber of loculi, or vacuities, occupied by a gelatinoid or mucoid substance formed 
by a metamorphosis of the matrix. In true myxo-sarcoma the secondary 
formations possess the same characteristic degeneration as the primary. 
Lipomatous Sarcoma.—In this neoplasm the cells are large and have many 
nuclei, and are infiltrated with fat, the effect of which, however, is not to 
destroy them. 
The tumor is soft to pressure, having little intercellular substance. It may 
grow to a large size, and will give rise to other deposits retaining the same 
peculiarities of structure. 
Osteoid Sarcoma is a sarcomatous tumor in which ossification has taken 
place in the matrix and the cells 
have been partly converted into 
bone-corpuscles. (Fig. 2129.) 
They arise only in the bones, and 
when central often expand their 
outer walls until they become as 
thin as parchment and crackle 
on pressure like that substance. 
While this expansion is in prog- 
ress, new bone is formed from 
the periosteum. (Fig. 2130.) 
Osteoid sarcoma when seated 
in the femur (Fig. 2131) or con- 
nected with the tibia (Fig. 2132) 
is very vascular. As the tumor 
increases, the vessels give way, forming little pools of blood, which yield an 
aneurismal sound. When the disease commences in the medullary cavity of 
Fig. 2129. 
a, Osteoid sarcoma in the tursal bones; 6, section of same. 
Fig. 2130. 
Central sarcoma of the radius, walls greatly expanded.—University Museum. 
a bone it is usually single, and exhibits no great tendency to secondary 
deposits or to diffusion. In the latter respect osteoid sarcomata differ very 
much from those originating in the periosteum, which are quite malignant. 
Central sarcoma of the bones is most commonly observed between thirty and 
thirty-five years of age. TUMORS. 
644 
Fig. 2131. 
a, Periosteal osteoid sarcoma of the lower third of the femur; b, section of same. 
Fig. 2132. 
Periosteal osteoid sarcoma of the tibia.—From the museum of the College of Physicians. 
Angeiolithic Sarcoma, sometimes called psammoma (Yirchow), is a neo- 
plasm consisting of flat, elongated cells, irregularly formed and of great size, 
with a central nucleus. The cells are arranged concentrically and incrusted 
with calcareous matter. The walls of the blood-vessels are wholly con- 
structed by these cells, the juxtaposition of which is not sufficiently close to 
prevent the blood from escaping between them. Pedunculated prolongations, 
or outgrowths, from the vessels occur, and these, consisting also of concentric 
Fig. 2133. 
Calcified sarcoma: a, flattened cells, with central nucleus; 6, vascular bud, with central globe of 
calcareous cells concentrically arranged. 
cell-laminae, become coated with lime-salts (Fig. 2133) and contain calcareous 
sphei'es. The absence of any wall separating the vessels from the cells of a ENDOTHELIAL SARCOMA. 
645 
sarcoma distinguishes the latter tumor in all its varieties from epithelial 
growths. The color of this variety of sarcoma is light gray. In consequence 
of the calcification it is necessarily brittle, and is readily broken down by 
compression. 
The seat of the neoplasm is the choroid plexus, also in the membranes of 
the brain, spinal cord, and nerves. 
Endothelial Sarcoma.—This is the name given to a neoplasm which, though 
presenting somewhat the appearance, in the arrangement of its histoid ele- 
ments, of carcinoma, yet when carefully studied is quite different, inasmuch as 
the cell-forms of the tumor originate by proliferation from the endothelium 
of the lymph-spaces, and not from epithelial elements. As these cells multi- 
ply they press apart the connective-tissue boundaries of the lymph-paths 
more and more, until loculi or alveoli are produced, being somewhat similar 
in appearance to those which exist in carcinoma. These alveoli, at first quite 
distinct, become less so, as the disease progresses, by the disappearance of 
the connective-tissue boundaries, so that in its maturity the neoplasm is seen 
to consist of large round cells, with a scanty interstitial connective tissue 
merely outlining vaguely-defined alveoli. The progressive stages of this new 
formation are well represented in the three following figures, produced from a 
tumor of the breast, for which I removed the entire gland at the clinic of the 
University Hospital. In Fig. 2134 the endothelial elements of the lymph- 
Fig. 2134. 
Endothelial sarcoma of the mamma. First stage, alveolated in appearance. 
spaces, at the left side of the cut, are seen multiplying to a moderate extent, 
forming elongated channels, separated from one another by condensed bundles 
of connective tissue, while to the right the proliferating cells are seen in- 
creased in number and in size and enlarging the lymph-spaces for their accom- 
modation. by which the tumor begins to assume the appearance of an alveolar 
carcinoma. In Fig. 2135 a microscopic view of another portion of the same 
tumor is given at a more advanced stage of development, and in this epi- 
thelial carcinoma is more accurately counterfeited, both in the magnitude of 646 
TUMORS. 
the cells and in the alveolar disposition of the connective-tissue frame-work 
of the growth; and, last, in Fig. 2136, at a still later stage of the same neo- 
Fig. 2135. 
plasm, is exhibited a third microscopic view, in which, by increased prolifer- 
ation of large endothelial cells (round and elongated), with a corresponding 
disappearance of connective tissue, the tumor resembles the ordinary round- 
celled sarcoma, the alveoli having been almost wholly lost. 
Prognosis.—The almost invariable recurrence of sarcoma after extirpation, 
and its tendency to diffusion, indicate a degree of malignancy which must 
necessarily render the pi'ognosis for a tumor of this nature exceedingly gloomy. 
When the growth increases very rapidly, or returns quickly after having 
been removed, it is not likely to be chronic in its course. The degree of ma- 
lignancy depends in a great measure on the nearness of its cells to the sim- 
plest or purest form of embryonic tissue. The small round-celled and spindle- 
celled sarcoma exhibit this property in a much greater degree than the large 
round- or the giant-celled varieties, and the same is true of those neoplasms 
which are pi’one to melanotic, myxomatous, and calcareous metamorphoses. 
The particular arrangement of the components of a sarcoma is also indica- 
tive of its malignancy, the condition being most pronounced when the cells 
of the growth are collected into groups circumscribed by alveoli of connec- 
tive tissue. The most benign of all the varieties of sarcoma is the one dis- 
tinguished as the giant-celled, in this respect being in striking contrast with 
the lymphadenoid, or that in which the cells are in the midst of a reticulum 
similar to that belonging to the lymph-follicles. The prognosis is rendered 
increasingly unfavorable when the disease appears in the form of multiple 
tumors. As long as the tumor retains a smooth or regular exterior and is 
sharply defined from the adjacent soft parts, it is an evidence that the disease 
is not extending and that it remains encapsulated. 
Course.—A sarcoma which develops in the midst of the muscles, in a bone, 
or in any other part of the body, appears either solitary or in multiple 
tumors. It increases by multiplication or proliferation of its cell-elements. 
These infiltrate the contiguous tissues and finally supplant them. When 
Endothelial sarcoma, at a later stage than that represented in the preceding cut. ENDOTHELIAL SARCOMA. 
647 
extirpated, a new growth appears in the cicatrix or very near to it. These 
neoplasms have little tendency to affect the lymph-glands; the alveolar 
Fig. 2136. 
Endothelial sarcoma, third stage. 
variety is not so, but behaves in this respect like cai’cinoma, which it so 
strongly resembles. Its diffusion or generalization is evidently through the 
blood-vessels, and sooner or later metastatic contamination follows in the 
internal organs and membranes, as the lungs, liver, kidneys, brain, peri- 
toneum, and pleurae. 
The softer forms of the disease are more prone to break down and ulcerate 
than those whose elements are arranged into more compact masses. In time, 
either from repeated hemorrhages or from general irritation, the patient suc- 
cumbs to the ravages of the disease. In other instances the tumor shows 
little disposition to invade the surrounding parts or the general system, re- 
maining for years encapsulated and defined, until perhaps some irritant, as a 
blow on the growth or an attack of illness, is superadded, when under such 
stimulus the latent malignancy of the neoplasm breaks out with resistless 
force and the disease advances rapidly to a fatal termination. 
Diagnosis.—Though sarcoma and carcinoma have several points of resem- 
blance, there are certain clinical and histological differences which will serve 
to distinguish the two affections from each other, and which may be arranged 
as follows : 648 
TUMORS. 
SARCOMA. 
CARCINOMA. 
Usually appears before thirty-five. 
Rarely traceable to an hereditary cause. 
Has little tendency to affect the lymph-glands. 
At first surrounded by a capsule. 
Arises generally in parts deeply placed. 
Not prone to attach itself to the overlying skin. 
Tendency to ulceration not great. 
Not painful. 
Remarkable absence of fat in the growth. 
Cachexia among the latest phenomena. 
Generally after the thirty-fifth year, except in 
cases where the prostate body, kidney, or omentum 
is affected, when it may occur even in infancy. 
Generally hereditary. 
Generally affects the lymph-glands. 
Devoid of a capsule. 
Arises in superficial parts. 
Tends to become adherent to the skin. 
Tendency to ulceration strong. 
Painful. 
Fat constantly present. 
Cachexia not long delayed. 
The histological distinction is radical. Sarcoma is devoid of nerves, its blood- 
vessels are without walls, it is composed of embryonic cells, and is without 
complete alveoli; whereas carcinoma contains nerves, its vessels possess dis- 
tinct membranous walls, and its histoid elements are epithelial. To these 
distinctive characteristics of the two diseases another may be added, one men- 
tioned by Waldeyer,—namely, the coalescence of cell-elements in sarcoma, 
which is said never to occur in the epithelial cells of cancer. 
Treatment.—Early excision is always to be recommended in sarcoma, and 
to be repeated when the growth reappears. When located in the central part 
of a bone, as, for example, the maxilla, the latter should be excised in whole 
or in part, according to the amount of osseous tissue implicated; and when 
seated in one of the long bones, as the tibia, the humerus, or the femur, 
amputation alone offers any chance of recovery. 
Glioma. 
This name has been given by Virchow to a tumor which in some respects 
bears a resemblance to glue. Its physiological type is found in the neuroglia, 
or interstitial substance of nervous tissue. Its exact place among neoplasms 
has not been definitely fixed. Some pathologists, as Klebs and Cohnheim, 
regard the new formation as a neuroma; others, and with greater propriety, 
place it among sarcomata. 
The growth is met with in both the gray and the white substance of the 
brain and spinal marrow, in the optic nerve, the retina, and other nerves ot 
special sense, and in one instance at least, on the authority of Virchow, it 
has occurred in the supra-renal capsule. 
The tumor has a soft, gelatinous consistence, does not differ in appearance 
from the neurine, cerebral and spinal, in which it grows, and shows no 
tendency to implicate the meninges of the brain or spinal cord. Examined 
microscopically, glioma is seen to consist of round and spindle-shaped cells 
imbedded in a scanty, granular, intercellular substance (neuroglia). These 
cells, except in size,—being smaller,—resemble in most particulars those 
which belong to certain sarcomata, with which the tumor corresponds in 
another particular,—namely, in the blood-channels of the growth being des- 
titute of walls other than those furnished by its cell-elements. (Fig. 2137.) 
It is this fact which explains the extravasations of blood frequently seen 
scattered through the substance of a glioma, and which allies the neoplasm 
with sarcoma. 
Although glioma occurs at all ages, it is more particularly a disease of 
childhood, and when existing in a typical form, free from other combinations, 
may be regarded in one sense as benign ; that is, as not prone to generaliza- 
tion, though it does enlarge by infiltration. At the same time this neoplasm 
is capable by its location and through pressure of so seriously interfering 
with functions essential to life as to prove fatal. 
Glioma frequently exists with other neoplasms, both benign and malig- 
nant, as fibroma (glio-fibroma) and myxoma (glio-myxoma), and also with 
sarcoma (glio-sarcoma), if the growth is at all different from the latter. GLIOMA. 
649 
Nor is glioma proof against retrograde transformations, being overtaken by 
fatty, cretaceous, cheesy, cystic, and osseous degenerations. 
Fig. 2137. 
Glioma from the pons varolii of a child; round and fusiform nucleated cells in the midst of an 
extremely delicate reticulated tissue ; on the right is a blood-vessel without walls. 
Diagnosis.—The diagnosis of glioma must necessarily be a matter of great 
uncertainty. When seated either in the brain or the spinal cord, it cannot 
be distinguished from other tumors which fix their habitation in these great 
centres, the symptoms of both being those resulting from pressure. When 
the disease appears in the retina, the surgeon will be able to recognize its 
true nature by the yellow, luminous reflex which is noticed emanating from 
the fundus of the eye, and by calling into requisition the ophthalmoscope 
the diagnosis will receive further confirmation by the disclosure of the growth 
itself. 
Treatment.—Seated as glioma often is in an inaccessible locality, the 
surgeon is powerless in some cases to accomplish any medical relief for the 
patient, and consequently the growth continues to progress slowly without 
opposition, until death follows from pressure or invasion of new installments 
of neurine. 
When, however, glioma is early detected in the eye, enucleation of the ball 
should be practiced without delay, as the disease tends to travel backward 
to the brain. 
Inflammatory Fungoid Neoplasm. 
An unclassified neoplasm has been described by Duhring* and by Gerber 
under the name of inflammatory fungoid neoplasm. Only a very limited 
* See Duhring’s Treatise on Skin Diseases, third edition, for an excellent summary of the new growth. 650 
TUMORS. 
number of cases of the disease have been observed. Hebra first observed 
this neoplasm in 1872, and again in 1874. A case was reported in 1878 to 
the Dermatological Society of New York by Piffard, and in 1879 another, 
by Duhring, before the American Dermatological Society. In addition to 
the above, Tilbury Fox, Gillot, Demange, and Hardaway, of St. Louis, 
have each recorded a case. Koebner has collected five cases. During the 
present winter (1883) a case of the kind (a male) presented himself at the 
clinic of the University Hospital. 
The neoplasm, usually multiple, appears on the forehead, face, and other 
parts of the body, the tumor being both 
flat and raised above the surface, and 
having different forms, round, oval, or 
oblong; some of the patches being 
brownish red and others violaceous or 
pinkish. (Fig. 2138.) The tendency of 
the neoplasm is to ulcerate and discharge 
a bloody serum. Metastasis has also 
been noticed. Preceding and accom- 
panying the neoplasm severe itching 
was a prominent symptom. 
Pathologists have been at some loss 
to know just where to place the neo- 
plasm. Duhring and Heitzmann, with 
others, place it among the sarcomata 
(or fibro-sarcomata). Longstreth, who 
made a very careful microscopic study 
of numerous specimens of the disease 
taken from Duhring’s patient after 
death, does not so regard it. 
Koebner recently succeeded in curing a case of this disease by hypodermic 
injections of arsenic. 
Fig. 2138. 
Duhring’s case of inflammatory fungoid neoplasm. 
Carcinomata. 
Under the head of carcinoma are included all tumors atj’picall}7, constructed 
and whose physiological type or derivatives consist of true epithelium. These 
growths are the most aggressive and malignant of all neoplasise. They 
destroy the tissues in which they develop, not by displacement alone, but by 
invasion and penetration, and, in many instances after a brief period, defiant 
of all human skill, they destroy life with unerring certainty. 
In referring carcinomatous new formations to the domain of epithelium, it 
may be necessary to consider exactly what sense is to be attached to the 
term epithelium, as different writers entertain different views on the subject. 
Those who give great prominence to connective tissue in the genesis of can- 
cer, as Rokitansky, Yirchow, Strieker, Mixon, Cornil, Ranvier, and others, 
believe that this tissue, by a retrograde metamorphosis through intermediate 
spindle and embryonic forms, may at length appear in an epithelial dress. 
It is probable that the advocates of this transmutation doctrine mistake the 
cells occupying the lymph-spaces (endothelium) for true epithelium. Others, 
as Koster and Recklinghausen, include in the idea of cancer-cell genesis 
the endothelial cells of the lymph-vessels which histologically are the con- 
geners of the connective-tissue corpuscles. On the other hand, these views 
are antagonized by Billroth, Waldeyer, Lucke, Rudnew, and others, who 
believe that the cell-elements of these neoplasms are derived wholly by pro- 
liferation from normally pre-existing epithelial cells. This view is based on 
a law similar to that of the invariability of species; that is, that cells of 
different kinds are not mutually convertible, or that after the embryonal di- 
vision of the blastoderm the cells which belong to a particular layer never 
lose their original characters, epithelial cells continuing as epithelial, and con- CARCINOMATA. 
651 
nective-tissue corpuscles as connective-tissue cells, throughout all subsequent 
mutations, pathological as well as physiological. Other pathologists, among 
whom are Rindfleisch, Klebs, Birch-Hirschfeld, and Woodward, while con- 
ceding to carcinoma an epithelial origin, insist on the transmutation of the 
connective-tissue corpuscles into epithelium, the metamorphosis being brought 
about by infection derived from the proliferating epithelium of gland-ducts, 
or acini, thus accepting and endeavoring to harmonize the views both of 
the Virchow and Billroth schools. As to the manner in which the infec- 
tion is communicated there is a difference of opinion. Whether it is effected 
by the epithelial cells leaving the interior of the gland-structures and inocu- 
lating the periglandular cell-elements by contact, or whether the contagion 
is accomplished by mere contiguity without such passage of the epithelium, 
the advocates of this doctrine are not agreed. Nor are they one in regard 
to the nature of the cells which are found in the periglandular connective 
tissue, some claiming them to be migrated white blood-corpuscles which 
have wandered out of the blood-vessels, while others believe them to be 
connective-tissue corpuscles which have passed from the stable to the active 
condition under the stimulus of a pathogenetic force. In explanation of the 
presence of cells in carcinoma which are present in the connective tissue 
external to the glandular apparatus, Creighton states that they are simply 
transpositions of epithelium, which, though at one time inside of the glan- 
dular acini, have reached their present location by infiltration, and that the 
alveoli of the new formation are produced by the displacement or thrusting 
apart of the bundles of connective tissue to make room for these accumula- 
tions of cells. 
Against most of the preceding theories, which have been constructed to 
explain the presence of the histoid elements and their disposition in car- 
cinoma, it may be said that they are only theories, in some respects mere 
assumptions, and therefore to be regarded with suspicion. For example, 
there is no evidence to prove that the cells which are seen in the periglandu- 
lar conjugate tissue are white blood-corpuscles, or that the epithelium of the 
acini is charged with a principle of infection which by communication is 
capable of converting connective-tissue corpuscles or endothelium into epi- 
thelium, or that the former are the genetic sources of carcinoma. Indeed, as 
to the last-named view (that of Koster), it has been shown very conclusively 
by the studies of Waldeyer, Woodward, Gross the younger, Formad, Reed, 
and others, that the endothelial lining of many alveoli in carcinoma remains 
unchanged, while in others no such lining exists, the endothelium having 
doubtless been destroyed by the pressure resulting from the accumulation 
of epithelial elements. We are, then, justified in assuming, in the absence of 
any other doctrine of equal plausibility, that true carcinoma is a new forma- 
tion of epithelial origin, whether the latter belongs to the skin, the mucous 
membranes, or their inversions which constitute glands. (Compare sections 
on alveolar sarcoma and epithelial cancer.) 
The picture presented by carcinoma, when studied in sections, consists 
in an accumulation of cells lying in a frame-work or stroma of connective 
tissue, the trabeculae of which are fashioned into numerous spaces (lymph- 
spaces) or alveoli of varying forms. 
The cells of carcinoma, starting from the pre-existing epithelium, exhibit 
various forms, determined in some degree by the seat of the new formation. 
They are squamous, round, oval, angular, columnar, and fusiform, contain 
one or several nuclei and nucleoli, and measure from to of an inch 
in diameter. (Fig. 2139.) The origin of these cells, as already stated, is the 
epithelium of the part in which they develop, and they multiply by prolifera- 
tion and endogenous cell-formation. After a time, as these elements increase, 
the basement-membrane of the glandular tube or acinus gives way, and the 
cell-contents escape into the periglandular lymph-spaces or channels bounded 
by connective-tissue bundles, and, accumulating therein, form masses of cells, 
the so-called cancel' cylinders. The alveolated appearance, which is a cbarac- 652 
TUMORS. 
teristic feature of the neoplasm, is formed by the expansion of the lymph- 
spaces or channels from the close packing of the epithelial cells. As these 
Fig. 2139. 
Variously-formed cancer-cells. 
lymph-spaces normally communicate with one another, the obstacles to patho- 
logical infiltration are not great. That connective tissue is not necessary for 
the construction of alveoli is evident from what occurs in carcinoma of 
the uterus, in which the walls of these chambers are formed by bundles of 
muscular tissue. (Fig. 2140.) 
Fig. 2140. 
Carcinoma of the uterus, alveoli bounded by bundles of muscular tissue. 
The trabecula, or stroma, is vascularized to a greater or less degree accord- 
ing to the variety of carcinoma. Some of these vessels are those normally 
existing in the part in which the tumor forms, others are new-formed. 
Lymphatic vessels also are present in the alveoli. Nerves abound in carci- 
nomatous growths. They belong to the tissue in which the new formation 
develops: hence the severe pain which accompanies cancer, and which is 
characterized by a quality which does not belong to other growths,—namely, 
shooting, darting, or stabbing. This somewhat diagnostic peculiarity in the 
pain can scarcely be regarded as entirely due to pressure from infiltration. It 
may be that the juice of the neoplasm acts as an irritant to the nerves of the 
infected district. In addition to the epithelia there are large numbers of CARCINOMATA. 
653 
other cells in carcinomatous growths. Those which are small, round, and new- 
formed infiltrate the connective-tissue stroma of the tumor, and evidently are 
lymphoid corpuscles, never being seen in the alveoli. Their number is some- 
what proportioned to the aggressive progress of the epithelial prolifei’ation. 
As the latter cells penetrate into the periglandular conjugate tissue, through 
lesions in the basement-membrane of the acini, the lymphoid bodies mul- 
tiply rapidly, and do their best to replace the devastation wrought in the 
connective tissue by constructing new stroma. (Fig. 2141.) These new 
Fig. 2141. 
Adenoma transforming into carcinoma. At the upper right side of the figure is seen a glandular 
acinus, intact, and lined with a single layer of epithelium; at the lower left half the epithelial ele- 
ments are accumulating into cylinders, having broken through the basement-membrane of a number 
of acini, and are infiltrating the stroma of the gland. The connective tissue giving the alveolated 
appearance to the tumor is seen filled with proliferating lympltbid cells, which become developed into 
new stroma. 
broods of lymphoid cells appear, therefore, to he a reactionary product, 
called into existence to resist foreign invasion, and devoid of any specific or 
malignant property. Their numbers may become so great as to conceal al- 
most entirely the true neoplastic epithelial elements, or to make the latter un- 
distinguishable from the former, at least those portions of the former where 
the cells are as yet small. Within the limits of the extremely attenuated 
basement-membrane which separates the glandular epithelium from the 
connective tissue are concentrated some of the secrets which may yet be 
found to play an important part in the causation of cancer, and I am not 
aware that there are any recorded observations which positively determine 
the order of precedence in the active proliferation of the two classes of 
cells, epithelial and endothelial. Certainly at no time has there been 
seen an exuberant increase of one set of cells without a like activity in the 
others. 
Extension.—Carcinoma once established in the tissues manifests an invin- 
cible tendency to extension, both local and general. 
Local extension is effected by cell-infiltration. The masses of epithelial 
accumulations, having once broken through the basement-walls of the acini, 
work their way like wedges through the midst of the connective-tissue 654 
TUMORS. 
stroma not only by the force of a continuous new formation at the original 
source of their production, but also by multiplication of those composing the 
moving masses or columns; and, as carcinomatous growths are not encap- 
sulated, it is impossible, from any external signs, to determine the limits 
of this infiltration,—a fact which must necessarily have great practical bear- 
ing in all operations for the removal of carcinomatous tumors. 
General extension.—The secondary deposits of carcinoma ordinarily occur 
along and through the lymphatic system of vessels, and for an obvious reason. 
The lymph-spaces which are crowded with the exuberant epithelial cells 
communicate with the lymph-vessels, and thus open ready paths for the 
dissemination of the disease. In the work of generalization or metastasis 
through the tymph-channels the lymphatic glands in immediate relation 
with those of the tumor are first implicated, after which the internal organs 
suffer. 
While it is true that metastasis in carcinoma is ordinarily accomplished 
through the lymphatic vessels, yet the veins cannot be excluded from partici- 
pating in the same work. The walls of these vessels are not proof against 
the penetrating power of epithelial plugs, cylinders, or nests, and when an 
entrance is effected by this route the seat of the secondary deposits will be 
determined by the particular system to which the vein forming the avenue 
for dissemination belongs. If a tributary to the portal system, the liver par- 
ticipates secondarily in the disease; if one of the systemic veins, the lungs 
suffer. When the route of infection is through the lymph-vessels, the latter 
emptying their contents into the brachio-cephalic trunks, the pulmonary 
organs becomo the receptacle of the new formation. 
Immediately connected with the subject of metastasis is the form in which 
infecting material is generalized. Is it through the medium of the liquid 
contents or juices of the carcinomatous neoplasm ? or is it by means of the 
epithelial cells transported from the original or primary tumor? The answers 
to these questions are the following: 
First, cancer- and other tumor-juices have been injected into the blood- 
vessels of lower animals by Dupuytren, Vogel, Billroth, and quite recently 
by Wile, and in no instance have the secondary effects been of a character 
different from those caused by any inflammatory irritant. It is true that 
other experimenters, as Langenbeck, Weber, and Folin, claim to have 
obtained a different result, and to have succeeded in producing secondary 
cancerous tumors identical with the neoplasm from which the juices had been 
taken. If the alleged results are correctly reported, in the light of other 
observations there must have been in the juices used, as suggested by For- 
mad, some cells belonging to the tumors from which the liquid contents for 
injection had been taken. 
Secondly, there are no experimental facts which prove that cancer-juice 
possesses any power to cause a gland to produce cells foreign to its own, as 
has been well put by Billroth; and as cells are found in lymphatic glands 
having the same form as those of the cancer with which by their vessels 
they are connected, the logical inference is that they have been derived from 
epithelial elements of the primaiy neoplasm, and that therefore from these 
the general infection takes place. Assuming, then, that generalization of 
certain tumors is effected through particles of the neoplasm containing living 
cells, these particles entering the lymphatic or venous channels are carried 
along in the current until they reach vessels which are too small for their 
passage, when they become arrested and form emboli, the cells of which con- 
tinue to grow and form secondary tumors, independently of any assistance 
from the tissues with which they are surrounded, further than that supplied 
by the blood-vessels of the part. The experiments of Nowinsky, of Klenke, 
and of Goujon show that living particles of carcinoma, when transplanted 
beneath the skin, under favorable circumstances will continue to grow, re- 
taining the same histoid characters as the growth from which they had been 
taken. CARCINOMATA. 
655 
Dr. Wile, by a number of very interesting experiments, has shown that 
what is true of pathological elements is true also of certain normal tissues, 
fragments of the periosteum introduced into the jugular vein of dogs having 
been found in the lungs developing into bone. 
Causes.—The increasing frequency of carcinoma gives peculiar interest to 
the subject of causation. An analysis of the annual reports of the registrar- 
general for England, made by Dunn, with reference to cancer, shows the 
disease to be on the increase, and at a ratio out of proportion to the growth 
of population. During the first decade (1860-70) the total number of deaths 
from cancer was 80,049, the annual average increase being 248. During the 
second decade (1870-79) the deaths amounted to 111,301, the annual aver- 
age increase being 320. If, as is assumed by the writer, the average increase 
of population is about one-tenth during each succeeding ten years, it is evi- 
dent that this dreadful malady is outstripping very much the numerical in- 
crease of population. Among the predisposing causes which certainly do have 
some influence in the development of carcinoma are age and sex. The disease 
is not seen before puberty, and in most instances occurs after forty or forty- 
five. The average age in cancer of the breast, in an analysis of 153 cases 
by Sibley, was 48.6 years, and in cancer of the uterus, in 119 cases by the 
same authority, 43.28 years. A singular uniformity in the number of deaths 
from year to year among females from cancer between forty-five and fifty- 
five is shown by the English reports of the registrar-general, being, for 1878, 
2348; for 1879, 2306; and for 1880, 2396. The same uniformity holds good 
with deaths among males from the same cause, being for the same years 
respectively 1226, 1264, and 1294. 
Females furnish a large excess of cases of the disease over males, which is 
explainable by the great frequency of the disease in the mammary gland and 
in the uterus. The relative frequency of the disease in the sexes is estimated 
by some writers at about six cases in the female to one in the male. 
Taking the reports of the registrar-general for England* for three years, 
1878 to 1880 inclusive, the deaths from cancer among females amounted in 
the aggregate to 25,890, while among males they were 12,851. It is thought 
by some writers that the greater the fecundity of the female the greater is 
the liability to cancer. 
The connection between carcinoma and the diminution or loss of functions 
of certain organs in consequence of advancing age has very generally at- 
tracted the attention of writers. Thus, in cancer of the mammary gland 
and of the uterus the disease exhibits a singular partiality for developing 
about the period of the menopause, oftener, perhaps, just before than after 
the important change referred to in the economy of these organs has taken 
place. So universal is it that all tumors making their appearance within the 
period named are viewed with suspicion. As in the state, when the monarch 
from decrepitude and age is no longer able to hold firmly the reins of author- 
ity, insuboi-dination and anarchy are developed, so in the realm of vital pro- 
cesses, with the decline of function, and when the force which regulates 
orderly or physiological cell-life is weakened or lost, there begins a monstrous 
and aimless accumulation of tissue-elements which observe neither order nor 
form. 
Heredity.—There is considerable diversity of opinion among writers on 
hereditary conditions as predisposing causes of carcinoma. The discussion 
necessarily includes the idea of the constitutional and local origin of cancer. 
The difficulty of obtaining correct information on the subject may account 
for the want of agreement among pathologists. Some patients purposely 
conceal family history from motives of pride; others are wholly ignorant in 
regard to the diseases from which their parents or other blood-relations have 
died, so that the surgeon is compelled to make his deductions on this subject 
either from personal knowledge or that obtained from disinterested parties. 
* British Medical Journal, April 14, 1883. 656 
TUMORS. 
The statistics of Sibley give a family history of cancer in patients of 8| 
per cent., or one-eleventh of all cases of the disease. Gross the younger, in 
an analysis of 389 cases of mammary cancer, gives 10.30 per cent, in which 
hereditary influence could be traced. My own observation does not accord 
with that of these authorities, being much more decidedly on the side of 
hereditary antecedents as a marked predisposing agency in cancer. In a 
number of instances I have seen two members of the same family attacked 
by carcinoma. Sibley gives 6 instances out of 34 in which carcinoma existed 
in the family and more than one member had suffered from the disease, than 
which there could be no stronger evidence of there having been some trans- 
mitted predisposing peculiarity of constitution. Paget, in an analysis of 322 
cases of carcinoma, traced the disease to other members of the family in 78 
instances. Baker makes the percentage of inherited cancer in private prac- 
tice 37.4. There are individual cases mentioned by authors which, so far as 
scattered cases go in the elucidation of a subject like the present, cannot be 
ignored. Thus, Paget refers to a patient who died of carcinoma of the 
stomach, two of whose daughters, and their children, to the number of four- 
teen, died of cancer. Broca mentions another instance in which fifteen out 
of twenty-six persons, the descendants of a Madame M ,* extending to 
the third generation, perished from cancer. Yery recently I removed from 
the tongue of a lady an epithelial carcinoma. Two of her sisters had been 
under my care, one with cancer of the mammary gland and the other with 
cancer in the abdominal walls. The experience of almost every surgeon will 
furnish numerous examples, of course not so remarkable as those cited fi*om 
Paget and Broca, but corroborative of instances of carcinoma in different 
members of the same family. 
The coexistence of carcinoma and phthisis in different members of the 
same family is a matter of common observation : the proportion, according 
to Sibley, in 130 cases examined, was 48 cases of phthisis. The two diseases 
may exist in the same person, as was the case in the wife of a clergyman 
who was at one time under my care, and who suffered from mammary 
carcinoma and pulmonary tuberculosis. 
Though it appears that the poor and laboring classes suffer most from the 
common maladies which befall humanity, yet in the particular disease of 
cancer this is not the case. Marc d’Espine has shown that among the well- 
to-do or wealthy classes the proportion of carcinoma is apparently 106 in 
1000, while among the poor and indigent it is but 72 in 1000. 
It might be supposed that cities and populous towns would furnish the 
condition peculiarly favorable to the development of carcinoma; and yet I 
think the experience of most surgeons will show that the disease is equally 
if not more common among the residents of the country. Haviland con- 
nects carcinoma with rivers, particularly those which are subject to great 
periodical risings. Dunn has confronted this statement by setting over 
against the rain-fall of eight years—from 1872 to 1879 inclusive—the deaths 
from cancer reported for each year and coming within the influence of river 
overflow. The results of this comparison cannot be said to verify Mr. Havi- 
land’s theory. 
The influence of emotional causes, as protracted grief, the nervous de- 
pression following loss of property, anxiety, and worry, as predisposing 
factors in carcinoma, has been forcibly impressed on my mind for several 
years, especially with reference to cancer of the mammary gland. 
The inflammatory theory, which has already been noticed as a cause of 
carcinoma, is again attracting no small degree of attention, and it is highly 
plausible that a process of this nature, or any local irritation, may be actively 
concerned in inducing the disease. Cancer of the lip, no doubt properly 
referred to the irritation of the clay pipe in smokers, is an example in point, 
as females rarely suffer from the disease in this locality. Yet carcinoma oc- 
curring in this way by no means establishes the local origin of the disease; 
• British Medical Journal, January 20, 1883. EPITHELIOMA. 
657 
rather the reverse, as epithelioma of the lip compared with the number of 
pipe-smokers is exceedingly uncommon, and this very fact would seem to 
imply that without some predisposition of a general character the local 
irritation would be powerless to evoke the disease. 
Much may be said on both sides, and in the light of our present knowledge 
the question must be regarded as an unsettled one. The drift of modern pa- 
thology is certainly setting strongly in the direction of the local origin of 
carcinoma, although there are not wanting many eminent observers whose 
faith in the constitutional origin of the disease is deeply rooted, and I must 
have stronger evidence than has yet been supplied to the contrary before 
abandoning a similar belief. 
Whether the prime or remote cause be a general or a local one, one thing 
remains undisputed, that carcinoma after a time is followed by a group of 
symptoms indicative of a profound disorder of the blood-making and nutri- 
tive systems, designated a cachexia. This consists in the loss of flesh, a 
dirty, sallow, and anaemic complexion, weary, worn, and distressed features, 
the tout ensemble of which conveys the idea of the presence of an ineradicable 
vice. These symptoms in cases of external carcinoma do not appear until 
particles of the tumor have been disseminated or lodged in internal organs 
of the body, where they become foci for other growths of a similar nature, 
causing decay and destruction of the structures in which they form, the 
septic products of such decomposition poisoning the blood and rendering it 
unfit pabulum for the tissues of the body. In addition to this, the repeated 
hemorrhages which so often attend the last stages of carcinoma empty the 
blood-vessels and give rise to general aniemia. 
Death from carcinoma occurs from several causes,—namety, hemorrhage, 
hectic irritation, septicaemia, and inanition, the result of mechanical pressure 
or obstruction. 
Surface carcinoma is prone to undergo ulceration, preliminary to which 
the tumor contracts an attachment to the overlying integument, the surface 
of which assumes a leaden, purple, or lilac color. The crater of the ulcera- 
tion, which is generally ragged at its border, includes not only the skin but 
the tumor-substance also ; and the discharges which issue from the sore are 
then ichorous and bloody, and emit a peculiar, highly-offensive odor, which 
often permeates the atmosphere of the room of the patient. 
The metamorphoses which carcinomata undergo are the fatty, cystic, 
colloid, fibrous, mucoid, caseous, pigmentary, and, rarely, calcareous. 
The fatty, colloid, and pigment degenerations affect the cell-elements of the 
neoplasm; the mucoid and fibrous are confined to its connective tissue or 
stroma. 
The varieties of carcinoma are the epithelial, scirrhous, encephaloid, telan- 
giectatic, colloid, and melanotic. 
Synonymous with epithelioma are the terms skin-cancer, cancroid, and epi- 
thelial cancer, noting a variety of carcinoma affecting the skin and mucous 
membranes. Two vai’ieties of epithelioma are recognized, based on the fox-m 
of the cell-elements,—namely, the squamous and the columnar. 
The most common seats for epithelial carcinoma are in the neighborhood 
of the outlets of the body, as the lower lip, tongue, gums, cheeks, fauces, 
pharynx, oesophagus, and larynx ; on different parts of the face, as at the 
angle of the eye; on the nose and eyelids; in the anus, rectum, vagina, and 
uterus, and on the penis. The disease has been observed in lymph-glands, 
and also in muscles, fascia, and bones, having invaded these structures by 
extension, not beginning in them, which would be incompatible with the 
epithelial origin of the disease. 
Epithelioma is more frequently observed in males than in females. It is 
stated by Dr. Marsden that of 1467 patients admitted into the Cancer Hos- 
Epithelioma. 658 
TUMORS. 
pital, London, 1022 were males. Koch, in an analysis of 145 cases, found 
132 to be in males and 13 in females. 
Epithelial cancel* is rarely seen earlier than forty, oftener between fifty-five 
and seventy years. 
In males, the most common seats for the disease are the lower lip, some 
portion of the face, and the glans penis; in females, the uterus, vulva, anus, 
and face. 
Much importance is justty attached to local irritation as a cause of the 
disease, as the contact of the clay pipe or a sharp tooth in carcinoma of the 
lip and the tongue. Traumatism may also provoke the development of the 
disease. A man of remarkable constitutional vigor, while lunching in the 
cars, wounded his cheek with a fork in consequence of a sudden lurch of the 
train while rounding a curve. In a few weeks the wound assumed all the 
characteristics of carcinoma, from which, in the course of eighteen months, 
he died. Chronic ulcers are liable to degenerate into epithelioma. In a 
patient whose foot I removed at the surgical clinic of the University Hos- 
pital, on account of an enlarging and malignant ulceration of the heel, the 
ulcer followed a wound made by a mowing-machine. A suppurating bursa 
may also be transformed into epithelioma. This wras the history of a bursa 
on the dorsal aspect of a club-foot, which had been converted into an open 
sore, from the effects of pressure, in the case of a lawyer, and on account of 
which I was obliged to amputate at the lower third of the leg. As car- 
cinoma of the mammary gland sometimes begins as an obstinate eczema 
around the nipple, so epithelioma of the anus is occasionally preceded by a 
similar eruption at the verge of this opening. Epithelioma occasionally ap- 
pears in old ulcers which have refused to heal, at the end of a stump. Epi- 
thelial cancer may appear in the scar-tissue arising from burns, scalds, or 
operations. Other examples of local irritants producing epithelioma are 
seen in the chimney-sweep cancer, caused by the contact of soot with the 
scrotum, and in that form of ulceration which affects operatives in coal-tar 
manufactories, the nature of which does not differ from that of the disease 
under consideration. 
Epithelioma may be hereditary; the most striking instance of the kind is 
one reported to Professor Gross by Dr. Foster, of Terre Coupee, Indiana, the 
disease occurring in three members of the same family. 
Epithelioma begins in various ways, sometimes as an indurated nodule, 
crack, or fissure, and at other times in a papillary or wart-like prominence in 
the skin or mucous membranes. When the disease commences in the form 
of a hard mass or nodule, it is usually charged with gx*eat malignancy, passing 
soon into ulceration, and invading the surrounding parts with great rapidity. 
In whatever form the disease begins, ulceration at length occurs. If seated 
on the skin, there is a certain degree of hardness or induration, which, 
though it may cover a considerable area, extends a very little beneath the 
surface. The ulcer is round, oval, or irregular in its outline, its surface 
smooth or granulated, and the discharge thin, ichorous, or sanious. On the 
lip and on other parts of the face the sore becomes covered with a dark 
scab or crust, beneath which is concealed the ulcer. This scab consists of 
an accumulation of epithelial scales cemented together by blood and the dis- 
charges from the sore. This crust at length becomes detached and drops 
off, only to be followed by another of a similar character. On mucous mem- 
branes epithelial carcinoma frequently assumes a warty or fungoid appear- 
ance, and the same is occasionally witnessed when the growth develops in 
the skin. The peculiar form of the outgrowth when assuming this character, 
whether on the skin or the mucous membranes, is determined by the infil- 
tration of the papillte. The granulations are sometimes so exuberant as to 
fill the mucous canal in which the ulcer is located, as is frequently observed 
inside of the rectum, and to a less degree in the mouth. As the disease ad- 
vances, the circumferential induration or infiltration enlarges, and is followed 
by a further destruction of tissue and a corresponding enlargement of the EPITHELIOMA. 
ulcer. The tendency, it will be observed, in most cases of epithelioma, is to 
extend superficially rather than deeply, and in this fact we have the expla- 
nation of the long exemption of the general system from infection. Why 
the disease should linger on the surface can be explained, in part at least, by 
anatomical peculiarities of structure, as the compact association of tegument- 
ary components offers mechanical resistance to infiltration ; hence the progress 
of epithelioma, when attacking mucous membranes or fixing its locality on 
the red surface of the lip, is usually much more rapid than when occupying 
the skin. When the morbid process appears in the form of a deeply-seated 
nodule, the devastation of structure is generally rapid and metastasis is not 
long delayed. 
The reason given for epithelial carcinoma tending to linger near the sur- 
face will explain the long immunity enjoyed by the lymph-glands against 
contamination. Cases are frequently seen by surgeons in which the ulceration 
has slowly progressed until it has reached several inches in extent (Fig. 2112), 
and lasting often for years before the appearance of symptoms indicating 
secondary deposit. In one case of my own, 
seventeen years, in a second, ten years, and in 
a third, nine years, elapsed. At length, how- 
ever, the lymph-glands in nearest relation 
with the ulcer are invaded, and by these 
routes the disease becomes generalized. 
It is difficult to fix even approximately the 
average period of lymphatic infection. The 
earliest period, I think, in which this has 
been observed in epithelioma is two months 
after the development of the growth. We 
shall err very little in stating that the 
metastasis varies from twelve to eighteen 
months, and that the intrusion is followed, 
often somewhat tardily, by the evidences of 
constitutional cachexia. This refers mainly 
to the cylindrical cell variety of epithelioma; 
squamous epithelioma is frequently exempt 
from metastasis. 
The progress of epithelioma is often for a 
considerable time attended with little suffer- 
ing, though at length severe pain is experienced, in its character similar to 
that realized in other forms of carcinoma, especially the hard or scirrhous 
variety, being lancinating and darting. 
The average duration of life in epithelial carcinoma will be found to be 
somewhere between three and four years, the patient dying from general 
irritation and extreme exhaustion, seldom directly from hemorrhage. 
Epithelioma consists of an increase of epithelial elements which infiltrate 
or grow into the surrounding and subjacent tissues. The cells correspond 
in form to those which normally belong to the part in which the neoplasm is 
located (see Fig. 2139): thus, in the skin and in certain of the mucous mem- 
branes, as the lips, tongue, palpebrse, prepuce, vagina, labia, portion of the 
uterus, etc., the cells are squamous; in the larynx, stomach, rectum, bladder, 
uterus, and the mucous membranes generally, the cells are columnar. The 
cells in epithelioma differ among themselves in other respects. In size they 
vary from f° tfs °f an diameter, the mean being about of 
an inch. Some contain a distinct oval granular nucleus having a diameter of 
sywg of an inch. In form the scales are flat, oval, and elongated, and exhibit 
irregular bodies. Other cells are seen in which the nuclei are in a state of 
active multiplication, one cell forming another (endogenous, brood, or mother- 
cell), and exhibiting a laminated appearance when seen by the microscope, 
while in other situations the cells are disposed in concentric layers (epider- 
mic globes or nests) and contain fatty and granular matters. The cells as 
659 
Fig. 2142. 
Epithelioma of the scalp. 660 
they penetrate the skin, the components of which form the stroma of the 
growth, arrange themselves into different forms, the presence of which de- 
termines the particular variety of the neoplasm, as the squamous, the 
cylindrical, or the tubular. 
TUMORS. 
Squamous Epithelioma.—In squamous epithelioma the cells are packed to- 
gether in such a manner as to form round or cylindrical masses, which are 
separated by a connective and vascularized tissue, exhibiting someAvhat the 
alveolated appearance seen in other forms of carcinoma. (Fig. 2143.) In 
Fig. 2143. 
Squamong epithelioma from the foot, viewed from the right Bide where the skin is normal; towards the left the 
cancer-cylinders are seen penetrating downward between the papillae and extending into the derm and subcuta- 
neous tissue. The several round bodies with concentrically-disposed lamina; are the nests or pearly bodies. X 40. 
the midst of this accumulation of cells are often seen bodies having a lustrous 
appearance, the globes epidermiques of Lebert, pearly bodies, laminated cor- CYLINDRICAL EPITHELIOMA. 
661 
puscles of Paget, to which allusion has been made. These bodies or nests 
consist of epidermic cells arranged in concentric layers. Fig. 2143 (low 
power) exhibits the arrangement of the histoid elements of a squamous epi- 
thelioma taken from the foot of a young man who had received a lacerated 
wound, the ulcer resulting from which, failing to heal, at length became trans- 
formed into a carcinomatous neoplasm. A magnified view from a small part 
of the same specimen is given in Fig. 2144. The cells are accumulated in 
Fig. 2144. 
Squamous epithelioma. Magnified view of a small portion of Fig. 2143. The cells massed into large 
groups, and one (left-hand side) shows the laminated or concentric arrangement of the layers of the 
pearly bodies. X 200. 
great numbers, and in the centre of each mass lie the pearly bodies, the dif- 
ferent masses being separated from one another by a vascularized connective- 
tissue stroma. 
Cylindrical Epithelioma.—This variety of epithelioma, first observed by 
Bidder, occurs only on mucous membranes and in the ovary. The neoplasms 
are usually met with in the stomach and the intestines. They are often mul- 
tiple, appearing as round nodules, and resembling, from their soft, juicy 
character, when seen by the naked eye, soft or encephaloid carcinoma. 
They are prone to ulceration and also to metastasis, the secondary deposits 
finding a new residence in the liver and lungs, especially in the former. 
Cylindrical-eelled epitheliomata are distinguished by the presence of tubu- 662 
TUMOIiS. 
Fig. 2145. 
/• rv. y, 
some of the cylindrical d^Wd^’ton^tud^naHy^n^othe^tnl**6*1 co1nnect,*e*ti«ue stroma; 
diately on a stroma and perpendicularly, formine conefor n transversely; cells resting imrae- 
and no attachment to the surrounding connective tissue. X 300 h lng’ however, no basement-membrane 
Fig. 2146. 
Tubular epithelioma from the nasal fossa1. X 300. SCIRRHUS. 
663 
lar cavities more or less irregular, and lined by layers of cylindrical cells 
which rest directly on a stroma consisting sometimes of connective tissue, at 
other times of embryonic tissue, or of mucous tissue. The cells are gen- 
erally elongated, contain one or more ovoid distinct nuclei, and rest on the 
stroma in the perpendicular position usually maintained in the normal state. 
(Fig. 2145.) The stroma is well vascularized, and when embryonic in char- 
acter the vessels appear to be destitute of walls, resembling sarcoma in this 
respect. 
A form of epithelioma styled tubular is also described by some authors, 
which, however, agrees so nearly with the cylindrical-celled variety in the 
arrangement of elements as scarcely to justify a distinction between the two. 
In the tubular neoplasm there are seen nests or pearly bodies imbedded in 
the midst of the epithelial cylinders, and the deepest layers of cells, or those 
next to the stroma, have the columnar form less marked than those of the 
cylindrical-celled epithelioma. (Fig. 2146.) 
Cylindrical-celled epithelioma is predisposed to colloid degeneration, and 
when a transformation of this nature takes place the tubular cavities become 
filled, either partly or wholly, with colloid material. It is this change 
which renders it often difficult to distinguish the transformation of epi- 
thelioma from colloid carcinoma, a task which can only be accomplished by 
studying such portions of the neoplasm as have not advanced to the stage of 
colloid transformation. 
Cylindrical epithelioma may also be confounded with adenoma of mucous 
membranes. The absence of cysts, and the disposition to penetrate into the 
deeper structures, instead of projecting from the surface, peculiarities belong- 
ing to the above form of epithelioma, will serve to establish the distinction. 
The prognosis in cylindrical-celled epithelioma is always grave. 
Scirrhus. 
Scirrhus (axififios, “ hard”) is the name given to a form of carcinoma remark- 
able for its great density or hardness. It is sometimes described as connective- 
tissue or fibrous carcinoma. It is most common between the fortieth and fifty- 
fifth years of life, the subjects of the disease in a considerable proportion 
of cases being women. The organs which suffer most frequently from 
scirrhus are the mammae, the stomach, particularly its pyloric orifice, the 
rectum, the uterus, and the oesophagus; less frequently the skin, lymph- 
glands, salivary glands, muscles, bones, lungs, and liver, and rarely, if ever, 
the testicle or the eye, are affected. Secondafy involvement of the lymphatic 
glands and metastasis to internal organs and other structures follow the 
primary tumor at no very distant period after its appearance. 
Of the causes concerned in the production of scirrhus very little is known. 
Chronic or catarrhal inflammations have been regarded as causative factors, 
as also traumatic violence. Hereditary peculiarities of organization cannot 
be excluded from the list of determining agencies. 
Scirrhus, when external, begins as a hard nodule, sometimes several distinct 
nodules, which finally coalesce, and which, at first possessing little sensibility, 
after a time become exceedingly painful, the pains being darting, shooting, 
stabbing, or pricking, often causing the sufferer to start and cry out from their 
severity. The pain, though often continuous, with occasional exacerbations 
of suffering, is generally paroxysmal, radiating in different directions along 
the nerves of the part, the attacks being influenced to some extent by irrita- 
tion reflected from the digestive apparatus, when deranged. As the disease ad- 
vances to the last stages, the patient enjoys few, if any, intervals of ease. Sleep 
can be procured only by the use of large doses of anod3Tnes, and, thus enforced, 
fails to refresh the wearied and distressed patient, and impairment of nu- 
trition and exhaustion of the body soon follow. The progress of the disease 
varies greatly, depending materially on the supply of blood-vessels, though 
it is generally much slower than that of the softer forms of carcinoma. 664 
TUMORS. 
In its advance the surface of the tumor becomes irregular or nodulated. At 
first movable upon the subjacent parts, it soon begins to contract attach- 
ments or adhesions, which lessen its mobility, or, finally, fix it firmly in 
place. Should the tumor remain movable, a noticeable clinical feature will 
be its stony hardness and great weight, out of all proportion to its bulk, 
when grasped and raised by the fingers. The tendency of the growth to 
lay hold of adjacent tissues is not confined to those which underlie the 
neoplasm, but extends to the skin, which it infiltrates and fastens to itself, so 
that not only is the integument glued to the growth and incapable of being 
moved independently of the latter, but it also becomes indurated and inelastic, 
and generally assumes a purple or leaden color, especially over those portions 
of the tumor which form prominent tubers or knobs. The invincible tendency 
manifested by scirrhus to draw into and incorporate with itself the soft 
tissues in which it develops explains several clinical features of the disease, 
—namely, the retraction of the nipple in cases of mammary cancer, from the 
shortening of the milk-tubes; the pitted, bacon-skin, or orange-rind appear- 
ance of the skin (lardaceous), caused by the contraction of the connective 
tissue which surrounds the follicular glands of the integument; and the ar- 
borescent configuration of dilated veins which appears over the surface. In 
some instances the infiltration spreads in such a manner as to cause no promi- 
nent or well-defined tumor, a deceptive swelling, which may entirely 
mask the nature of the disease. This swelling is the result of a serous trans- 
udation caused by mechanical obstruction—from fibrous contraction—of the 
venous trunks, which receive the blood from the tumor, and not from the 
presence of specific or epithelial elements. The accuracy of this will be 
demonstrated the rapidity with which this superinduced swelling will often 
disappear upon placing the arm in a posture which will relieve the vessels 
from pressure. While infiltration is a notable feature of scirrhus, the diffusion 
of epithelial elements is not equal in all directions. The tendency is to 
travel in the direction of the larger blood and lymphatic vessels which 
supply and drain the growth, and hence it is that in mammary scirrhus the 
axillary glands often become early infected. The progress of scirrhus does 
not always mean increase in bulk of the neoplasm; often the reverse is the 
case. The strangulating effects of infiltration will often destroy almost every 
trace of the original tissues in which it occurs,—withering or atrophic scirrhus. 
In two instances I have seen the mammas increase rapidly to a certain size and 
then begin to contract and lessen until every vestige of the glands had disap- 
peared, leaving a flat surface and one covered by a hard, tawny-colored skin 
resembling cicatricial tissue. In one of the cases referred to, the scirrhus 
commenced in one breast, and, after passing through the stages described, 
attacked the other breast, and when both glands had disappeared the disease 
or infiltration continued to spread down the front of the chest and upon the 
abdomen, the contraction becoming at length so great as to double the 
body of the poor sufferer on itself until the chin approached closely to the 
pelvis. 
When scirrhus develops in hollow viscera, as the oesophagus, the pylorus of 
the stomach, or the lower intestine, it encroaches rapidly upon the lumen of 
these organs, and after a time offers insuperable obstructions to the passage 
of liquid or solid matter. 
When external, sooner or later the skin at one or more points over this 
form of cancer becomes thinned out by tension and infiltration until ulcera- 
tion or sloughing follows, and deep, open sores are formed, from which a 
thin, sanious or ichorous fluid distills, emitting a very offensive odor, and ex- 
hibiting no tendency whatever to heal. As the work of structural destruc- 
tion goes on, bleeding, even upon the removal of local dressings, frequently 
follows, sometimes amounting to a hemorrhage, when a vessel of considerable 
size gives way under the erosive action of the disease. Even small vessels, 
when opened, which would close spontaneously if divided in an operation 
in sound tissues, will continue to pour out blood in ulcerating scirrhus, no SCIRRHUS. 
665 
doubt from their walls being glued to the inelastic fibrous tissue of the 
growth, thus preventing both their retraction and contraction. Not only 
does the contraction induced by the morbid process destroy the tissues which 
the neoplasm infiltrates, but sometimes by obliterating the vessels which fur- 
nish the blood-supply it destroys its own vitality, and the growth is over- 
taken by gangrene, resulting in its ejection from the surrounding parts as a 
slough, leaving an ulcer which spontaneously heals. This was the case in a 
female patient once under my care in the Philadelphia Hospital suffering 
from mammary cancer, although it did not prevent a recurrence of the disease 
in the adjoining tissues. 
Scirrhus may provoke inflammation at the outer boundaries of the neo- 
plasm beyond the sphere of epithelial infiltration, and in this way become 
encapsulated by a wall of organized lymph, which for a long time will prevent 
the extension of the disease. 
The constitution, in the early stage of scirrhus, exhibits few, if any, 
signs of the disorder: indeed, it is not uncommon to find a patient at the 
first development of the tumor enjoying more than ordinarily good health, 
Fig. 2147. 
Scirrhus, or hard mammary cancer. The section exhibits the fibrous trabecula: bounding the alveoli, and 
the latter occupied by epithelial glandular cells. X 300. 
perhaps accumulating fat at the time; and, were it not for the mental 
anxiety and unhappiness always awakened by the presence of an unwelcome 666 
TUMOltS. 
tumor, many patients would never suspect that a deadty malady had taken 
up its abode in the body. Sooner or later, however, some uneasiness is ex- 
perienced in the growth, which at length ripens into pain. The lymph-vessels 
receive the carcinomatous material and convey it to the lymph-glands in 
nearest relation to the tumor. These glands, loaded with infection, become 
round and hard, and by pressing upon adjacent venous trunks interfere with 
the flow of blood back to the heart, thus causing oedematous swellings of the 
parts below; soon the glands send the scirrhous elements onward into the 
efferent vessels, along which, mingled with the lymph, they are transported 
to the venous system, and finally are lodged in the capillaries of some of the 
internal organs, where, retaining the power both of multiplication and of in- 
fection, these elements begin the work of mischief anew, forming other centres 
of irritation and destruction. The resulting pain prevents sleep, the nutrition 
begins to be disturbed, the appetite is lost, the patient loses flesh and strength, 
the countenance becomes sallow, sunken, and careworn, until at length, the 
lymph, the blood, and all the secretions being vitiated, the sufferer, worn out 
by pain and exhaustion, welcomes death as a happy escape from an unre- 
lenting foe. 
The average duration of scirrhus is about three years. Cases, however, 
are occasionally met in which the disease has remained latent for a long 
time. In one instance, that of a lady whose breast I removed, it was ten 
years before the growth became aggressive. 
Pathology.—A section of a scirrhous or hard carcinoma shows a dense 
homogeneous and whitish substance, which yields, on pressure or by scraping, 
a more or less cream-like or grayish-white fluid, which is called the cancer- 
juice, and which is rich in cell-forms. When pressed between the fingers, the 
liquid has a slightly viscid feel. It is constituted largely of materials repre- 
Fig. 2148. 
Scirrhous carcinoma of the mamma,—a deeper or more central section taken from the tumor 
represented in the preceding figure. The cancer-cylinders composed of a narrow row of cells, 
and contained in correspondingly narrow alveoli. X 300. 
senting the fatty and other metamorphoses of the tissues which have been 
devitalized by the disease. Few blood-vessels will be seen in the neoplasm. ENCEPHALOID, OR SOFT CARCINOMA. 
667 
When studied with the aid of the microscope, the tumor will be found to 
consist of a stroma or frame-work of fibrous tissue, the trabeculae of which 
are pressed asunder by cell-infiltration in such a manner as to form variously- 
shaped chambers or alveoli, depending on the manner in which the sections 
have been made, some being round, others oval, and still others elongated. 
These alveoli are filled with compact masses of variously-formed cells,—can- 
cer-cylinders. (Fig. 2147.) The fibres of the trabeculae exhibit a slightly wavy 
appearance, and in their midst are proliferating cells. The alveoli, which 
are the boundaries of the lymph-spaces, are seen distended or enlarged by 
the accumulation of free epithelial elements which have broken through the 
basement-layer separating the glandular acini from the lymph-spaces, and 
in no place are they attached to any basement-membrane. While in some 
parts of a scirrhous tumor there will be seen, with the massive trabeculae and 
capacious alveoli, cancer-cylinders of considerable magnitude, in other parts, 
and especially those more central, there will be found a great preponderance 
of connective tissue over the cell-constituents of the neoplasm (Fig. 2148), 
necessarily increasing the hardness and weight of the growth. This con- 
densation and close packing of the connective tissue, with a corresponding 
diminution of cell-elements, is a common condition in the more central por- 
Fig. 2149. 
Atrophic or cicatricial scirrhus from near the centre of a carcinomatous tumor. 
tions of scirrhus, especially of the atrophic variety of the disease (Fig. 2149), 
and gives to the neoplasm more the appearance of a cicatrix than of a tumor. 
Encephaloid, or Soft Carcinoma. 
Various names have been given to soft carcinoma, as encephaloid, medullary, 
and fungus hsematodes, the latter being the vascular or telangiectatic variety. 
Encephaloid carcinoma attacks both internal and external organs, being 
notably common in the liver, the mamma}, the testicle, the ovary, the kidney, 
the salivary, thyroid, and parotid glands, and the bladder and antrum. Fe- 
males °uffer more frequently from the disease than males. Though no period 
of life is exempt from encephaloid carcinoma, it is most common between 
thirty-eight and sixty years. Twice I have seen soft carcinoma attack the 
mammae in very aged females,—in one at the age of one hundred, and in 668 
TUMORS. 
the other at the one hundred and seventh year,—in both instances quickly 
proving fatal. 
The clinical features which distinguish encephaloid from scirrhous carci- 
noma generally are very characteristic. In encephaloid the tumors attain 
much greater magnitude, are more likely to be multiple by metastasis, and 
progress more rapidly, than in scirrhus. That remarkable tendency to lay 
hold of and to contract the tissues, which is a dominant feature of scirrhus, 
is noticeably absent in encephaloid; also the integument covering a neo- 
plasm of the latter kind, instead of being adherent, dimpled, knobbed, and 
often dense and oedematous, is uniformly smooth or rises into globular masses 
and is attenuated by the extension of the accumulating cancer-products, 
while the tumor-mass is soft, elastic, or sensibly compressible, and its base 
often less extensive than its free portion, characters by no means belonging 
to scirrhus. 
Fluctuation is another differential quality possessed by soft cancer, and 
one which so closely imitates that of abscess that errors have many times 
been committed and a knife inconsiderately thrust into the growth before the 
difference has been discovered. The error is not a harmless one, as it pre- 
cipitates the ulceration of the tumor, with all the evils attendant upon fungous 
granulations, hemorrhages, and foul discharges. 
The occurrence of ulceration in encephaloid disease will, of course, be 
determined in a great measure by the rate at which the tumor grows. 
When its progress is rapid, the lesion may arise in four or five months, 
though seldom under any circumstances is it postponed beyond eighteen 
months. In this respect it occurs earlier than in scirrhus. Again, when ul- 
ceration does occur, the granulations are much more exubei’ant (fungoid) 
and the bleeding is more easily provoked and more profuse than is common 
in scirrhus, the ulcer of the latter being excavated, ragged, and crater-like. 
The life-history of encephaloid cancer is unlike that of scirrhus, the latter 
averaging two and a half or three years, while the former rarely extends 
over two years. Indeed, the disease has been known to run its course in as 
many months, as in the cases mentioned by Paget and Gross,—the first in 
seventeen days, and the last in eight weeks. In both instances the patients 
were young; and it is a rule that the earlier in life soft cancer develops the 
more rapidly is it fatal,—a result entirely in harmony with the physiological 
activity of tissue-nutrition. Exceptionally, encephaloid has been known to 
last for fifteen and even thirty yeai’s. 
The infection of lymph-glands occurs at a somewhat later period in enceph- 
aloid carcinoma than in scirrhus. This probably is to be accounted for by 
the external development or outgrowth of the neoplasm. In scirrhus the 
pain is ordinarily extremely severe, in encephaloid it is less so; the latter will 
also bear an amount of handling without causing any suffering to the patient 
which in the case of scirrhus would be followed by the severest paroxysms 
of pain ; and, finally, the cachexia due to the poisoned state of the fluids of 
the body appears sooner in soft than in hard cancer. 
Between encephaloid and scirrhus there are also anatomical differences. 
The latter rapidly destroys the tissues in which it is located, and replaces 
them chiefly by scar or contractile tissue, poor in blood-vessels, while the 
elements of the former, at least for a considerable time, are diffused through 
the structures in which it originates and in those adjoining, finding their way 
into the fissures or crevices between muscles, blood-vessels, and nerves, thus 
causing the destruction of tissue by necrosis, and the vascularity of the 
tumor is very great. It is, however, the microscopic picture of encephaloid 
disease, revealing the arrangement of histoid elements, which definitely 
establishes its nature. In general, it may be stated that in encephaloid 
carcinoma the epithelial elements greatly preponderate over the stroma. 
The connective-tissue trabeculae are delicate, and the alveoli which they 
circumscribe quite large and occupied by accumulations of cells (Fig. 2150) 
and an intercellular material. The blood-vessels cling to the trabeculae. ENCEPHALOID, OR SOFT CARCINOMA. 
669 
Just in proportion to the preponderance of cell-forms over the connective- 
tissue stroma will be the softness of the tumor. It does not follow, how- 
Fig. 2150. 
Encephaloid, or medullary carcinoma of the mammae. Cancer-cylinders of great size and not filling 
the alveoli, or lymph-spaces. The cells composing the cylinders imbedded in an intercellular substance 
and the connective-tissue trabeculae alive with proliferating corpuscles. X3U0. 
ever, that because the neoplasm is soft the alveoli will be large. This prop- 
erty will be present when these chambers are quite numerous and small. 
The condition of softness or compressibility depends upon the absence, in a 
great measure, of connective tissue. When a section of these tumors is made, 
the surface exhibits a brain-like appearance, having a white, reddish-yellow, 
or variously-colored aspect. When the carcinoma is constituted largely of 
dilated blood-vessels with attenuated walls, the connective-tissue elements 
being very scanty, the tumor, in consequence of its great vascularity, fre- 
quently pulsates and yields the usual purring sound and bruit which belong 
to aneurism. When such a growth ulcerates, and is followed by a mass of 
protruding or fungoid granulations, the neoplasm is spoken of as a fungus 
hcematodes. Occasionally the blood-vessels of an encephaloid carcinoma 
become dilated into numerous pouches, or diverticula, and closely resemble 
an erectile growth (telangiectatic carcinoma). 670 
TUMORS. 
Encephaloid cancer sometimes very closely simulates sarcoma (Fig. 2151), 
the stroma being scanty and seen like a faint tracing branching in different 
Fig. 2151. 
Encephaloid simulating sarcoma. 
Fig. 2152. 
Cancer-cylinders in encephaloid of the mammae undergoing fatty degeneration; cells ex- 
hibiting a granular appearance. 
directions and forming large alveoli. The distinction, however, can be made 
by observing that the cells contained in the alveoli are devoid of any inter- 
cellular material, and can without difficulty be brushed away from the sides 
of the alveoli. COLLOID CARCINOMA. 
671 
In all the highly-vascularized forms of encephaloid tumors it is common 
to find in their intexdor clots of extravasated blood, which have formed by 
ruptux-e of some of the thin-walled vessels. 
The cell-elements of encephaloid cai’cinoma are somewhat unstable, and 
liable to be ovei’taken by processes affecting their nuti’ition, causing degenera- 
tions of different kinds. Among these the most common ai*e the fatty, colloid, 
and melanoid ti'ansformations; less common ai-e the caseous and calcai-eous. 
Fatty Carcinoma.—In fatty degenei’ation the epithelial cells of the alveoli 
(cancei*-eylindei‘s) become filled with particles of fat and exhibit a gi-anular 
appearance, at the same time shrinking away from the walls of the lymph- 
spaces in which they lie. (Fig. 2152.) A similar degeneration may affect 
the connective-tissue coi'puscles of the sti’oma; indeed, fatty changes may 
always be seen in progi*ess in some portions of encephaloid cancer. 
Colloid Carcinoma.—In this fox-m of carcinoma the cells which occupy the 
alveoli become filled with a yellow, pale-white, or greenish colloid or gelatinous 
matter, which as it accumulates distends 
them into large globular x*efracting vesicles, 
ultimately causing their dissolution, until at 
length the alveoli become filled with this 
partly transpai’ent glue-like material (Fig. 
2153), which is easily tuimed out of the loculi 
in which it lies. As the sti’oma in colloid 
cancer often remains unaffected by the neigh- 
boring changes, the walls of the alveoli, which 
are dense, have an unusually distinct defini- 
tion, so stinking that this species of cancer 
has been designated alveolar carcinoma. A 
somewhat characteristic feature in colloid car- 
cinoma, especially when poi’tions of the stroma 
have undergone similar changes with those of 
the epithelial cells, is the assumption by con- 
fluent alveoli of a round or slightly oval form, 
Colloid cancer exhibits a preference for the 
liver, stomach, rectum, and mammae. 
Colloid cai’cinoma is most common between 
forty and sixty years of life. Its tendency to 
metastasis is less than that of scirrhus or other* 
varieties of encephaloid, a fact accounted for 
by the younger Gross by the mechanical ob- 
struction offered to the movements of the 
cells by the adhesive quality of the colloid 
material. Colloid cancer when occurring as 
a tumor is usually irregular or tabulated on 
the surface, and well supplied with blood-ves- 
sels, and is capable, when an outgrowth or an 
infiltrate, of destroying the tissues in which 
it appears. 
Fig. 2153. 
Melanotic Carcinoma consists in the deposit 
of dark or black pigment-granules in the epi- 
thelial cells of the alveoli and also lying free 
in the connective-tissue trabeculae. The pres- 
ence of this pigment imparts a dark, even 
black, appearance to the neoplasm. Mela- 
notic carcinoma is frequently encountered 
in the eye, and also in the skin of the body. 
When general ized, the secondary deposits are foun d to con tain a similar pigment. 
Colloid caroinoma of the leg. Walls of 
the alveoli or loculi distinct and filled with 
colloid matter.—From a wax model in 
the University Museum. 672 
TUMORS. 
Cheesy and calcareous degenerations are not common in carcinoma. The 
former may occur from loss of vascularity in a portion of the neoplasm, and 
the latter when the tumor is closely related to some portion of the skeleton, 
as the tibia, the femur, or the humerus. 
Diagnosis.—It is not difficult to distinguish by ordinary clinical observa- 
tion the different varieties of carcinoma from one another. 
Epithelial carcinoma, for example, generally begins as a fissure or a wart- 
like formation, with a hardened border or base, is seated either at or near 
the outlets of the body, where the skin and mucous membranes blend, pur- 
sues, as a rule, a slow, chronic course, and exhibits little tendency to infect 
the lymph-glands. Encephaloid carcinoma begins in the form of one or more 
nodules, grows rapidly, has a soft consistence, tends to ulcerate, early poisons 
the lymphatic glands, and runs its course with rapidity. The telangiec- 
tatic variety is detected by its soft, spongy feel, and often by the purring 
sounds which result from the numerous and delicate vessels which it contains. 
The melanotic variety of the disease is known by its dark color. The colloid 
carcinoma is distinguished by the regularity of its surface, and by having 
neither the firmness of scirrhus nor the softness of typical encephaloid, its 
density or consistence being alike at all parts of the tumor. The progress 
of colloid, also, is slow, as compared with that of other forms of soft cancer, 
and the pain is less severe. 
Between encephaloid and scirrhus the following differential features may 
be stated: 
In consistence, soft, compressible, and elastic. 
Growth rapid. 
Acquires large bulk. 
Pain moderate. 
Later implication of lymph-glands. 
Common before forty years. 
When ulceration occurs, the ulcer is deep, its 
borders irregular, livid, and undermined, with 
abundant and foul discharges, and often giving 
rise to profuse bleedings. 
Frequently affects the testicle among other 
ENCEPHALOID. 
Hard. 
Growth slow. 
Bulk diminishing with the progress of the dis- 
ease. 
Pain severe. 
Early implication of lymph-glands. 
Rather later in life. 
Ulcer rather shallow, with perpendicular edges; 
little discharge; bleeding infrequent. 
Rarely affects the testicle. 
SCIRRHUS. 
Encephaloid carcinoma may be confounded with adenoma (atypical) and 
sarcoma. Certain differential characteristics belonging to the three neo- 
plasms have already been noticed, but it will not he out of place to contrast 
these growths just here in connection with others, in order that all may be 
collected into one general grouping. Although the surgeon may arrive at a 
tolerably correct diagnosis by a careful study of the clinical history of the 
three distinct morbid growths named, yet by the microscope alone can he 
determine beyond doubt tbeir true nature. 
The clinical differences between carcinoma and sarcoma are as follows: 
Occurs after forty. 
Subcutaneous veins over the tumor enlarged. 
Progress rapid. 
Prone to ulceration. 
Implicates the lymph-glands. 
Not common in periosteum and bones. 
When ulcerating, granulations moderately re- 
dundant. 
Not encapsulated. 
Ends fatally in twelve to eighteen months. 
CARCINOMA. 
Occurs before forty. 
Only occasionally, and rarely is the enlargement 
very marked when present. 
More rapid when pursuing an acute course. 
Ulcerates reluctantly. 
Rarely implicates the lymph-glands. 
Common. 
Exuberant fungous granulations. 
Often encapsulated. 
Frequently continues two years and more. 
SARCOMA. 
By the revelations of the microscope all uncertainty can be removed. 
Thus studied, the two tumors will be found to differ in physiological deriva- 
tives, in histoid elements, and in the disposition of the same. TREATMENT OF CARCINOMA. 
673 
DERIVED FROM EPITHELIUM. CELLS 
EPITHELIAL. 
DERIVED FROM CONNECTIVE TISSUE. 
CELLS CONNECTIVE-TISSUE TYPE. 
Cells irregular in form and size. 
Cylindrical plugs. 
Stroma arranged into alveoli or loculi. 
Quite uniform in both respects. 
Not in circumscribed masses. 
Alveoli, even in the alveolar variety, quite im- 
perfect, the trabeculae being mere traces of con- 
nective tissue. 
Intercellular substance, cells and trabeculae 
closely united together. 
Blood-vessels wall-less. 
Intercellular material, cells and trabeculae 
loosely associated. 
Blood-vessels with walls. 
In distinguishing carcinoma from atypical adenoma, the microscope will be 
found to furnish very satisfactorily the key to the differential diagnosis. 
Alveoli formed by the lymph-spaces in the con- 
nective tissue. 
Epithelial cells break through the basement- 
membrane and infiltrate the periglandular con- 
nective tissue. 
CARCINOMA. 
Alveoli formed by the dilatation of the glands. 
Epithelial cells, though accumulating in large 
numbers, fail to infiltrate, being contained in the 
glandular acini, as the basement-membrane re- 
mains intact. 
ADENOMA. 
Treatment.—In spite of the vast progress which has been made in the 
study of malignant neoplasms during the last few years, the surgeon is com- 
pelled to confess, with no small degree of mortification, that, notwithstand- 
ing all the splendid achievements which have crowned his art, he remains 
powerless to cure malignant disease. 
Although carcinoma is a hopeless malady, and in most instances defies 
both local and constitutional treatment, yet it does not follow that on this 
account the poor victim of so relentless a disease is to be abandoned to his 
or her fate without medical or surgical aid ; on the contrary, much can be 
done to prolong life and to palliate suffering. Though it is true that car- 
cinoma is entirely lawless, that we possess no remedy which is capable of 
extirpating, modifying, antidoting, or even materially staying its progress, 
yet it is equally true that the work of devastation is intensified by every 
circumstance which lowers the physiological forces of the body; hence a 
most important indication in the treatment is to preserve with jealous care 
the various functions of the organs in the very best possible working order. 
With this object in view, every source of irritation calculated to disturb the 
digestive, circulatory, or respiratory systems must be avoided or removed. It 
must not be forgotten that the inevitable tendency of a malignant neoplasm 
is to corrupt the blood by planting in that fluid its own seed, and thereby 
render the pabulum of the tissues unfit for their nutrition. It is, therefore, 
the duty of the surgeon to maintain the general health on the highest possi- 
ble plane. This involves, first, a carefully-arranged diet, selecting such arti- 
cles of food as will contain a large amount of the elements of nutrition and 
yet not tax the digestive organs. Ordinarily it will be found that milk, eggs, 
fresh meats in moderation, and farinaceous articles will be most acceptable to 
the stomach, while salt meat, fats, rich dressings, hot bread, and pastry should 
be avoided. The bowels, if torpid or constipated, will require to be gently 
acted upon once every day or two by the use of some mild saline, as Rochelle 
salts, to be taken early in the day, three-quarters of an hour before the 
morning meal. The patient should have the benefit of fresh air by riding, 
or, when this is not possible, by quiet walks, never prolonged to the extent 
of fatigue. Cheerful company will also conduce greatly to the comfort of 
the patient, by preventing morbid thoughts and diverting the mind from the 
physical ailment. When the appetite flags or the general strength begins to 
fail, benefit will be realized from the employment of tonics, the best being a 
combination of extract of gentian, or quinine with iron, arsenic, and strych- 
nia. Cod-liver oil, when it is well borne by the stomach, can often be ad- 
ministered with benefit along with Blanchard’s preparation of the iodide of 
iron. Some practitioners are wont to vaunt arsenic as possessing some 674 
TUMORS. 
specific property antagonistic to the carcinomatous elements. The late Dr. 
Washington L. Atlee and Dr. Parker, of New York, have spoken in terms 
commendatoiy of this agent, but I have never seen any other effect which 
could be ascribed to the use of the remedy than that of a tonic. The same 
may be said of iodine, of silica, used by Batley, and also of Chian turpentine, 
which has lately attracted some notice from the representations made by a 
London physician in regard to its power in controlling uterine carcinoma. 
Pain, which is one of the dreadful entailments of the disease, must be 
moderated by opiates, and, whatever may be said against the use of these 
agents, it is far better to tolerate some inconvenience from their employment 
than to endure the suffering which prevents sleep during the night, and makes 
the weary hours of the day witnesses to a helpless struggle against a foe 
which only gains a more easy and speedy victory by the very opposition 
encountered. 
Local Treatment.—This includes the use of remedies proper to the tumor 
both in its closed and in its open or ulcerating state. In the former condition, 
whatever will conduce to the rest of the tumor will be important. Thus, 
if the growth is heavy or drags, a proper sling or support will be necessary. 
Moderate compression will frequently lessen the sensibility and retard the 
growth of the neoplasm, not only by fixing the tumor, but also by keeping 
out of its vessels a certain amount of blood. 
Compression in the treatment of carcinoma—an old plan—was revived by 
Mr. Arnott, of London, and was applied by using a rubber air-cushion fash- 
ioned to suit the form of the tumor, and fixed to a brass spring, thus enabling 
the operator to graduate the degree of pressure at pleasure. It is possible to 
reduce the size of a tumor by pressure, if kept up with considerable force 
and for several weeks in succession, but it never exterminates a carcinoma; 
it only represses its growth, and may do harm by causing an earlier general- 
ization of local elements. The report of the surgeons of the Middlesex Hos- 
pital, who made a practical test of pressure in the treatment of carcinoma, 
was adverse to its use. Compression may also be applied by means of adhe- 
sive strips. When the growth is sensitive or painful, covering the part with 
a belladonna plaster, or by one in which iodoform or opium is incorporated 
with the belladonna, will frequently afford relief; and with the same object 
in view, a mixture of equal parts of laudanum and tincture of belladonna 
may be applied, by wetting a piece of lint or old linen with the liquid and 
laying it over the part, covering it with a piece of oiled silk in order to 
preserve the dressing moist. 
Cold.—The application of cold is sometimes followed by a good result in 
relieving pain and appai’ently repressing the growth of a malignant neoplasm. 
An ice-bag filled with broken pieces of ice constitutes the most eligible method 
of employing cold and at the same time not wetting the clothing of the patient. 
I have by this plan secured long intervals of exemption from pain when ano- 
dynes could not be taken. Arnott, who introduced cold into the treatment 
of carcinomatous neoplasms, carried the coagulation to the extent of destroy- 
ing completely the vitality of the tumor. The slough thus produced, however, 
did not include the growths in their entirety, but only a small portion, and, 
therefore, was by no means radical. 
When ulceration takes place, a different class of remedies will be demanded. 
The surgeon must contend with foul discharges, which render the atmosphere 
of the patient’s chamber extremely offensive, and frequently with profuse 
hemorrhages, which seriously deplete the system and hasten the fatal termi- 
nation of the disease. Under these circumstances frequent ablutions of the 
ulcer should be practiced, employing for the purpose solutions of chlorinated 
soda, of permanganate of potash, or of listerine, which latter is admirably 
adapted for the purpose of cleansing foul ulcers. Pledgets of lint or old linen 
wet with this liquid and laid over the open surface of the tumor are not only 
soothing, but rectify for some time the bad smell which emanates from the 
watery and ichorous discharges which flow from the vessels of the sore. TREATMENT OF CARCINOMA. 
675 
Carbolated oil, employed in the same manner, by many patients is preferred 
to all other remedies, exerting as it does a decided sedative effect on the 
nerves of the exposed surface. 
Chloral is another remedy which frequently is found to give comfort, and 
should be applied in the same manner as listerine, the solution having the 
strength of ten grains to the ounce of water. 
When these agents fail to afford relief from local suffering, there are others 
to which the surgeon may resort, as iodoform, opium, and morphia. Any 
one of these articles sprinkled over the surface of the ulcer will in many 
instances secure a suspension of pain, or at least greatly lessen its severity. 
The internal use of Harlem oil, in doses of fifteen or twenty drops, some- 
times appears to exert a mitigating influence over the pain of cancer. 
Hemorrhage, when it occurs, will be best controlled by the use of per- 
sulphate of iron, tannic acid, or powdered alum. Whichever one is selected, 
the powder should be thickly strewn over a piece of lint or a little pledget 
of charpie, and the dressing placed upon the bleeding surface. Liquid prep- 
arations are also used in these cases as haemostatics. Among these the most 
valuable are alcohol, phenol sodique, Monsel’s solution of iron, saturated 
solutions of alum, and infusions of matico. Yery hot water, applied by 
wringing out a napkin previously dipped in boiling water and pressing it 
for a short time against the bleeding surface, is often effectual in arresting 
the flow of blood from small vessels. It may be necessary, when the bleed- 
ing is very profuse, to apply, in addition to the means already mentioned, 
a compress and pressure by a roller bandage. When the blood issues from 
single points, touching them with a stick of nitrate of silver often will seal 
them up. In cases disposed to repeated bleedings I have found that the 
application of a crayon of this caustic to the surface of the granulations once 
every two or three days will not only lessen the ichorous discharge, but 
prevent the recurrence of hemorrhage. 
The radical treatment of carcinoma, however, is the great and absorbing 
question which interests both surgeon and patient. By this is understood 
the removal of the neoplasm from the body. The measures employed for 
this purpose are cauterization, injection, electrolysis, and excision. 
Caustics.—These agents constitute the popular resources of charlatans for 
the treatment of cancer, and have, through the ignorance and rashness of 
“cancer doctors,” caused an incalculable amount of suffering and damage to 
the subjects of carcinoma. It is unfortunate that there are no means afforded 
by either civil or criminal law to protect humanity against the practice of 
these pretenders. It is not uncommon to see bones laid bare and neci’osed, 
or portions of the mammary gland remaining undestroyed and in a state of 
ulceration, from the reckless and ignorant use of potent caustics. 
In small patches of epithelial carcinoma the disease can be removed with 
little or no difficulty by caustics, and in such cases, where patients dread the 
knife, it will be the proper plan to adopt. 
The active constituents of the caustics which have been in popular use are 
chloride of zinc, caustic potash, and arsenic. Of this number the first two 
are those to be preferred. Chloride of zinc is an exceedingly painful caustic, 
the suffering lasting many hours, but it is very effectual in its work. Caustic 
potash desti’oys the tissues with great rapidity, but has the disadvantage of 
causing troublesome hemorrhage in many localities. 
The chloride of zinc is used either as a paste (one part of the salt and 
three parts of gum arabic mixed and moistened with a little water) or in the 
form of arrows, in making which the paste, prepared as in the preceding 
formula and allowed to dry, is cut into pieces, each about one-eighth of an 
inch wide and one-half inch in length. 
In applying the paste, a portion of it is laid over the diseased surface (which 
if not open must first be denuded by blistering), the surrounding healthy por- 
tions being protected by a ring of adhesive plaster, and over all a strip of 
the latter should be placed. In estimating the amount of paste which will TUMORS. 
be required to penetrate a certain depth of tissue, it will be found that this 
caustic will usually destroy an amount of structures equal to three or four 
times its own thickness,—that is, a paste one-eighth of an inch thick will 
produce a slough from three- to four-eighths in depth. 
In using the an-ows, incisions are to be made into various portions of a 
tumor, and the caustic points inserted, being separated about one inch. The 
pain incident to so extensive a use of the caustic must be assuaged by opiates. 
After the destruction has been accomplished, the separation of the dead mass 
will be facilitated by the use of poultices, renewed once in eight hours. In 
using caustic potash for the removal of malignant growths, it is necessary to 
protect the adjoining sound tissues by surrounding the diseased part with a 
ring of wax, gutta-percha, or adhesive plaster. The caustic is then rubbed 
over the affected surface, and the disorganized structures are scraped away as 
they soften. This process is to be continued until the entire new formation 
has been removed, which usually can be effected at a single sitting. If it is 
apprehended that the caustic will penetrate too deeply, its action can be 
promptly arrested by applying some acid agent, as acetic acid, which will 
neutralize the alkali and convert it into a harmless acetate of potash. The 
same acid can occasionally be applied to the surrounding skin during the 
progress of the operation, should it appear that the caustic is spreading 
beyond its legitimate boundaries. When the diseased part has been destroyed, 
it only remains to cover the surface of the sore with a pledget of lint held in 
place by a compress and an adhesive strap. When the hemorrhage is too 
free, or does not cease spontaneously, it can be controlled by sprinkling sub- 
sulphate of iron on the bleeding surface and applying a compress. After the 
lapse of twenty-four or thirty-six hours, a light flaxseed-meal poultice should 
be laid over the cauterized part, to hasten the separation of the remaining 
slough, after which granulation and cicatrization will be favored by dressing 
the ulcer with a slightly-stimulating ointment, the unguentum resinse an- 
swering the purpose very well. The use of caustic potash is attended with 
very severe pain at the time of its application, but its duration is usually brief; 
when the operation requires considerable time, the patient should be placed 
under an anajsthetic. 
Arsenic, I presume, is very rarely employed as a caustic at the present 
time. Its absorption, followed by fatal poisonous effects, has so often oc- 
curred that it has been wisely discarded as a local application in cancer. 
Like chloride of zinc, it can only act after the cuticle has been removed. 
Caustics have no advantage whatever over the knife; on the contrary, 
they are inferior in every sense. The pain attending and following their 
use is vastly greater than that produced by the scalpel. The removal of the 
tumor and the subsequent healing are very slow as compared with excision. 
Recurrence of the disease is very frequent; probably more so than after 
extirpation by cutting instruments. The statement that in consequence of 
the penetration of caustics into the tissues adjoining the neoplasm for which 
they are applied, there is greater probability of the infiltrated elements of 
the cancer being reached, is altogether unfounded, and is no argument in 
favor of their employment, as the knife of the surgeon in excising a tumor 
usually goes into what appears to be healthy tissue at a greater distance 
from the disease than does the extension of any caustic action. 
Caustics, therefore, in the treatment of malignant tumors, in my judg- 
ment, occupy a very narrow field, one which I would limit to cutaneous 
carcinoma (epithelioma), and then to be resorted to only when patients are 
unwilling to submit to excision. 
Injections.—The introduction of caustics and other substances hypoder- 
mically into malignant as well as other growths, with a view to their de- 
struction, has been practiced by Simpson, Broadbent, and others. For this 
purpose Broadbent employed acetic acid (one part of the acid to three parts 
of water). This agent was selected by reason of its cell-destroying proper- 
ties. From twenty drops to one fluidrachm of this agent were introduced TREATMENT OF CARCINOMA. 
677 
into the tumor by the ordinary hypodermic syringe. Time has shown that 
little is to be expected from this plan of treatment. 
Electricity has also been pressed into service as a tumor-destroying agent; 
hut, except in the particulars of modifying pain and, possibly, in some instances 
lessening the progress of the neoplasm, it has no power to cure carcinoma. 
Galvano-cautery.—This instrument can be used for the removal of car- 
cinomatous growths in certain localities, for example, the tongue. The 
operation is often entirely bloodless. 
Paquelin cautery.—This cautery in surface carcinoma or epithelioma can be 
made available for the destruction of the diseased tissue. 
Ecraseur.—Malignant neoplasms can be successfully attacked by the 
ecraseur. The parts best adapted for the instrument are the penis, the 
tongue, and the cervix uteri. 
Ligature.—Resort has been had to the ligature for the removal of carcino- 
matous tumors, chiefly limited to those of the tongue. It is inferior in every 
respect to the knife, the ecraseur, and galvano-cautery. 
Excision.—The extirpation of carcinoma by the knife is to be preferred to 
all other plans of treatment. It is expeditious, is attended with very little 
suffering, and is more thorough than any other method. 
In extirpating a carcinomatous tumor by the knife, the surgeon should 
make it a rule to carry his incisions into the sound tissues some distance 
from the growth. He should also examine with the utmost care every part 
of the wound and its vicinity, to ascertain that no part of the disease has 
escaped his dissection ; nor should a single fragment of tissue be allowed to 
remain to which the slightest suspicion is attached. In going over the 
ground the finger will prove a valuable aid to the eye, as by the touch we 
often can detect a degree of structural alteration which would escape dis- 
covery by the organs of sight. All enlarged glands require to be removed. 
Incisions should be planned so as to secure a sufficient tegumentary covering 
for the wound; and where the tissues are too scant, or in closing would be 
subjected to too great tension, additional covering may often be obtained by 
taking a flap from adjoining parts. 
Diseased skin should always be sacrificed, even if the wound in consequence 
should require to heal by open granulations. 
In the extirpation of epitheliomata, rather than close the wound by 
bringing its sides together, some surgeons prefer to borrow a sufficient 
amount of adjoining sound tissue with which to close the gap, believing that 
by so doing the liability to recurrence of the disease is lessened. I have 
seen nothing confirmatory of this opinion. 
In all operations for the removal of carcinoma, as little blood should be 
wasted as possible; to this end, vessels which bleed freely should be tem- 
porarily secured by serres-fines as the operator proceeds. In order to favor 
undisturbed and rapid healing, no wound should be closed until bleeding 
has entirely ceased. No clots should be allowed to remain, and, on the 
theory of low organisms being influential in retarding reparative processes, 
it is well to wash the entire exposed surface of the wound with some ger- 
micidal liquid, as carbolized water, or, what is more pleasant, dilute listerine.* 
The introduction of a drainage-tube through the wound constitutes an im- 
portant part of the dressing. No more sutures than are absolutely necessary 
should be employed in approximating the edges of the wound. The sites of 
these stitches are often seen to be first elected by the disease when recurring. 
They frequently seem to degenerate into keloid. 
The general treatment following operations for carcinoma will not materi- 
ally differ from that proper to be adopted in wounds from other causes, and 
consists in keeping the patient quiet, attending to ventilation and cleanliness, 
directing, after the subsidence of surgical fever, a light, easily-digested diet, 
consisting of milk, animal broths, eggs, bread, butter, rice, oatmeal, and 
* The constituents of listerine are thyme, eucalyptus, baptisia, gaultheria, mentha arvensis, and 
benzo-boracic acid. 678 
TUMORS. 
fruits. Unless the patient sutfers considerably from pain, opiates aro to be 
avoided; and when the necessity for their administration does arise, they 
should be withdrawn at the earliest possible moment. Tonics, as quinine, 
iron, or the mineral acids, will be indicated when the strength of the patient 
requires some artificial help. 
Conditions forbidding operations.—Under no circumstances are operations 
for malignant disease performed with the expectation of working a cure, but 
only to prolong life. In many instances they are badly timed, and hasten 
rather than postpone the fatal event. Therefore it is proper to lay down 
some general rules which are to guide the surgeon in determining the ques- 
tion of operation. 
1. All operations are contra-indicated in multiple carcinoma; that is, 
where the disease exists in different organs or parts of the body at the same 
time. 
2. Operations are to be declined when other and necessarily mortal dis- 
eases coexist with cancer, as pulmonary tuberculosis, organic disease of the 
kidneys, or disease of the brain. 
3. The knife should be withheld in case of acute carcinoma; that is, 
where the neoplasm, after its appearance, grows very rapidly, infiltrating 
widely the surrounding tissues, infecting the lymph-glands, and contracting 
attachments which lessen the mobility of the growth. Under these circum- 
stances the disease soon recurs after excision, often, indeed, before the wound 
heals, and the death of the patient is materially hastened. 
4. Equally important is it not to operate when, simultaneously with the 
appearance of the neoplasm, the skin is found indurated and oedcmatous, 
adherent to the tumor, having a tawny color and its surface marked by 
numerous little depressions, resembling somewhat the rind of a lemon. 
Cases of this nature never admit of surgical interference, especially in 
mammary cancer. 
5. When the tumor is adherent to the skin and the parts on which it 
rests, and when the axilla, if it is a mammary cancer, is filled with hard and 
closely-united axillary glands, the arm swollen and oedematous, and the 
lymph-glands of the neck enlarged, the case is not one for operation. 
6. No operation is allowable wThen the disease has become generalized, 
a condition which is readily recognized by the cachectic impress, which 
appears in the sallow, pinched face, with emaciation and loss of strength. 
7. A tumor which, after making its appearance, remains quiet, not in- 
creasing in size, and is unattended by pain or by any change in the tissues 
in which it is located, should be left alone. I have seen such growths remain 
in this state for years, and give no trouble until after injudicious interference. 
8. Operations for the purpose of palliation are proper under certain cir- 
cumstances, as when a carcinomatous tumor has ulcerated and the patient is 
subjected to profuse recurring hemorrhages, or when the pain is so intense as 
to prevent sleep and is rapidly producing exhaustion. CHAPTER XXXVII. 
DISEASES OF THE MAMMARY GLAND. 
The mamma) rest upon the great pectoral muscles, to the sheath of which 
they are loosely connected by delicate fibrous tissue. They belong to the 
class of compound, racemose glands, which reach full development only in 
the female, remaining rudimentary in the male. They consist of lobes, fif- 
teen or twenty in number, each one being made up of lobules, and these, 
again, of acini or vesicles. From each lobe, by the conjunction of the differ- 
ent ducts, there is formed a principal excretory duct, which at the base of the 
nipple becomes dilated into a sac, and, again becoming contracted into a tube, 
is continued to the summit of the nipple, where it and others, in number 
corresponding to the lobes, open on the surface. The glandular elements 
are surrounded and bound together by white filamentous and also elastic 
connective tissue. The gland-acini or vesicles consist of a basement or struc- 
tureless membrane resting on connective tissue, covered with an intricate 
net-work of capillary vesicles, and contain nucleated, flat, oval, and columnar 
cells. The entire mass of the gland is enveloped by cellulo-adipose tissue, 
and anteriorly is covered by skin. 
The nipple is composed of the terminal ducts united by connective and 
muscular tissue, mingled with which are lymphatics, nerves, and blood- 
vessels, all covered by a corrugated or rugose skin, beneath the cuticle of 
which and for some distance around (areola) are numerous pigment-cells, the 
presence of which imparts the dark color which normally belongs to this 
structure. Within the boundaries of the areola are numerous large sebaceous 
and hair glands, none of which exist on the nipple. The nipple, in virtue of 
the contractile fibres in its composition, is capable of erection under certain 
irritations, both local and general. The lacteal ducts as they pass through 
the skin of the nipple are extremely small, a fact which, in connection with the 
existence of contractile fibres, will explain the modus by which a stillicidium 
of milk is prevented during lactation. In suckjng, two factors are concerned 
in giving free flow to the milk,—first, the suction-power, and, second, the 
warmth of the child’s mouth causing relaxation of the contractile tissue. 
The breasts undergo important changes under the operation of causes con- 
nected with the female economy. When the young girl reaches puberty, or 
on the establishment of the menstrual function, they suddenly increase, the 
enlargement being due either to a great addition of adipose tissue or to the 
development of tbe glandular elements, the ducts and acini of which up to 
the above-mentioned period are almost solid, with only a trace of epithe- 
lium. The nipple has a pink color and becomes somewhat raised, the entire 
gland assuming a conical shape, and becoming prominent, but not pendent. 
The mamma) often undergo periodical enlargements at each recurring men- 
strual period. The sympathy which exists between the ovary, the uterus, and 
the mamrme has a pathological as well as a physiological importance. Con- 
ception and gestation are also followed by a gradual enlargement of these 
glands, and after parturition and lactation the increase is still more marked. 
With the enlargement following puberty there is an increase in the terminal 
or cmcal extremities of the glandular portion of the organs, with an accumu- 
lation of epithelium. These changes give to the breast its lobular form so 
readily recognized by the touch, and it is to the unusual accumulation of 
epithelium and fat-cells that we attribute the voluminous mamma) of the 
nursing mother. DISEASES OF THE MAMMARY GLAND. 
680 
The arteries which supply the breasts are chiefly derived from the inter- 
costal branches of the internal mammary, some twigs also being derived from 
the axillary. 
The veins empty into the mammary and axillary. 
The nerves are derived from the intercostal, cervical, and axillary plexuses. 
The lymphatics terminate in the axillary glands. 
The breasts of boys at puberty frequently undergo a slight enlargement 
and become hard and painful. It is not very uncommon at this time to find 
a serous fluid discharged from the nipple. 
This rapid sketch of the anatomical elements of the mammae and their 
arrangement will enable the reader who may not be entirely familiar with 
their structure to understand more clearly those pathological changes to 
which these glands are liable. 
The abnormalities observed in regard to the mammae are—first, entire 
absence of one or both glands. Dr. Lonsier mentions a case of absence of 
the breast in a mother, who transmitted a similar vice of conformation to 
a daughter; and Dr. Handyside* records another instance of the congenital 
absence of the mammae in two brothers. The parents of the latter presented 
nothing abnormal. Second, multiple breasts, there being more than two. 
A case is mentioned by M. Robertf of a mother having several mammae. 
St.-HilaireJ has placed on record the case of a lady who had four breasts, 
symmetrically placed on each side. A projection resembling a cow’s tail 
occupied the median line between the lower breasts. A Roman woman is 
described by Lyncens as having four beautiful breasts ranged one above 
another. Bartholin§ met with a Danish woman who had three breasts, the 
supernumerary one placed in relation to the other two so as to form a tri- 
angle ; and G. Hannoeus|| saw a lady having the same number, all beautifully 
formed and giving milk. They were arranged in the same line. Another ease 
is given, by M. Percy, of a similar character in a woman of Treves. The 
same published the case of a woman seen by M. Garre, a military 
surgeon, who had five breasts ; two pairs were symmetrically arranged, and 
the fifth was located on the median line above the umbilicus. Four of the 
glands were full of milk and large, the fifth was like that of a young girl. 
M. Percy writes that Anne Boleyn, wife of Henry VIII., had six fingers, six 
toes, and three breasts. Third, imperfect development, there being only a 
rudimental nipple-attachment to the pectoral surface, with perhaps a sen- 
sible thickening of the surrounding parts within a narrow circumference. 
Fourth, asymmetrical development, one being large and the other small. 
Fifth, though rare, a misplaced gland, being situated in a foreign locality. 
Some remarkable examples of this kind have been observed. M. Jussieu** 
speaks of one in which the gland was situated in the inguinal region, and 
Sannoisft mentioned a woman who had four breasts, two being placed on 
the back. A third case is given by Robert,JJ of a mother, one of whose 
breasts was located on the inner side of the thigh, from which she nursed 
a child, who, when able to walk, was in the habit of standing under his 
mother’s clothes to suck. 
Affections of the Nipple. 
The Congenital Abnormalities of the nipple which have been observed are 
its absence, extreme smallness, partial division (forming two processes), and 
multiplicity. 
In the “Nashville Journal of Medicine and Surgery” for April, 1883, Dr. 
• Journal of Anatomy and Physiology, 1873, vol. vii. p. 56. 
f Journal G6n6ral de Medecine. 
j American Journal of Obstetrics, vol. xi. p. 719. 
| Ibid. || Ibid. 
Dictionnaire des Sciences Medicates, t. xxxiv. 
•* Lancet, vol. xi. p. 618. 
ft Dictionnaire des Sciences M6dicales, t. xxx. p. 376. 
jj American Journal of Obstetrics, vol. xi. p. 719. AFFECTIONS OF THE NIPPLE. 
681 
Turney has published the history of a mother who had a supernumerary 
misplaced mamma situated in the axilla, and without a nipple. 
Dr. Hurt* reported a case of a lady the areola of whose breast was studded 
with small nipples. During lactation the milk was discharged from each one. 
Dr. B. Woodmanf mentions an instance of a mother with three nipples. 
Her eldest daughter presented the same abnormity. 
One of the most remarkable cases is that given in the “ Centralblatt fur 
Gynaekologie,” November 6, 1886, in which there were eight breasts and 
eight nipples. 
The surgical affections of the nipple, including those of the areola, may 
be benign, contagious, and malignant. 
Retracted Nipple.—This condition of the nipple may be either congenital 
or inflammatory. When the former, the nipple is both atrophied and deeply 
sunk in a sulcus beneath the level of the surrounding integument, and does 
not admit of improvement. When there is no atrophy, the defect sometimes 
admits of at least partial correction by using a long narrow cup, such as is 
employed in connection with artificial leeching, which being placed over the 
part and exhausted of its air from time to time will gradually draw the nipple 
out by elongating the elements of which it is composed. In the parturient 
female this treatment may be practiced during the last months of gestation. 
Retraction is often due to inflammatory shortening of the anatomical com- 
ponents of the nipple. If the inflammation has been acute, some improve- 
ment may be anticipated, as the new elements are unstable and likely to be 
in a measure absorbed; when the result of chronic inflammation, the deform- 
ity will in all probability remain permanently, as the transudation is usually 
organized into a higher (connective) tissue. Retracted nipple is one of the 
clinical signs of scirrhus of the breast resulting from the contraction of the 
fibrous constituent of the gland. 
Ulceration.—Ulcers of the nipple occur in different forms. When the uleera- 
tion is linear, and occupies the grooves described in the anatomical resume of 
the part, it is a fissure; when the epidermis is shed both from the concave 
and convex surfaces of the plications, the condition is termed an abrasion; 
and when the destruction of tissue extends through the depth of the cutis, the 
sore constitutes an erosion. These ulcers have in some instances assumed 
a phagedsenic intractability, resulting in the entire destruction of the nipple. 
All of these lesions are met with in nursing women, especially primiparse, and 
are the result of maceration and traumatism by the mouth of the child in 
sucking. Some nipples are notably predisposed to these accidents from some 
peculiarity of structure, or they may arise on account of the reluctance with 
which the milk in some instances is delivered from the nipple, in consequence 
of which the infant is provoked to unusual tugging at the parts. 
Treatment.—Much may be done to prevent these lesions of the nipple by 
carefully washing the parts two or three times daily with equal parts of rose- 
water and alcohol, or with lotions of borax, or of gallic acid and glycerin. 
Bathing the nipple and areola with claret wine also constitutes a good pre- 
ventive, its value being chiefly due to the tannin which it contains. When 
any of these remedies is employed, the nipple must be thoroughly cleansed 
with hot water before the infant is placed to the breast. 
When a lesion does form, whether fissure, abrasion, or erosion, the nipple 
becomes red and inflamed, a serous, often sero-sanguinolent, fluid is dis- 
charged from the affected surface, and severe pain is produced whenever an 
attempt is made to nurse the child. 
The measures ordinarily employed to correct these lesions are bathing the 
parts with weak solutions of sulphate of zinc, boracic acid, or alum, and, 
after drying the nipple, brushing over the abraded surface some collodion, 
* St. Louis Medical and Surgical Journal, vol. xxxix., No. 5, p. 306, 1880. 
f Transactions of the Obstetrical Society of London, vol. ix. p. 50, 1868. 682 
which as the ether evaporates leaves a thin protective film, which acts as a 
shield to the broken skin. When the ulcers are obstinate in healing, the 
process of repair will be hastened by touching the part with a crayon (fifty 
per cent.) of nitrate of silver or one of sulphate of copper. Touching the 
abrasions or ulcers with a solution of bichloride of mercury (gr. |-J, water, 
or with iodoform, often acts with magical promptness in effecting a cure. 
Of course the infant should not be allowed to take the naked nipple, but the 
latter should be protected by a shield. The teat of the heifer or the artificial 
rubber nipple is the appliance usually resorted to in such cases. 
DISEASES OF THE MAMMARY GLAND. 
Eczema and Psoriasis of the nipple have been observed by Paget and other 
English writers as in some instances the forerunners of carcinoma. I have 
twice noticed the connection of the two diseases. 
Benign eczema yields readily under the local application of calomel or 
oxide of zinc ointment. Malignant eczema is amenable to no remedy short 
of excision of the gland. 
Abscess of the areola is occasionally seen, resembling in all respects the 
ordinary furuncle, and no doubt originating in the follicles of the connective 
tissue. Hot fomentations or poultices, to favor the formation of pus, and its 
subsequent evacuation by incision, constitute the treatment. 
Neoplasms.—Sebaceous tumors, fibromata, dermoid tumors, angeiomata, 
and epitheliomata affect the areola of the nipple. 
Sebaceous tumors belong to the class of retention cysts, and consist in a 
dilatation and hypertrophy of one or more of the walls of the sebaceous 
glands, which prevail in this region, with an accumulation of sebum. 
Fibromata, or molluscous growths, sometimes spring from the areola. 
They have a pedunculated form, and are composed of connective tissue and 
integument. 
Dermoid tumors or cysts, containing sebaceous matter and hair, have occa- 
sionally been met with in this region. 
Angeiomata occupying the areola seldom exceed the size of a chestnut. 
The histological elements of these growths conform in all particulars to 
those of naevi elsewhere. 
Epithelial carcinoma may also select the areola, and presents the same ap- 
pearance and pursues the same course as when occurring in other regions 
of the body. 
Treatment.—All growths, even epithelial, occurring within the boundaries 
of the areola should be removed by excision. 
Syphilis.—Among the multitudinous external lesions of syphilis are con- 
dyloma and chancre of the nipple,—the former following the constitutional 
disease, the latter appearing as a primary sore, and communicated by con- 
tact with mucous patches in the mouth of a syphilitic child. A chancre in 
this locality will invade the general system with the same certainty as when 
seated on the genitalia, the axillary glands receiving the infection in the 
san\e manner as do the inguinal. 
The treatment is that proper to syphilis in other parts of the body. 
AFFECTIONS OF THE MAMMARY GLAND IN THE FEMALE. 
The affections which are encountered in the mammary gland are hy- 
pertrophy, atrophy, neuralgia, hyperesthesia, mastitis (or inflammation), 
abscess, disorders of the secretory functions, erysipelas, and new formations 
or tumors of various kinds. 
Hypertrophy. 
The mammary glands undergo enlargement from a variety of causes. 
There is an hypertrophy which is stimulated hy precocious development, ATROPHY. 
683 
by unusual exaltation of sexual appetite, by lactation, and by accumulation 
of adipose tissue. These are examples of physiological increase. There also 
is an enlargement of the mammse which is stimulated by disorder of the 
menstrual function. None of these, however, are included in the hypertro- 
phy under consideration. 
The affection generally includes both breasts, and commences in early life, 
both at and after puberty. Twice I have witnessed the enlargement confined 
to one gland, and in both instances in unmarried females over twenty-eight 
years of age and apparently enjoying good health. Numerous examples of 
such hypertrophy in both married and unmarried women have been recorded 
by surgical writers. In general hypertrophy the gland, in addition to its 
great bulk, is pendulous, flabby, and susceptible of being pressed into almost 
any shape, its lobules being easily separable and the skin frequently corru- 
gated. (Fig. 2154.) The size sometimes attained by the mammse in these 
cases of hypertrophy is extra- 
ordinary, instances having been 
recorded in which the gland has 
weighed over sixty pounds. In 
the museum of the University at 
Vienna there is a mammary gland 
preserved weighing thirty-two 
pounds, and Jean Booel* relates 
the case of a girl whose breasts 
weighed thirty pounds. 
Dissections and microscopic ex- 
aminations show the increase of 
bulk in hypertrophy of the gland to 
be in some cases largely due to a new 
formation of connective tissue, with 
the increase of which the lactifer- 
ous ducts and their acini become 
abnormally elongated without any 
change in the epithelial lining of 
the secretory canals of the gland. 
In other cases there is a hyper- 
plasia not only of the connective 
tissue, but also of all the glandular 
elements, as occurs in adenoma. 
Nothing is positively known in regard to the cause of these freaks of growth 
in mammary hypertrophy. 
Treatment.—Neither local nor general remedies appear to exercise any 
controlling influence over these enlargements of the glands. Iodine has been 
used both externally and internally without benefit. When the general 
health of the patient is impaired, or if the function of any particular organ 
is at fault, it will be proper to administer such agents as will meet the re- 
quirements. Relief will be obtained by supporting the pendent masses by a 
suspensory bandage or sling of the breast, in addition to which systematic 
pressure might be made, with some prospect of arresting the growth. Ex- 
cision of one or both glands has been performed in a number of cases. The 
removal of one breast—the larger—has been followed by an arrest in the 
growth and sensible wasting of the remaining gland. The operation would 
be justifiable only when the bulk of the glands became so great as to affect 
the health or greatly to interfere with the duties of life. 
Fig. 2154. 
Hypertrophy of the mammae. 
Atrophy. 
Atrophy or wasting of the mammae is one of the structural changes which 
follow the loss of function from senility: hence after the menopause has 
* American Journal of Obstetrics, New York, 1878, vol. xi. p. 719. 684 
DISEASES OF THE MAMMARY GLAND. 
been passed, the breasts undergo a certain degree of involution; the ducts 
and acini, with their epithelium, shrink away, or may even entirely dis- 
appear. It is true these changes in the glandular elements always occur 
to some extent during the interim of pregnancies, but under the stimu- 
lating effect of lactation the breasts again acquire their usual development. 
These, however, are physiological mutations in entire harmony with the 
sexual economy of the female, while in the former case the changes are 
degenerative and pathological, and are connected with an increase of the 
peri-acinous connective tissue, which is fatal to the renewal of the old 
secreting forces. 
There are instances also of young married females who have borne chil- 
dren and yet whose breasts remained almost entirely devoid of milk. These 
are cases of glandular atrophy, the secreting part of the breast being either 
rudimental or largely absent. Lastly, atrophy of the mammae may be pro- 
duced by neoplasms or by the products of inflammation destroying the 
gland-tissue. Iodine, once supposed to produce wasting of the mammae 
when exhibited internally for a long time, is now known to exert no such 
effect. 
Whatever may be the cause determining atrophy of the mammae, there 
are no means in existence which can either recall the lost tissues or restore 
their functions. 
Neuralgia. 
Neuralgia of the mammary gland is almost exclusively confined to young 
females, rarely being seen after twenty-five years of age. The pain is parox- 
ysmal, darting, and acute, often radiating from a circumscribed portion of 
the breast along those nerves derived from the axillary plexus and from the 
descending branches of the superficial cervical plexus. When following the 
course of the intercostal filaments, the patient often is unable to take a full 
breath without experiencing the most severe pain in the side, the symptoms 
resembling in some respects those of pleurisy. 
The subjects of mammary neuralgia are for the most part thin, delicate, 
anaemic females who suffer from some derangement of the uterine or ovarian 
functions (particularly dysmenorrhoea), whose nervous systems are inordi- 
nately excitable, and who labor under disorders of the digestive organs. 
Treatment.—Tho treatment will consist first in ascertaining the probable 
source of the neuralgia and removing that as far as possible. In general, 
those remedies which improve the secretions, impart tone to the system, 
enrich the blood, and arrest menstrual irregularities, associated with pure air, 
a nutritious and easily-digested diet, and out-door exercise, either in a car- 
riage or on horseback, will be found to meet the indications. This includes 
the use of various tonics, as quinine, iron, strychnia, arsenic, gelsemium, and 
myrrh. The use of opiates internally should be avoided, unless the pain 
grows unendurable and prevents rest, when some preparation of opium 
will become necessary. The local remedies which can be used with advan- 
tage are plasters composed of belladonna or of opium. A liniment consisting 
of olive oil, tincture of aconite, and chloroform, applied to the affected breast 
by means of a piece of thin flannel charged with the liquid, will frequently 
lessen the pain when other measures fail. A mammary gland prone to 
attacks of neuralgia will often be benefited by the support of a properly- 
constructed corset, between which and the breast there should be interposed 
a layer of fine cotton-wool. 
Hyperaesthesia. 
A condition of extreme sensibility of the mammary gland is occasionally 
met with in young unmarried females under eighteen or twenty years of 
age, to which the term hyperaesthesia is very properly applied. The inordi- 
nate sensibility may be confined to one gland, or it may affect both, and is MASTITIS, OR INFLAMMATION OF THE MAMMAE. 
685 
frequently associated with a similar state of the skin along the spine; indeed, 
it may be still more general, including the entire surface of the thorax. In 
cases of this nature the mamma is prominent, tense, and very elastic, with 
its nipple erect and rigid. The slightest touch of the skin covering the gland, 
or any attempt to press upon the latter, is attended with tremors and excla- 
mations expressive of the most intense suffering,—indeed, has been suffi- 
cient to throw the patient into an hysterical paroxysm. Ilypersesthesia of 
the mammae is never seen in females possessing a sound sexual system. It 
is one of the entailments of disorders of the organs of generation. Its sub- 
jects are pale, weak, anaemic girls, whose lives are rendered miserable by 
derangements of the catamenia, and who suffer from painful, irregular, 
or suppressed menstruation, accompanied by flatulence, palpitation of the 
heart, constipated bowels, headache, and other symptoms which indicate 
disorder of the digestive apparatus. 
Treatment.—The management of a case of this kind requires a radical 
change in habits of life. The young girl must exchange tightly-fitting 
dresses and overheated and badly-ventilated chambers for loose costumes 
and the open air. She must retire early and rise early. The trashy, 
sensational, and overwrought works of fiction, which often constitute the 
staple of reading of such patients, and which appeal only to the emotional 
element, must be replaced by works of an entertaining and at the same 
time instructive character. Under a regimen of this kind, with a plain, 
substantial diet, in which milk, meat, bread, butter, and eggs should occupy 
a large place, it is not uncommon to see these eccentricities of sensation 
entirely disappear without a single dose of medicine. The therapeutic 
resources which will often be called into requisition when other measures 
fail are iron, strychnia, gentian, pepsin, and cod-liver oil, with some of the 
preparations of malt or Burgundy wine. Sea-bathing constitutes a powerful 
tonic, and at suitable seasons will prove a valuable auxiliary to other reme- 
dies. When the hypertesthesia is attended by paroxysms of very acute suf- 
fering, the local application of belladonna ointment or of laudanum and hot 
water will give relief. 
Mastitis, or Inflammation of the Mammae, is rarely seen except during 
lactation. 
Primiparse are peculiarly predisposed to mastitis. The inflammation gen- 
erally occurs within one month after parturition, but may arise after the 
lapse of eighteen or twenty months. Infants are liable to a form of mastitis 
which gives rise to a hard, general swelling of the undeveloped organ. 
The causes of mastitis are varied. The secretion of milk may be furnished 
to a degree greater than can be received by the efferent ducts, or the child 
may be too feeble to unload the breasts, in either case allowing the lactifer- 
ous ducts to become over-distended and thus create inflammatory reaction; 
or traumatic violence may develop the affection. The breast is much ex- 
posed to several sources of irritation during the period of nursing, from being 
frequently uncovered, from forcible dragging on the nipple by the child 
while sucking, and also from rude handling of the organ by the infant. It 
is not improbable that many cases of mastitis begin, as alleged by Nelaton, 
as an inflammation of the lymph-vessels of the nipple, which is propagated 
thence to the deeper parts of the gland. Perhaps the most influential ele- 
ment in causing inflammation of the mammae is defect in structure,—that is, 
an imperfect development of the nipple, wThich is stunted, shrunken, or de- 
formed, and therefore incapable of giving free egress to the secretion. Ac- 
coucheurs inform us that fifty per cent, of cases of mammary inflammation 
and abscess originate from this cause. 
The inflammation may attack the cellulo-adipose tissue, the parenchyma, 
or the post-mammary connective tissue of the gland. It is sometimes limited 
to the subcutaneous tissue of the areola. When commencing primarily sub- 
cutaneously, the inflammation is likely to extend into the interlobular con- 686 
DISEASES OF THE MAMMARY GLAND. 
neetive tissue of the gland; and in like manner the converse is true, in- 
flammation of the gland proper tending to travel peripherally, at length 
involving the structures underlying the skin. 
Symptoms.—Mammary inflammation begins in the form of one or more 
hard knots or indurations somewhat deeply placed in the body of the gland, 
and corresponding to individual lobules. These isolated masses of indura- 
tion or infiltration multiply, and become so closely united by the exudation 
as to appear like a single mass. With the extension of the inflammation the 
organ throbs, becomes tender and heavy; its surface is hot and tense and has 
a dusky, shining, or livid hue. Frequently the inflammation is of an erysip- 
elatous character, commencing in the skin and rapidly extending to the sub- 
cutaneous and interlobular tissue, accompanied b}T great tenderness and 
oedema, y,nd pitting on making pressure with the finger. The effect of the 
inflammation is to lessen the secretion of milk, while at the same time the 
mechanical pressure made b}T the infiltrate upon the lacteal ducts causes in 
many places the milk to accumulate in portions of them, and also to resist 
the escape of the secretion. 
With the local conditions there are always present well-marked constitu- 
tional symptoms. Often the inflammation is ushered in by a chill or by an 
alternation of heat and rigors, followed by a hot, dry skin, an accelerated 
pulse, and an elevated temperaturo, accompanied by a dry, coated tongue, 
thirst, and headache. 
The tendency in all cases of mastitis, unless met by an early and decided 
antiphlogistic treatment, is to suppuration or the formation of abscess; 
indeed, this result is often unavoidable under any circumstances. 
Treatment.—Much may be done to prevent the occurrence of mastitis by 
attending to the condition of the secretory portions of the gland. Many 
cases arise from the ignorance both of nurses and of mothers on this point. If 
the milk is allowed to accumulate and become clogged in the ducts, either on 
account of a superabundance of the secretion or from inability on the part of 
the infant to empty the gland, the danger of inflammation will be imminent; 
hence the necessity of drawing the breast by artificial means, as the breast- 
pump or the mouth of a nurse applied to a properly-constructed cup. It is 
not uncommon under these circumstances for women to employ the services 
of a young pup; though to many mothers the bare suggestion of such a 
measure would be highly repugnant. 
When the inflammation is fairly established, and the local and general 
symptoms assume an acute character, the local abstraction of blood by 
leeches, and the exhibition of a saline cathartic, will be important measures, 
followed by the application over the breast of an ice-bag or a bladder filled 
with broken ice, which, by lowering nervous sensibility and vascular action, 
unloading the vessels of their blood and thus lessening the pressure of the infil- 
trate upon the acini and ducts of the gland, removes an important obstacle 
both to the secretion and to its outflow. Though the employment of cold in 
mastitis is an old remedy, for the suggestion of the use of ice for the same pur- 
pose we are indebted, I believe, to I)r. H. Corson, of Plymouth, Pennsylvania. 
The violence of the inflammation having subsided, its further resolution can 
be favored by a lotion of lead-water and laudanum. Another and directly 
opposite plan of treatment will frequently succeed, particularly in the more 
subacuto cases of mastitis,—namely, the application of heat. To obtain 
the full value of this agent it should be conjoined with medicated moisture, 
which may be effected in one of two ways: first, by saturating lint with a 
liquid composed of equal parts of laudanum, tincture of belladonna, and 
water and applying the same over the gland as hot as can be borne. Over 
the lint must next be placed a piece of oiled silk and a thick pledget of fine 
cotton-wool. The renewal of this dressing will become necessary every four 
or six hours. The second method of utilizing heat and moisture is by poul- 
tices made from linsced-meal sprinkled with laudanum and tincture of bella- 
donna, or with a solution of muriate of ammonia, and applied as hot as the parts will endure it, observing the same means for retaining the heat and 
moisture as were directed to be observed with lint. 
A very excellent application, after the acute symptoms have passed over 
and when it is desired to stimulate the vessels to the work of removing 
inflammatory tissue, will be found in the use of cosmoline, camphor, chloro- 
form, and extract of belladonna (cosmoline, gij ; pulv. camphor®, 5iij 5 
spt. chloroformi, f‘5iss; ext. belladonn®, 5\j- M.). This ointment is to be 
rubbed gently for fifteen or twenty minutes once or twice daily into the 
breast, the friction being always made from the base towards the nipple, 
which is in the course of the lacteal ducts. The rubbing will be done most 
conveniently by one hand, while with the other placed under the breast the 
gland is well supported. As long as it is discovered that the breast grows 
softer and less sensitive it is pru- 
dent to continue this manipula- 
tion ; but should the parts become 
more tender, hot, and tense, the 
rubbing must be discontinued and 
resort again be had to the hot 
lotions or poultices. 
As in inflammation elsewhei’e, 
so in the breast, there often re- 
mains some degree of induration 
from a partial organization of the 
cell-infiltration ; this should be re- 
moved as perfectly as possible, as 
it not only interferes with the func- 
tion of the organ, but may favor 
the development of malignant 
growths, or at least predispose 
to a recurrence of inflammation, 
with its unpleasant consequences. 
To secure the disposal of this 
material, massage and pressure 
constitute the most certain agen- 
cies. The first must be executed 
with great gentleness, and the 
second can be most effectually 
applied by the usual suspensory 
and compressing bandage of the 
breast. (Fig. 2155.) Adhesive plasters, usually recommended for the pur- 
pose. are far inferior to the roller bandage neatly applied. 
The mastitis of infants disappears under a lotion consisting of equal parts 
of tincture of arnica, tincture of opium, and tincture of belladonna. 
ABSCESS. 
687 
Fig. 2155. 
Suspensosy and compressing bandage of the breast. 
Abscess. 
There are three locations in which a mammary abscess may form: first, 
in the subcutaneous connective tissue ; second, in the interlobular tissue; and, 
third, behind the gland, in the connective tissue between the latter and the 
great pectoral muscle ( post-mammary abscess'). 
Women, though liable to suffer from mammary abscess at any time while 
nursing, in most instances have this accident occur during the first two or 
three months. 
The causes which are concerned in developing mastitis are equally in- 
volved in the formation of abscess, though the suppuration in the three situ- 
ations named does not originate from one and the same cause. The super- 
ficial or subcutaneous abscess is met with in pale, anaemic subjects, and often 
follows the condition of great vascular fullness which takes place contempo- 
raneously with the first influx of milk. The interlobular abscess begins in 688 
DISEASES OF THE MAMMARY GLAND. 
many instances as a lymphangitis, provoked partly by the violence done to 
the nipple by the child in sucking, and partly by the accumulation of the 
lacteal secretion ; it is not impossible that there are conditions of the saliva 
of the child, as in stomatitis, which excite inflammation of the lymph-vessels 
of the gland by infection, as micrococci in abundance are present. Submam- 
mary abscess may result from caries of a rib or from intra-thoracic abscess 
making its way externally through an intercostal space. 
Subcutaneous Abscess.—In this abscess neither the local nor the constitu- 
tional symptoms compare in severity with those resulting from deep suppu- 
ration of the gland. The tenderness of the skin is not great, its color not 
livid or leaden, nor its veins distended. There are no hard lobules or distinct 
nodules of infiltrated tissue, the induration being more diffused and resembling 
that observed in an ordinary phlegmon. Pus finds its way in a comparatively 
short time to the surface, its presence being easily recognized by the symp- 
toms of pointing and fluctuation. Though rigors may occur, announcing the 
advent of suppuration, they are slight, and are rarely followed by any marked 
constitutional disturbance. It is not common in cases of superficial abscess 
for the disease to involve any extended surface of the subcutaneous connective 
tissue, the collection of pus being usually circumscribed or walled in by the 
ordinary barrier of lymph. The exceptions to this are found in women of a 
scrofulous organization, or broken down in health from previous, disease, 
wrhen the inflammation and suppuration may travel from the summit to the 
circumference of the breast, even running on, as in phlegmonous erysipelas, 
from which it does not materially differ, to the complete destruction of 
the areolar tissue, which is afterwards discharged in fragmentary sloughs 
through sinuses. The inflammation which terminates in a superficial abscess 
may be propagated by continuity of structure to the interlobular tissue, and 
deep suppuration follow. The fact of such extension is always revealed by 
a marked aggravation both of local and of general phenomena. 
Treatment.—The treatment of subcutaneous mammary abscess is quite 
simple. It is comprised in the application of hot flaxseed-meal poultices and 
laying open the abscess as soon as fluctuation is well established. 
Interlobular Abscess.—In addition to the characteristic symptoms already 
detailed as denoting mastitis, there are experienced severe pain in the area of 
induration and swelling, and tension of the entire breast, accompanied by 
throbbing pain; the skin, though quite movable and but slightly tender, is 
often oedematous, presenting a dusky purple color, with enlargement of the 
veins, both signs indicative of venous obstruction from parenchymatous 
pressure. Rigors alternating with flushes of heat and succeeded by free 
sweating are among the prominent constitutional symptoms. 
By recalling the anatomical peculiarities detailed in the opening of this 
chapter the behavior of this form of abscess will be readily understood. The 
law which prevails in the body in regard to suppuration, and which not only 
provides for encapsulating the products of inflammation, but leads the pus to 
seek the safest outlet or that surface towards which the least resistance will 
be encountered, operates under special disadvantage in the mammae. The 
lobules, lobes, and ducts of the gland are closely bound together by dense 
but not abundant connective tissue, the trabecular spaces of which commu- 
nicate, but not with the freedom of ordinary areolar tissue, and hence the 
infrequency of sharply-defined or circumscribed interlobular suppuration, the 
tendency of the pus to become diffused in all directions, and the tardiness 
with which it approaches the surface,—facts extremely suggestive in a prac- 
tical point of view. The swelling of the breast is sometimes enormous, the 
gland acquiring not unfrequently almost double the natural size. At length a 
point on the skin appears, commonly not far from the seat of the original hard- 
ness of the gland, which, from its peculiar color and the readiness with which 
it yields to pressure, discloses the near approach of pus to the surface. Un- INTERLOBULAR ABSCESS. 
689 
fortunately, this does not always follow. Instead of traveling surfaceward, 
the matter may burrow in different directions through the gland, forming 
numerous tortuous sinuses in the midst of the lobules, and causing serious 
disorganization of the breast. I have seen the organ utterly destroyed by 
suppurating channels branching in all directions through it. 
Treatment.—When resolution has failed in a case of interlobular mastitis, 
and the inflammation advances to suppuration, it is to be hastened by hot 
poultices, repeated once every five or six hours. Frequent examinations 
must be made by pressure and palpation, with a view to detect the earliest 
evidence of pus, which, when recognized, should be liberated by a free in- 
cision. In cases where the surgeon remains in doubt as to the existence of 
pus, the exploring-needle will clear up all obscurity. 
The good offices of the physician, however, do not cease with lancing the 
abscess. The unusual tendency in the pus to diffusion, and the want of con- 
tractility in the tissues from which it issues, require that mechanical measures 
be employed, both to compel the discharge of the matter and to obliterate 
the cavities in which it was formed. These important indications are best 
carried out by systematic compression of the entire gland after the plan 
devised by Foster. This consists in covering the breast with a plate of com- 
pressed sponge,* a piece of thin lint being interposed between the latter and 
the skin, and binding the dressing as firmly to the part as may be consistent 
with the comfort of the patient, with a roller bandage applied in oblique and 
circular turns. By wetting the latter with warm water the sponge will 
absorb sufficient moisture to cause its expansion, by which the tissues of the 
breast are pressed together and at the same time the pus forced out of the 
sinuses. The dressing requires to be renewed once in twenty-four hours. 
In simple abscess, when there is no evidence of burrowing, it will only be 
necessary, after making a free incision and giving exit to the pus, to introduce 
a drainage-tube into the sinus and apply moderate compression by adhesive 
strips. 
A mammary gland which has become the seat of abscess is no longer fit 
for nursing, and in extensive abscess it is best that the child should be 
weaned, as the sound breast, from the sympathy which exists between the 
two glands, cannot be used without causing some congestion in the diseased 
one. 
A woman suffering from mammary abscess requires to be supported by 
tonics, as quinine and iron, and to be liberally fed on nutritious diet. Wine 
and the different preparations of malt will prove valuable auxiliaries to the 
treatment. * 
In chronic cases of mammary abscess, where the sinuses are tardy in 
closing, the cure will be facilitated by injections of a weak solution of sul- 
phate of copper or tincture of iodine (Byford), followed by compression. 
The pus in these cases often is mixed with milk in consequence of ulceration 
of some of the lacteal ducts. 
An abscess may be prevented from healing in consequence of the arm not 
being kept at rest, the movements of the pectoral muscles disturbing the 
work of repair. 
Hemorrhage is one of the possible contingencies of abscess. Only once 
have I seen it occur, when the bleeding was very profuse. An injection of 
Monsel’s solution of iron (f‘5i to water fgvi), followed by accurately-adjusted 
pressure, will be the proper treatment in a case of this nature. 
When from neglect or bad management the mamma has been traversed 
in all directions by sinuses, and its structure largely destroyed, it should be 
extirpated in its entirety, with a view both to getting rid of the abscesses and 
to removing diseased tissue, which at some future time, if allowed to remain, 
might invite the development of malignant disease. 
* A fine sponge sufficiently large to cover a trifle more than the entire breast, after being wet, is 
subjected to powerful pressure under weights and allowed to remain until dry. 690 
DISEASES OF THE MAMMARY GLAND. 
Post-Mammary Abscess.—Inflammation in the connective tissue binding 
the mamma to the great pectoral muscle, ending in suppuration, constitutes 
post-mammary abscess. The disease may be primarily located in this region, 
or it may be a secondary result, the pus either originating within the thorax 
and passing through its 
walls, or being derived 
from caries or necrosis 
of an underlying rib. 
The symptoms of post- 
mammary abscess are 
quite characteristic. The 
gland preserves its form, 
is free from localized 
indurations, stands off 
strongly from the body, 
its mobility is diminished, 
and when pressed upon 
leaves the impression of 
being supported on an 
elastic cushion. (Fig. 
2156.) The progress of 
the disease is slow, the 
pain is not severe, and 
there is no great sensi- 
bility of the breast when 
handled. When of long 
standing, the pus may 
break through the capsule which incloses the gland and invade the inter- 
lobular spaces. 
The diagnosis in doubtful cases can be established by the use of the ex- 
ploring-needle. 
Treatment.—As soon as the existence of the abscess has been verified, 
one or more incisions should be made at the periphery of the gland, prefer- 
ably at its lower semicircumference, thereby securing by gravitation a more 
certain drainage of the pus. 
Fig. 2156. 
Post-mammary abscess. 
Cold Abscess,—A form of mammary abscess is met with, which, from the 
subjective character of the inflammatory signs and the slow progress of the 
disease, is designated cold or chronic abscess. In the great majority of cases 
it occurs in the breasts of women who are nursing, and whose health has 
been much impaired by chronic disease. Occasionally it is observed in un- 
married females, and almost invariably it is one of the evidences of a scrofulous 
habit of body. When one or other of these conditions is present, it will 
often require only a very trivial excitant to provoke the disease, as a slight 
obstruction or blocking up of the milk-ducts, rough handling of the gland, 
or a sudden check of perspiration. 
The initial symptoms of the abscess are the formation of one or several 
masses of induration pretty deeply imbedded in the substance of the gland, and 
a slight feeling of soreness, with some increase in the weight and size of the 
organ. The hard nodules, which consist of a new formation of inflammatory 
tissue around the lactiferous lobules, will often remain unchanged for several 
months, and create on the part of the patient great uneasiness under an 
apprehension that the disease is carcinoma. The surgeon, however, will be 
able to discover several features in the swelling which do not harmonize with 
the idea of cancer. These are the coexistence of several hard lobules in 
different parts of the affected gland, which at their commencement were 
distinct from one another, tenderness without pain, no adhesion of the skin 
to the subjacent parts, and rarely any enlargement of the axillary glands; 
the patient will probably be under the age most fruitful in the development LACTEAL CYSTS. 
691 
of carcinoma. The termination of the nodules is not always the same. 
They may undergo a caseous metamorphosis, soften, and finally disappear, 
or they may end in suppuration, during the progress of which the adjoining 
masses of indurated tissue coalesce, converting the different foci of suppura- 
tion into large depots of pus, involving a considerable portion of the gland, 
in some instances the entire organ, lobular and interlobular, along with its 
adipose tissue and its capsule. In two instances I have seen the breast hope- 
lessly disorganized by a chronic abscess, the presence of which had not even 
been suspected, the disease having been regarded as one of cancer. 
The pus which forms in chronic mammary abscess is often mingled with 
flakes of lymph and masses of casein derived from the milk-ducts. The 
general system rarely sympathizes in any marked degree with the local 
mischief, except by a transient rigor or creep, with perhaps an evening exacer- 
bation of heat, the palms of the hands being warm and the cheeks slightly 
flushed. 
The diagnosis of cold abscess can be most satisfactorily demonstrated by 
the use of the exploring-needle. 
Treatment.—The treatment of cold or chronic mammary abscess will 
consist in opening a way by the knife for the escape of the pus, to be followed 
by the same dressings as those directed for acute abscess,—namely, com- 
pression by means of roller bandages. Should the sinuses manifest an in- 
disposition to heal, injections of sulphate of copper, tincture of iodine, or 
weak solutions of nitrate of silver will hasten their obliteration. Bearing 
in mind the constitutional state which predisposes to this form of abscess, 
the surgeon will not overlook the importance of tonics, good diet, and pure 
air. 
In view of the time which often is consumed in effecting a cure of an old 
chronic abscess of the mamma, where the gland has been honeycombed, 
it will be best, both as regards the present and the future well-being of the 
patient, to excise the remnants of the disorganized gland. 
TUMORS OF THE MAMMA. 
Tumors of the mammary gland are divided into cysts and neoplasms. 
Cysts of the mamma are of two kinds, retention and neoplastic. 
Cysts. 
Retention Cysts consist of a dilatation of some portion of the secreting 
part of the gland, either of the ducts or their acini, the contents being the 
lacteal secretion or other fluids formed either from chemical changes in the 
milk or retrogressive transformations of the epithelium. 
Lacteal Cysts—Galactocele.—This is a tumor containing milk, either nor- 
mal or changed in its character. The walls of the tumor are either a dilated 
lacteal duct or a dilated lacteal sinus. When involving the latter, the enlarge- 
ment is generally superficial, near the base of the nipple, or within the region 
of the areola, the parts in which the normal dilatations (sinuses) of the ducts 
exist; when located in the former, the tumor is usually more deeply seated. 
Two other varieties of lacteal cyst are met with. In one the overdisten- 
tion of the duct is followed by its rupture or ulceration, allowing the contents 
of the swelling to escape into the periglandular connective tissue. The 
occurrence of an accident of this nature changes somewhat the anatomical 
elements of the tumor. In the first variety the cyst-wall—that is, the dilated 
duct or acinus—is lined by a squamous epithelium, while in the latter the 
circumscribing wall is formed by the condensation of the periglandular con- 
nective tissue, and is, indeed, a true extravasation cyst. 692 
DISEASES OF THE MAMMARY GLAND. 
The other form of the lacteal cyst is that in which the opening through 
the duct is very small, the lesion occurring some considerable time after the 
formation of the original tumor, the distinguishing clinical and histological 
characteristics being the lobed shape of the swelling, one portion consisting 
of the dilated duct and the other of the new wall formed out of the peri- 
glandular connective tissue, and the presence of an epithelial lining in the 
first and its absence in the last. 
Lacteal cysts do not occur often, and when present make their appearance 
during the early period of lactation, either a few days after parturition, when 
the first milk-tide fills to repletion the ducts and sinuses of the gland, or 
later, when the activity of the organ supplies a much greater amount of 
secretion than can be consumed by the infant. On the other hand, examples 
are recorded in which lacteal cysts have developed during gestation and 
also several years after the subject had ceased to bear children. In one 
instance of galactoeele for wrhich I was consulted the cyst followed soon 
after the death of the infant. At whatever time the tumor appears, it is 
attributable to mechanical causes, either of an obstructive nature, as exter- 
nal pressure from inflammatory or neoplastic products, or from centrifugal 
pressure, the result of an undue accumulation of the lacteal secretion. 
The contents of a galactoeele are either fluid or semi-solid (the butyroid 
tumor of Yelpeau). An interesting tumor of the latter kind, the size of a 
child’s fist, was reported by Dr. Walter F. Atlee.* When fluid, the secretion 
of a galactoeele has the ordinary characteristics of pure milk or cream, or it 
may be a yellow, fatty, oleaginous material. The semi-solid derivatives are 
from the liquid contents determined by the operation of physical and chem- 
ical agencies. When the liquid or serous constituent disappears partially or 
completely, there remains in the first instance a whey-like fluid containing 
numerous cheesy masses, in many points resembling to the eye the pus from 
a cold or chronic abscess, while in the latter case the residuum is quite solid 
or consistent, and forms a whitish or yellowish caseous, curd-like mass, com- 
posed of oil-globules, devitalized epithelium, and the proximate principles of 
fat, olein and margarin. 
Lacteal cysts are generally somewhat spherical in outline, the surface being 
slightly irregular. In consistence the tumors are soft and fluctuating, devoid 
of pain or unusual sensibility, unattended by discoloration of the overlying 
skin, seldom larger than a walnut or a lemon, and almost invariably solitary. 
Scarpa has given a case of lacteal cyst which appeared in a young mother, 
twenty years of age, ten days after confinement, from which ten pounds of 
milk were drawn by trocar and canula. 
Diagnosis.—The sudden appearance of a soft, fluctuating swelling, occur- 
ring soon after parturition or during lactation, without any pre-existing 
signs of inflammation, without pain or tenderness, with no discoloration of 
the skin, and its size changing Avith the varying activity of the gland, are 
strong presumptive signs of the tumor being galactoeele. The diagnosis will 
be rendered still more certain by resorting to the grooved needle. When 
the cyst has not been seen until the contents have assumed a more solid 
consistence, greater difficulty will be experienced in reaching a conclusion. 
If there has been a previous history corresponding to the phenomena 
detailed as characteristic of the fluid galactoeele, it will at least render the 
milk origin of the cyst probable, although certainty can only be attained by 
an exploratory incision. 
Non-Lacteal Cysts. 
A second form of retention cyst exists, unlike galactoeele in several par- 
ticulars. jFirst, they are most common either during the active child-bearing 
period of women, though altogether without reference to lactation, or during 
the passive or functionless condition of the gland following the menopause. 
* The American Journal of the Medical Sciences, April, 1874. NON-LACTEAL CYSTS. 
693 
It is on this account that they have been described by authors as evolution 
and involution cysts. Second, these cysts differ among themselves in form, 
being single or simple, multiple, and multilocular. Third, with the difference 
in form there is often a difference in place. The single or simple cysts gen- 
erally select central superficial or subcutaneous parts of the breast, and 
involve either the dilated portions of the lacteal ducts at the base of the 
nipple or the sebaceous glands of the areola. The multiple and multilocular 
cysts, on the contrary, exhibit a preference for the deeper or more posterior 
parts of the gland, though they may occur at its periphery. Fourth, the 
contents of these cysts consist of serum alone, have a saline taste, and are 
very slightly coagulable by the usual reagents, heat, nitric acid, or alcohol; 
or of serum variously tinged with the haematin of the blood ; or of a viscid 
or oleaginous, glairy material (mucoid cysts) (fatty cysts), and sometimes of 
a fluid resembling milk. When the sebaceous glands constitute the basis of 
the cyst, the contents will not differ from sebaceous cysts elsewhere. Ilair 
may also be contained in this tumor (piliferous cysts). The serous cysts 
are decidedly the most common. 
Whatever may be the form of these retention cysts, they all—save the 
sebaceous—have their origin in some part of the glandular constituent of the 
mamma, by a dilatation either of the ducts or of the acini. There are three 
ways in which the single and multiple cysts are formed: first, by the dilata- 
tion of a single duct or acinus; second, by the conjoined operation of dilata- 
tion and hyperplasia of the intertubular and interacinous connective tissue, 
by which a number of ducts or acini are destroyed, their places being occu- 
pied by the expansion of those which remain,—these changes always being 
associated with an increase of the glandular epithelium; and, third,, by the 
rupture of ducts from distention, and the escape of their contents into the 
meshes of the surrounding conjugate tissue, thus forming a tumor which 
combines the characteristics both of a retention and of an extravasation cyst. 
Cysts produced in the two former ways possess at first thin walls, which 
afterwards may become thicker and stronger by inflammatory additions or 
by increased nutrition, and which rest against a vascularized connective tis- 
sue. They are lined with a squamous epithelium. The thickness of the 
walls is particularly noticeable in cysts which arise after the menopause, or 
during the latter part of the active period of the mammae. Single cysts 
originating in the acini often exhibit in their interior a number of incomplete 
loculi, all communicating with a common cavity, these probably being the 
remains of the lobular septa of several acini. In a breast which I removed 
from a patient in the Pennsylvania Hospital, the inner surface of some of 
the cysts was studded with papillary or coral-like outgrowths, rich in blood- 
vessels. The multilocular cyst is formed by the acini of a number of lobules 
undergoing dilatation, the intermediate partitions at the same time remain- 
ing intact, thus forming a tumor composed of a number of distinct and 
non-communicating cavities. In some instances unilocular and multilocular 
cysts are observed in the same gland. Multiple cysts may pervade the 
entire mamma, even to the extent of destroying in a great measure the 
normal structures of the gland. Unilocular cysts, whether single or mul- 
tiple, are most common in the mammae of the young, or before thirty years 
of age. 
The causes which are chiefly concerned in the production of retention 
cysts are mastitis,—traumatic and other forms,—sclerosis of the connective 
tissue, and morbid growths developing in the breast, in all of which the 
ducts are subjected to undue pressure, and of course to obstruction. 
Cysts vary in size, ranging from the bulk of a mustard-seed to that of a 
lemon or a hen’s egg. Cases are recorded of tumors of this nature having 
attained an extraordinary size. Marini particularly mentions a case in which 
nine pounds of liquid were drawn from a mammary cyst. When they grow 
to considerable magnitude, the skin, especially in multilocular tumors, is liable 
to ulcerate in consequence of extension. Twice I have removed cysts which 694 
DISEASES OF THE MAMMARY GLAND. 
were much larger than the foetal head, and which had entirely replaced the 
mammary gland. 
Cysts may develop in one or both mammary glands, though not often 
simultaneously. In a case of multiple cyst occurring in one breast of a 
maiden lady of thirty-five years, for which the breast was removed, the 
other gland became similarly affected after an interval of three years. 
Cysts which are peripheral and simple commence at first as a distinct 
swelling, not at all prominent, but recognizable by the touch, from which 
the patient often shrinks on account of some soreness being experienced. 
The tumor is generally spherical in form, and in its beginning is rather firm, 
growing softer and more elastic, with distinct signs of fluctuation, as it 
increases and becomes more prominent. The skin covering the cyst growrs 
more attenuated, but exhibits no tendency to form adhesions to the walls 
of the tumor; not unfrequently a serous or sero-sanguinolent fluid escapes 
spontaneously, or can be pressed from the nipple. Little or no pain is real- 
ized, and under favorable circumstances the translucency of the swelling by 
the light test can be distinguished. The general health of the patient ap- 
pears to suffer little or no disturbance from the local disease. In multilocular 
the lobulated form of the tumors can often be both felt and seen 
through the skin. (Fig. 2157.) 
A section of a multilocular cystic mammary gland exhibits numerous dis- 
tinct cavities of various sizes, from a pin’s head to a bird’s egg, lined by a 
Fig. 2157. 
Fig. 2158. 
Hultilocular cyst of the mamma. 
Cystic disease of the breast, from a female 
about thirty-five years old. On the inner 
surface of some of the cysts are seen papil- 
lomatous or vascular outgrowths. 
smooth moist membrane, and separated from one another by walls of con- 
nective tissue of different thicknesses. (Fig. 2158.) 
Diagnosis.—The diagnosis of cystic disease of the mamma is not always 
an easy task, especially when the object is to differentiate between it and the 
softening cysts of carcinoma. The exploring-needle enables the surgeon to 
determine the presence of fluid, and when the history of the tumor has been 
one of a slowly-progressing painless growth, the overlying skin healthy and 
sharing no disposition to become attached to the subjacent swelling or to 
ulcerate, when there is no retraction of the nipple, no enlargement of the 
axillary glands, and the general health remains undisturbed, it is fair to 
assume that the cyst is not malignant. 
Treatment.—In simple unilocular cysts a cure is sometimes effected by 
the local use of discutient remedies, among which are solutions of muriate ol 
ammonia (muriate of ammonia 5b alcohol f‘3i, water fgv. M.), equal parts LACTEAL OBSTRUCTION. 
695 
of soap liniment and solution of the acetate of lead, and tincture of iodine. 
All of these remedies except the last, which is to be applied with a camel’s- 
hair brush, ai*e to be applied on gauze-flannel, which, after being well moist- 
ened with the lotion, is placed over the locality of the cyst and covered with 
oiled silk. This di*essing will inquire to be renewed once in seven or eight 
hours and continued for several weeks. A more certain plan of ti’eatment 
is by injection, using for the purpose the undiluted tinetui-e of iodine and 
introducing it into the cavity of the cyst by means of a hypodermic syringe. 
Should this fail, it will be pi'oper to lay open the cyst and pack the interior 
with lint, in order to obliterate the cavity by granulations. The seton, 
recommended by some writers, is inferior to both injection and incision. 
Multilocular cysts are not amenable to any of the above plans of ti*eat- 
ment, but require to be extirpated by the knife ; and when veiy numei’ous, 
involving a large portion of the gland, the latter should be removed in its 
entirety. 
Hydatid Cysts. 
Hydatid cysts are the rarest of all diseases of the mammary gland. In no 
instance have I seen a tumor of this nature. Professor Gross (the younger) 
notes the cases of Haussman, of Beidin, sixteen in number, together with one 
reported by Launstein and one by Landau, eighteen in all. 
The parasites when establishing a habitat in the mamma x’each the gland 
either through the blood-vessels or by tunneling their way fi’om the adjoin- 
ing cavities through the walls of the chest. The source of the worm is the 
tsenia echinococcus, or tape-worm, and when the parasite reaches the mamma, 
as in other soft parts of the body, it soon becomes surrounded by a fibro- 
vascular membi’ane, the product of subacute inflammatory action. 
The cysts, though generally single and tilled with an albuminous, opales- 
cent fluid, may contain one or more smaller sacs. This was time in the two 
cases given by Do Haen and Lassus. 
The youngest patient with mammary hydatid cyst was twenty and the 
eldest fifty years of age. The largest number of cases occur between twenty 
and thirty years. 
These cysts gx-ow to the size of an almond or of an ordinary-sized orange, 
if allowed to remain for a few years. 
Symptoms.—The signs which belong to an hydatid cyst are the presence of 
a slowly-increasing, elastic, cix*cumscribed, movable swelling, situated some 
distance from the nipple, imparting to the hand or fingers, on percussion or 
pressure, a sensation of fremitus, or trembling, causing no altei’ation in the 
skin or veins over the site of the swelling, inducing no enlai'gement of the 
lymph-glands of the axilla, except in rare instances, and producing no im- 
pairment of the general health. These, unlike retention cysts, are often 
very painful. This was particularly true of Mr. Heniy’s case, a patient in 
the Middlesex Hospital, and also of one recoi'ded by Yon Graefe, although 
the cyst described by the last-named author was located in the great pectoral 
muscle behind the mammary gland. It is also worthy of note that in Mr. 
Henry’s patient two of the glands in the axilla were considerably enlarged, 
a condition i*arely witnessed in benign tumors of the mamma), and calculated 
somewhat to embarrass the diagnosis. 
Treatment.—Excision constitutes the most expeditious and x’adical plan 
of treatment, being much more certain than that by injection or by elec- 
trolysis. 
Lacteal Obstruction. 
The mammary gland is liable to become enlarged from an accumulation of 
milk in its ducts in consequence of the latter not being emptied of their secre- 
tion, in which case the breast undergoes a uniform enlargement without any 
localized indurations in its substance. 
This condition arises in consequence of the child being too feeble to exer- 696 
DISEASES OF THE MAMMARY GLAND. 
cise the necessary suction-power, or where the production of milk is largely 
in excess of the demand for its use, or in the process of weaning the child. 
The enlargement is one demanding prompt attention, as, if neglected, it may 
be followed by mastitis. 
Treatment.—The accumulation must be removed by suction with the 
breast-pump; and if the engorgement is due to the absence of the child in 
weaning, and when the object is to dry up the milk, it will be proper, in addi- 
tion to unloading the overdistended ducts of their contents, to use an ointment 
of belladonna freely over the breast. In the aspiration of the breast it will 
be best not to empty the gland completely of the secretion, but only to an 
extent which will prevent inflammatory accidents. The presence of a small 
quantity of milk in the ducts will serve to resist the too free formation of the 
secretion, by the pressure exerted upon the epithelial elements of the acini. 
NON-MALIGNANT TUMORS. 
The non-malignant tumors of the mammary gland are lipoma, fibroma, 
myxoma, adenoma, and angeioma. 
Lipoma. 
Lipomata rarely, if ever, form in the secretory portion of the mammae, 
their location being in the adipose tissue lying between the skin and the 
gland, and occasionally beneath the latter. When occupying the former 
locality, and seated near the nipple, a few milk-ducts may be found traversing 
the fat. A submammary lipoma becomes such secondarily, the tumor begin- 
ning either above or below the gland, and gradually getting beneath it as it 
increases in size. These tumors occur more frequently in early than in late 
life, and are by no means common. Only once have I removed a growth of 
this nature, the patient being a female under twenty-eight years of age, and 
at the time three or four months advanced in pregnancy. 
The examples of an enormous amount of mammary fat which have been 
recorded by Cooper, Brodie, and others cannot be regarded in the light of 
tumors, being rather hypertrophies, or a form of obesity usually observed in 
advanced life. As these depositions of fat take place at the functionless 
period of the gland, or the period of its involution, the adipose constituent 
may go on increasing until it almost wholly replaces the glandular elements. 
The diagnostic signs of a lipoma of the mamma are the presence of a 
superficial, slowly-developing, painless growth, having a soft, doughy, lobu- 
lated feel, and under compression causing the superincumbent skin to be 
thrown into fissures or dimples. 
Treatment.—A lipoma is a perfectly benign and harmless neoplasm, and, 
except when it acquires considerable bulk, is incapable of causing any incon- 
venience. When, therefore, the new formation is small and manifests no 
disposition to grow, it may safely be left alone. If, however, it is found 
steadily to increase in size, it should be excised by dividing the overlying 
integument and enucleating the mass with the fingers. The connective tissue 
which encapsulates the tumor will generally admit of this being done without 
difficulty. 
Fibroma. 
There are three pathological changes met with in the mammae in which 
fibrous tissue plays an important part. In one there is a localized hyper- 
plasia of connective tissue, forming a distinct, hard, ovoid or nodulated 
tumor (Fig. 2159); in a second there is a general new formation of fibrous 
tissue extending throughout the entire gland (hypertrophic fibroma) ; and, last, 
there is a condensation and shrinkage of the connective tissue, both of the 
new formed and the old, which lessens the size of the gland (atrophic fibroma). FIBROMA. 
697 
In each of these fibrous transformations the seat of the new element is in 
the intertubular and interacinous connective tissue, and accordingly there 
often exists along with the latter more 
or less of the glandular material of the 
breast, the presence of which formed 
the adeno-fibroma of Klebs (Fig. 2160), 
a name obviously inaccurate, as the 
glandular elements included were not 
new formed, but only pre-existing ones 
enveloped or surrounded by the fibrous 
tissue. 
In either the hypertrophic or the 
atrophic forms of fibromata, with the 
progress of the neoplasm the milk- 
ducts and their acini become more 
and more compressed by the inter- 
tubular connective tissue, until ulti- 
mately they may be entirely destroyed, 
so that when such tumors are removed 
and subjected to a microscopic exami- 
nation no traces of glandular elements 
whatever are found, the neoplasm con- 
sisting wholly of pure white or dull 
white bundles of interlacing fibrous 
tissue, so completely woven together 
that when cut into it creaks or “ cries” under the knife. Localized or cir- 
cumscribed fibromata are in a large proportion of cases solitary or single. 
They are extremely hard or slightly elastic to pressure when pure, are round 
or ovoid in form, and 
their surfaces irregular 
or knobbed. These tu- 
mors quite frequently 
occupy the upper and 
outer part of the breast, 
are not very deeply seat- 
ed, and for the most part, 
though not always, are 
painless, and seldom at- 
tain any great bulk. 
Fibromata of the mam- 
ma) are most common 
during the early develop- 
ment of the gland, that 
is, between puberty and 
the sixteenth or eigh- 
teenth year, and also 
during the entire period 
of its greatest functional 
activity, or extending 
from the eighteenth to 
the thirty-fifth year. 
The single and the mar- 
ried are neai'ly alike lia- 
ble to the formation of 
these growths. 
Fibromata undergo various degenerations, as the cystoid, fatty, myxo- 
matous, calcareous, osseous, and angeiomatous. 
Cystic transformations of fibromata are somewhat protean in their char- 
acter. In one case central softening of the tumor takes place, forming a 
Fig. 2159. 
Fibroma mammae. 
Fig. 2160. 
“ Adeno-fibroma” from the mamma. Acini divided transversely, and 
separated by new formation of fibrous tissue. 698 
DISEASES OF THE MAMMARY GLAND. 
cavity which contains a gelatinous or ropy material, answering to myxoma; 
in a second the contents have the consistence of a sero-albuminous fluid, 
coagulating when tested by the usual reagents, heat and nitric acid ; in a 
third case there will be seen projecting from the interior of the new-formed 
cavity several papillary or dendritic proliferations of connective tissue, some 
of which are quite rich in blood-vessels, the walls of which, being extremely 
delicate, are liable to rupture. It is this latter accident which explains the 
presence of blood-clots sometimes seen in the cavity of a softened fibroma. 
The tumor described by Yirchow under the name of intracanaliculary fibroma, 
though presenting a macroscopic resemblance to the neoplasm just described, 
differs in the following respect,—namely, that in the former tumor both the 
interlobular connective tissue and the lacteal ducts are involved, these being 
greatly distended and choked up with vegetations composed of vascularized 
new formation of intertubular tissue. 
When a cystoid fibroma becomes the seat of fatty degeneration, the source 
of the fatty contents may be due either to retrogressive changes in the epi- 
thelial elements of that portion of the secreting parts of the gland included 
in the tumor, or to a similar transformation of its connective or fibrous 
element. 
There is also a fatty degeneration of fibromata which occurs altogether 
independent of cystoid change, and in which the fat-gi-anules are diffused 
through or appear in the midst of the bundles of fibrous tissue, and in many 
places entirely replace the latter, yet the general outline of the tumor re- 
mains unchanged, just as a muscle may be the seat of a similar transformation 
without materially altering its form. 
The deposition of lime-salts among the fibres of a fibroma constitutes the 
calcareous change, and when such deposition assumes the ordinary arrange- 
ment of the Haversian system of bone it is, of course, an example of the 
osseous degeneration, a transformation which I have never seen. 
The so-called telangiectatic fibromata conform in some respects in their 
anatomical structure to vegetations, the vascularity consisting in numerous 
dilated blood-vessels which are supported on a scanty framework of connec- 
tive tissue and resemble papillomatous or dendritic outgrowths. 
The condition is seldom, if ever, seen independent of cystoid change. 
When cystic changes overtake a fibroma the fact can be discovered by the 
frequent escape of a straw-colored or sanguinolent fluid from the nipple, the 
diminished resistance of the tumor to pressure, or its change from hard to 
soft consistence; and this is true whether the mutations of the neoplasm 
have been fatty, mucoid, or myxomatous; and when embodying calcareous 
matter, by its unequal density, being firm and elastic at one point and stony 
hard at another. 
Mammary fibromata grow very slowly, generally not exceeding in size a 
cherry or a hickory-nut, and rarely attaining the bulk of a pullet’s egg, even 
after several years’ standing. A few exceptions have been noticed by writers 
in which these growths have increased to the size of a cocoanut and weighed 
many pounds. When cystic transformation attacks a fibroma the increase 
of the neoplasm is materially greater and more rapid than when the tumor 
is solid. 
Fibromata are benign formations, and seldom occasion any trouble by 
their pressure except that which grows out of a lurking suspicion on the 
part of the patient that the tumor is or may prove to be cancer. I have had 
fibromata of the mammae under observation for many years,—in one case for 
twenty years,—in some witnessing no perceptible change, while in others the 
tumors have softened and gradually disappeared. They frequently vary in 
size, at one time increasing, and again growing smaller. These alterations 
are often closely related to sympathetic reactions, and to functional changes 
in the activity of the mammary gland. Thus, the tumor may enlarge during 
menstruation or during gestation and lactation, and again diminish after 
ovulation and the drying up of the milk. MYXOMA. 
699 
The growth of mammary fibroma is often brought to a halt, and sometimes 
the tumor undergoes atrophy, when the subject is attacked by some chronic 
disease in which the general processes of the system are exhausted,—an effect 
very unlike that which, under similar circumstances, is seen to follow car- 
cinoma, which almost invariably takes advantage of lowered vitality to 
perpetrate its worst ravages. 
Diagnosis.—The diagnosis of a mammary fibroma is a matter of great 
importance, not only for the mental peace of the patient, but for determining 
the action of the surgeon. The foremost consideration is to settle the ques- 
tion of malignancy. 
There are several points of resemblance between a fibroma and a carcinoma 
of the mamma. In both the tumor may have a stony hardness and knobbed 
surface, in both there may be severe pain ; but there are many other features 
in which the two growths disagree, and which can be most effectively pre- 
sented by placing them in contrast, as below: 
FIBROMA. 
CARCINOMA. 
Appear generally before thirty-five. 
May appear shortly after puberty. 
Growth slow. 
No tendency to become adherent to the skin or 
subjacent parts. 
No retraction of the nipple. 
Severe pain exceptional, and rarely of a stab- 
bing kind. 
Little tendency to ulcerate. 
No infection of the axillary lymph-glands. 
Does not become generalized, producing a 
cachexia, or affecting the general health. 
Recurrence extremely rare. 
After thirty-five. 
Never so. 
Often rapid. 
Marked tendency to do so. 
Retraction common. 
Pain a very common symptom, and of a severe, 
darting kind. 
Great tendency to ulcerate. 
Infection common. 
Metastasis almost invariable. 
Recurrence the rule. 
Treatment.—As long as a fibroma exhibits little or no tendency to in- 
crease, it may be safely left without any surgical interference. If the general 
health is disturbed, and the tumor supersensitive, relief will be experienced 
by administering tonics, especially iron in some of its forms. Minute doses 
of the bichloride of mercury (gr. -fo) given in solution three times a day, 
after meals, and continued for several months, will sometimes produce a 
decided impression, both in improving the general health of the patient and 
in arresting the progress of the neoplasm. The sensitive state of the breast 
will be lessened by supplying to the gland 4 sufficient support. 
Injections have frequently been made into fibromata, the substances used 
being either tincture of iodine or ergot, but the success of these methods has 
not been sufficiently encouraging to invite repetition. When the tumor con- 
tinues to grow, and becomes sufficiently large or painful to constitute an 
incumbrance, or to deprive the patient of needful rest, it should be excised, in 
doing which it is not necessary to remove more of the gland-tissue than will 
suffice for the entire extirpation of the fibroma. 
Myxoma is one of the rarest neoplasms found in the mammary gland. 
Unlike fibroma, the period of occurrence is somewhat later in life, being 
most common between the fortieth and the fiftieth year, or after the func- 
tional activity of the gland has passed its zenith, and when the menopause is 
approaching. 
The seat of mammary myxoma is in the conjugate tissue connecting the 
lactiferous ducts and lobules, which reverts or becomes transformed into 
its original physiological jelly-like, translucent, mucous substance, having a 
yellow, straw, grayish-white, or light-green color. 
The microscopic appearance of this substance does not differ from myxoma 
elsewhere, being made up of a number of oval, fusiform, and stellate cells 
Myxoma. 700 
DISEASES OF THE MAMMARY GLAND. 
imbedded in an abundance of viscid or ropy intercellular material, and 
intersected in vai'ious directions by filaments of connective tissue. 
Myxoma of the mamma does not follow a chronic course. Its progress is 
rapid, and, instead of the morbid process being confined to a single small area 
of the breast, it may develop in several distinct portions simultaneously or in 
rapid succession, simulating in some respects multiple cysts. These isolated 
depots of rudimentary tissue may at length coalesce until the entire gland is 
converted into a soft gelatinous mass. The disappearance of the glandular 
components of the mamma in myxoma must be attributed either to mechan- 
ical pressure from the intertubular and interlobular connective tissue, or to a 
coincident proliferation of some portion of the connective tissue which escapes 
the force that remands it to its prime physiological origin and determines a 
formation of intracanalicular obstructive vegetations. 
Myxoma of the mamma is not proof against other changes, as the fatty, 
cystic, fibrous, and vascular, terms which imply that along with the mucous 
material there are present fat-cells, or that a cavity more or less complete has 
been formed in the neoplasm from softening of its substance, or that the latter 
is intersected by delicate trabeculae of fibrous tissue, or by a net-work of 
tortuous and dilated blood-vessels. 
The clinical symptoms of myxoma are far from being decisive. Its coun- 
terfeit in several particulars of cystic disease, of sarcoma, and of carcinoma 
necessarily renders the diagnosis somewhat uncertain. 
Like cystic disease, myxomatous tumors are soft and fluctuating. Like 
sarcoma, they grow rapidly and have a slightly elastic feel, and, as in carci- 
noma, they tend to become attached to the superincumbent skin, to ulcerate, 
to be accompanied by enlargement of the lymphatic glands, to become pain- 
ful, and often to recur after excision. Nothing, therefore, short of an ex- 
ploratory puncture will supply the required information. 
Prognosis.—Although myxomata are disposed to return after being re- 
moved, yet it does not follow from this fact that the neoplasm admits of 
being generalized. Those cases of mammary myxoma in which it is said 
that secondary deposits took place in internal organs were most probably 
examples of tumors in which a sarcomatous element was conjoined with the 
myxoma. 
Treatment.—Excision is the only remedy, and, as the tendency to recur- 
rence has been remarked, the entire gland should be removed. 
Adenoma. 
Adenoma of the mamma, which figured so prominently in the neoplastic 
literature of the past few years under the names of adenoid (Velpeau), 
adenocele, adenomata (Broca), potyadenoid, partial hyperti-ophy of the 
mamma (Lebert), etc., is now known to be comparatively a very rare for- 
mation. 
At present many cases of fibroma are diagnosed as adenoma. It is only 
b}7 the aid of the microscope that a differential diagnosis can be made. These 
neoplasms have been carefully studied by Cornil and Banvier in France, by 
Waldeyer, Liicke, and others in Germany, and by Gross the younger and 
Formad in this country. 
Mammary adenoma consists of a new formation of lacteal gland-tissue, its 
histoid elements being composed of newly-formed dilated acini, filled with 
epithelium resting on a distinct basement-membrane. The interacinous con- 
nective tissue is abnormally scanty and contains active proliferating cells, 
and there is no orderly grouping of the acini into lobules as is seen in the 
normal gland. (Fig. 2161.) Microscopically, adenoma presents, on section, 
a whitish or reddish-white color. 
The clinical signs of an adenoma are the presence of a hard, painless 
tumor, having a slightly irregular or nodulated surface, appearing to be 
a part of the gland,—sometimes movable,—and seldom exceeding in size a SARCOMA. 
701 
pigeon’s egg. The skin over the site of the growth usually remains un- 
changed; a sanguinolent discharge escapes often from the nipple, which is 
not retracted ; the surface veins 
are not enlarged or dilated; and 
the axillary lymph-glands re- 
main unaffected. Married women 
between thirty-five and forty, 
who have borne children, form 
the subjects for adenoma. 
This neoplasm is prone to un- 
dergo cystic change—colloid and 
otherwise—by degeneration of 
the epithelial elements of the 
dilated acini. 
The growth of adenoma is 
slow, and there is evidence to 
show that the neoplasm is ca- 
pable of metastasis, and of its 
liability to be transformed into 
carcinoma there can be little doubt. Between the two growths there is a 
fundamental difference, in that the basement-membrane of the acini in ade- 
noma remains intact, while in carcinoma it is broken and allows the cells to 
infiltrate the interlobular connective tissue. Between adenoma and fibroma 
there need be no confusion, though the latter does contain glandular ele- 
ments, but with these distinctive characteristics, that the latter are not new- 
formed, and that instead of there being a very small amount of the peri- 
acinous and peritubular connective tissue, there is in fibroma an extraordinary 
hyperplasia of the same. 
The prognosis in cases of adenoma is favorable, though recurrence after 
removal may occur. 
Treatment.—The fact that adenoma is prone to reappear after removal 
renders it advisable, in all cases where an operation becomes necessary, to 
excise along with the neoplasm the entire mammary gland. The liability of 
adenoma to become changed into carcinoma by lesion of the basement-mem- 
brane makes it important, whenever the diagnosis is reasonably certain, that 
an early ablation of the affected mamma should be made. 
Fig. 2161. 
Adenoma of the mammary gland. 
MALIGNANT TUMORS. 
The malignant tumors which attack the mammary gland are sarcoma and 
carcinoma. 
Sarcoma. 
Sarcoma of the mamma frequently passes for carcinoma, which in some of 
its clinical aspects it resembles, though in many others the dissimilarity is 
quite striking. 
When the neoplasm appears as a localized, sharply-bounded or defined 
tumor in the breast, it receives the name of circumscribed sarcoma; and when 
generally disseminated through the gland, diffused sarcoma. Other divisions 
of this new formation are made, based on the possession of certain physical 
properties, as hard, solid, and soft sarcomata; and, again, cystic and myxo- 
matous sarcomata, expressive of degenerative changes which the growth 
often undergoes. As in other localities, so in the mammse, there will be found 
all the varieties of sarcomata, as the round-, spindle-, and giant-celled. 
When the intercellular basis is arranged in such a manner as to form a 
net-work of fibres, each interspace containing a cell in imitation of lymph- 
follicles, the tumor is designated a lymphadenoid sarcoma, and alveolar sar- 
coma when the cells are collected into groups separated by intervening walls 
of connective tissue, which traverse the neoplasm in different directions, 702 
resembling closely in this particular carcinoma. The manner in which the 
two can be distinguished from each other has been described in detail under 
the head of differential diagnosis of sarcoma and carcinoma. 
The degree of hardness in mammary sarcoma depends largely upon the 
variety of the neoplasm, being greatest in the spindle-celled, and least in the 
round-celled. 
In cases of sarcoma where the tumor combines the qualities both of hard 
and soft, degeneration of its cells is in progress at those points which yield 
most readily. These cell-elements may finally either disappear entirely, or 
undergo those fatty or mucoid transformations which confer on the growth 
the title of cystoid. 
Sarcoma of the breast is generally a solitary tumor. It may occur indif- 
ferently at any portion of the gland, though the upper half appears in the 
majority of cases to form the initial seat of these neoplasms. 
Sarcoma of the mamma is a disease of early or mature life, generally 
occurring somewhere between twenty and thirty-five years, and is more 
common among married than among unmarried women; even girls under 
puberty have been the subjects of the growth. 
A certain though not invariable connection has been observed between age 
and the variety of a sarcoma. Thus, the spindle-celled neoplasm, which may 
be regarded as the highest possible development of its cell-components, 
occurs somewhere between twenty and thirty, or during the time when the 
functional capacities of the gland are at their full tide; whereas the round- 
celled variety of tumor is most frequent between thirty-five and forty-five, 
or when the meridian of functional activity in the mammae has been passed. 
The growth of mammary sarcomata seems to be singularly independent of 
those perturbating causes which often impart a fatal impulse to other morbid 
formations, as the former remain without any unusual increase during men- 
struation, pregnancy, and nursing. 
The variety of a sarcoma determines to some small degree its tendency to 
local reproduction and to generalization. In this respect the round-celled 
tumor is charged with peculiar malignancy both as to local recurrence and 
its tendency to invade the general system, often returning in three or four 
months and proving fatal in from twelve to fifteen months. A spindle-celled 
sarcoma, though exhibiting the same local and general behavior as a rule, 
neither recurs after extirpation nor 
attacks the internal organs so quickly 
as the round-celled variety. In one in- 
stance I removed a tumor of this nature 
of enormous size ten years after its first 
appearance, the patient remaining en- 
tirely well during that time; five years 
have elapsed since the operation, and 
no recurrence has taken place. 
DISEASES OF THE MAMMARY GLAND. 
Fig. 2162. 
The Spindle-Celled Sarcoma, usually 
firm or hard, presents certain clinical 
characteristics. The tumor is round, 
ovoidal, or slightly nodulated in form, 
firm in its consistence, largely discon- 
nected with the gland, and therefore 
capable of being moved independently 
of the latter, securing accommodations 
displacement of the gland-substance. 
The skin over the site of the tumor, 
with the increase of the growth, either 
remains but little changed, or exhibits a dull reddish-brown color, and becomes 
stretched and attenuated, though disinclined to contract adhesions, to become 
inflamed, or to ulcerate (Fig. 2162), unless the overstretching becomes ex- 
Sarcoma of the mamma. CYSTIC SARCOMA. 
703 
treme, when sloughing of the integument is liable to occur, followed by a 
proliferation of fungoid granulations. 
The macroscopic or physical appearances presented in a section of firm 
sarcoma are a white, gray, or faintly red color, the latter depending on the 
degree of vasculai'ity and a certain amount of tumor-juice, sero-sanguinolent 
in appearance; sometimes, interspersed through the neoplasm will be seen 
small blood-clots. 
Round-Celled Sarcomata are soft, elastic growths, having an irregular sur- 
face, and, whatever may be their dominant color, they are alwaj’s tinted with 
a light shade of red, being vascular. When a yellow tint prevails it 
indicates that the cells of the neo- 
plasm are being transformed into fat 
(fatty degeneration). Apoplectic clots 
are very common in this variety of 
sarcoma, as might be anticipated from 
its soft structure and from the great 
abundance of blood which it contains. 
This tumor increases rapidly, presents 
a soft, brain-like appearance, and fre- 
quently attains a great size. In con- 
sequence of the skin being excessively 
stretched to accommodate the grow- 
ing new formation, ulceration, fungoid 
protrusions, and hemorrhages are not 
at all uncommon. These tumors are 
particularly prone to infect the gen- 
eral system, and when removed ex- 
hibit a remarkable tendency to local 
recurrence. (Fig. 2163.) 
Fig. 2163. 
Cystic Sarcoma of the breast differs 
both in its structure and in its mode 
of formation from those cysts which 
result from degenerations and trans- 
formations of the cells of new growths, 
and which consist largely of a commingling of dilated milk-ducts with the 
ordinary elements of the neoplasm. These dtiets distended into sacs contain 
in some parts of the tumor variously-shaped vegetations, and at other parts 
are filled with a straw-colored or a blood-stained fluid. The amount of inter- 
tubular, interlobular, and interacinous conjugate tissue varies in different 
portions of the neoplasm, in some parts being almost entirely replaced by 
spindle- and round-cells, the former predominating, in other places inter- 
secting the growth in different directions and forming imperfect and very 
irregular alveoli, and in other situations exhibiting a real hyperplasia. It is 
this want of uniformity in the construction of cystic sarcoma which renders 
intelligible the ever-changing sensations of resistance communicated to the 
touch when the fingers are passed over the growth. It also explains the 
lobulated form, which is the prevailing one in these neoplasms. These tumors 
grow to a great size, have a hemispherical form, and stand off directly from 
the body. The skin after a time assumes a reddish-brown appearance, and 
though it becomes greatly stretched and attenuated by the increase of the 
neoplasm, and though the subcutaneous fat disappears, it seldom becomes 
adherent to the growth, and consequently ulceration is long delayed. The 
lymph-glands of the axilla remain free from infection, and little if any pain 
is experienced. 
In making a section of a cystic sarcomatous mamma, the new formation 
will be seen to be disseminated through the major part of the breast, with 
intervening portions of normal gland-structure. 
Sarcoma of the mamma, with ulceration and protruding 
fungoid granulations. 704 
DISEASES OF THE MAMMARY GLAND. 
The tendency to recurrence and to metastasis in cystic sarcoma of the 
breast varies. The malignancy is increased in proportion as the round-cell 
elements preponderate. 
I removed from a lady, forty years of age, a colossal mammary tumor of 
this nature, the skin being so extremely thin and discolored that I entertained 
but little hope that its vitality would be preserved, and yet six years have 
elapsed and no recurrence of the disease has taken place. 
Causes.—The causes which are concerned in the development of mammary 
sarcomata are enveloped in obscurity. That traumatism may occasionally, 
not often, be ranked among the immediate factors concerned in the genesis 
of these neoplasms there can be little doubt, but this is far from explaining 
the predetermining conditions which are required in a last analysis of causa- 
tions calling into existence such a tumor. That it is something independent 
of the physiological changes connected with the evolution and involution of 
the gland is also clear, as the unmarried suffer in common with the married. 
It is a suggestive fact that the favorable period of life for sarcoma is that in 
"which the connective-tissue elements of the mamma) are in a moi’e active and 
mobile condition than its epithelium, and when possibly physiological energy 
may favor pathological formations on an inflammatory basis. 
Diagnosis.—A tumor which makes its appearance in the mamma of a 
patient under thirty-eight years of age, grows with considerable rapidity, is 
soft, moderately hard, or elastic, or combines in itself at different localities 
all these qualities, is hemispherical in shape, often lobulated, but not knobby, 
shows little tendency to become attached to the skin or break down and 
ulcerate, even when the latter becomes very thin, when in progress of 
growth there is experienced little if any pain, and when the lymph-glands 
in nearest relation to the breast remain free from contamination, such a 
growth may be accepted as a sarcoma. 
Prognosis.—The prognosis in mammary sarcoma will be formed some- 
what upon the particular variety of the neoplasm. In the round-celled and 
cystic forms of the disease both local recurrence and generalization of the 
tumor-products may be anticipated. In one case of a cystic sarcoma of 
the breast, which 1 removed from an unmarried femalo, four years elapsed 
before it returned, when it developed in the other gland ; and in a second case 
which I excised, the patient being a young married woman without children, 
there has been no return of tho disease, though more than six years have 
passed since the operation. A cystic neoplasm is generally admitted to be 
less malignant than the round-celled sarcoma; and this accords with the 
history of the few cases which have come under my own observation. The 
tendency of spindle-celled sarcomata to recur may be measured by the firm- 
ness of the tumor and the development of its cells, the soft, small-celled 
growths manifesting an almost invariable tendency to reappear at the seat 
of operation, while the firm, large-celled variety, with the cells compactly 
massed in the delicate stroma of connective tissue, exhibit comparatively 
little tendency to recurrence or metastasis. 
Treatment.—In the treatment of mammary sarcoma an early recourse 
must be had to the knife. However small the growth, the entire gland 
should be extirpated, carrying the incisions sufficiently far into what is 
regarded as sound tissue to include all the diseased structures. Should re- 
currence follow, it must be attacked again and again by the knife, or as long 
as there are no evidences of secondary deposits in internal organs. 
The two forms of carcinoma which affect the mamma are scirrhus and 
encephaloid. These growths are the most formidable and constitute by far 
the most common neoplasms which find a habitat in the female breast. The 
clinical aspects of the disease are exceedingly varied, scarcely two cases 
being alike in their life-history. 
Carcinoma. SCIRRHUS. 
705 
Scirrhus. 
Scirrhous or fibrous carcinoma usual!}7 appears between the fortieth and 
fiftieth years of life, or during that period when the functional activity of 
the gland is on the decline, its work as a secreting organ over, and when, 
like any unused part, retrogressive changes—the involution of decay—com- 
mence. 
Gross the younger, in an analysis of 642 cases, found the average age to 
be forty-eight, though the disease is not at all uncommon after sixty or sixty- 
five. Twice I have seen scirrhus in very aged patients. In one case the 
patient, living in Lancaster County, was known to be one hundred and seven 
years old; the tumor at the time I saw her was in a state of ulceration. The 
second case was in the person of an old lady residing in Philadelphia. The 
tumor was located in the left breast, and in six months after its appearance 
caused the death of the patient on the completion of her one hundredth year. 
Although occurring in both married and unmarried females, the former 
class suffer much more frequently than the latter. Women who have borne 
children furnish relatively a larger number of cases of mammary cancer 
than those who are barren. 
Scirrhus, whether occurring as a hard lump, or tuber, or as a disseminated 
infiltration, is devoid of any encapsulating wall. Its cell-elements not only 
invade all parts of the gland, but tend to transcend its limits and penetrate 
the skin, the fascia, and the muscles which underlie the breast. The breasts, 
according to my own experience, are about equally liable to suffer, though 
the disease is said to manifest a preference for the right gland. Occasionally 
both mammffi are attacked simultaneously or within a few months of each 
other. All portions of the gland are nearly equally liable to become the 
initial seat of the tumor, though perhaps a slight majority of cases occupy 
the axillary half. 
In the circumscribed or tuberous form of the disease, a lump of stony 
hardness will be felt imbedded in the breast, rather nearer to its cutaneous 
than to its pectoral face, the surface of which will be found to be irregular, 
hard, and knobby; if not sensitive to the touch, it becomes so shortly after 
having been handled. With the progress of the disease additional install- 
ments of the gland are involved, until at length the whole is converted into 
a solid, knotty tumor, the great weight of 
which, altogether disproportioned to its 
size, constitutes a peculiar and significant 
feature of the growth. The pain, if not 
hitherto marked, now becomes extremely 
acute, coming on in paroxysms, and is of 
a darting, stabbing, or shooting character. 
The sudden intensity and severity of these 
unannounced attacks of pain, traversing 
the breast, and extending frequently up 
to the neck and down the arm like cur- 
rents of electric fire, often make the poor 
sufferer start and shriek with anguish. 
This inexorable feature of scirrhus is one 
of the most dreadful attendants of the 
disease. Very soon the skin becomes ad- 
herent over the site of the tumor, from 
which it cannot be pinched up, at length 
giving to the surface a depressed, dimpled, 
and corrugated appearance. Correspond- 
ing to these points of adhesion, the skin 
becomes discolored, presenting a purple, leaden, or lilac hue, and is travel’s ed 
by numerous small blood-vessels. The nipple, sometimes early and at other 
times at a more advanced stage of the disease, becomes retracted (Fig. 2164) 
Fid. 2164. 
Retracted nipple, with ulceration. 706 
DISEASES OF THE MAMMARY GLAND. 
from the contraction of the fibrous tissue underlying the areola and the 
shortening of the milk-ducts. Following the attachment of the skin to the 
neoplasm, and at the place of such adhesion, ulceration occurs (Fig. 2165), 
when the scirrhus becomes an open sore, with hard, everted, irregular 
edges, the crater of which extends down into the tumor-substance, and from 
which a thin, watery, acrid, ichorous or sanious discharge flows, having a 
peculiar, offensive odor belonging to no other disease, and irritating and 
excoriating the parts with which it comes in contact. The granulations 
which cover the sides and floor of these ulcers have usually an indolent, 
lifeless, sloughy appearance, and often are the source of profuse and ex- 
hausting hemorrhages. Occasionally they become redundant, rising above 
the level of the sore, and projecting as a fungoid mass over the adjoining 
Fig. 2165. 
Fig. 2166. 
Scirrhus ulcerating. 
Fungoid granulations in an open scirrhus. 
skin. (Fig. 2166.) These granulations are very imperfectly vitalized, have a 
very precarious existence, and frequently slough off, to be followed by others 
equally frail and short-lived. After a time the glands of the axilla receive 
the infection, becoming enlarged, hard,—occasionally soft,—and sensitive; 
later on those next in order, the cervical, participate in the disease. Pre- 
ceding the contamination of the axillary glands there often may be traced a 
dense, cord-like roll of connective tissue leading from the gland to the axilla, 
revealing the involvement of the lymph-vessels which follow this line to their 
destination. JSTor is the infiltrate confined to the gland alone. A time comes 
when the breast becomes less movable, having contracted attachments to the 
pectoral fascia and muscles. It is not uncommon to find the disease invading 
ithe intercostal muscles and the periosteum of the ribs. 
Scirrhus of the breast does not ordinarily increase in volume wTith the age 
of the tumor, but rather diminishes, in consequence of the invincible tend- 
ency to contraction of the fibrous components of the breast. This process 
may continue until the gland-tissue almost entirely disappears, leaving a 
small, shriveled, puckered, and distorted tumor, to which the name atrophic 
scirrhus has been given. In some instances in the course of the disease 
numerous secondary, hard, sensitive nodules appear in or beneath the skin, 
varying in size from a pin’s head to a pea. (Fig. 2167.) These enlarge, and 
when close together coalesce. Recurrent scirrhus often assumes this pecu- 
liar form. These secondary new formations are not limited to the region of 
the mamma. In a lady who consulted me on account of a carcinoma just 
commencing in the left breast, multiple growths of this nature occupied the 
shoulder, arm, and side of the body. ENCEPHALOID CARCINOMA. 
707 
When a dissection of a scirrhous breast is made, a certain amount of adi- 
pose tissue will be found occupying the subcutaneous tissue; on cutting 
through this towards the more central part of the gland, a hard core or 
scirrhous mass is encountered, which, being extremely dense and devoid of 
elasticity, on being laid open creaks under the knife, and presents a pale 
white or slightly grayish surface, with numerous darker-colored spots, the 
section resembling very much the interior of a raw potato. (Fig. 2168.) 
Fig. 2167. 
Fig. 2168. 
Scirrhus of the mamma, with secondary nodules of 
the same nature. 
Section of a carcinomatous breast. 
Another phase of atrophying scirrhus is that in which the disease is dif- 
fused. The infiltration extends rapidly through the derm and subcutaneous 
tissue. The skin becomes hard and has a tawny color, and under the pro- 
gressive contraction of the fibrous element of the breast the gland-tissue 
entirely disappears, leaving over the former site of the mamma an expanse 
of scar-like cutaneous tissue almost as dense and as hard as a board. This 
condition answers to the “ cancer en cuirasse" of the French, and may ex- 
tend from one breast to the other and spread over a large surface of the 
chest. As it scarcely exists without the underlying fascia, pectoral and 
intercostal muscles, along with the ribs, being implicated in the morbid 
process, patients so affected often complain of a sense of stricture around 
the chest, with inability to take a full breath, and more or less difficulty 
in breathing. Finally, there are many cases of diffused scirrhus in which 
with the commencement of the disease the skin and subcutaneous tissue 
become extensively infiltrated with epithelial elements, and when from the 
first the skin and gland are so generally adherent that at no point can the 
former be raised from the latter. Frequently, too, the skin is brawny and 
beset with numerous depressions, giving to the surface an appearance which 
may not inaptly be compared to that of the rind of an orange; or it may 
be that the integument is puckered, plicated, or gathered into hard ridges, 
which rise some distance above the general level of the tumor. These 
are most unfavorable conditions, and contra-indicate operative measures. 
When scirrhus reaches the axilla, the same process of fibrous contraction 
continues as occurs in the breast, the effect of which is to compress the 
blood-vessels of the armpit and present a mechanical obstacle to the onward 
flow of the venous blood. The result is oedema of the arm, which often 
attains two or three times its natural size, and adds greatly to the discomfort 
of the patient. 
With these local phenomena follow, in due time, secondary deposits in 
internal organs, or the generalization of the new formation, which is an- 
nounced by the loss of flesh and strength and a sallow color of the face, with 
sunken and pinched features. 
Medullary, Encephaloid, or Soft Carcinoma.—Encephaloid or soft carci- 
noma is by no means so frequently met with in the mamma as scirrhus. 708 
DISEASES OF THE MAMMARY GLAND. 
With the latter it has many clinical features both of similarity and of dis- 
similarity. 
The points of similarity between encephaloid and scirrhus are as follows: 
both commence as a tolerably firm, somewhat irregular tumor, at first quite 
movable in the breast, but soon becoming so identified with the gland as to 
be immovable; in both adhesion between the tumor and the skin occurs at 
some time in the course of the disease; in both the superficial veins of the 
integument over the breast become enlarged ; in both the nipple is retracted; 
in both the axillary lymph-glands are infected; in both pain is severe; in 
both secondary deposits or metastases follow; in both local recurrence follows 
operations; and in both the disease proves fatal. 
The points in which the two tumors differ are quite striking and differen- 
tial, and may be accepted as symptomatic. 
First, encephaloid carcinoma appears, as a rule, later in life than scirrhus, 
being more common after forty-five years; second, it is much more rapid in 
its growth ; third, the neoplasm, though irregular or tuberous on its surface, 
as is the case in scirrhus, is unlike the latter, the tubers being scarcely ever 
all alike in density, some being hard while others are quite soft; fourth, 
the tumor is soft and elastic, and often attains a very large volume; fifth, it 
undergoes ulceration more rapidly, that event seldom being delayed beyond 
ten or at most twelve months; after ulceration has occurred, fungous protru- 
sions follow, which are often discolored by blood-clots, and from which profuse 
hemorrhages take place (fungus hsematodes) (Fig. 2169); sixth, it is said 
not to contaminate the axillary 
glands so quickly, though in 
this particular I think there is 
very little difference; seventh, 
the tumor is less sensitive to 
pressure, and the pain comes 
on later and is altogether less 
intense; eighth, recurrence fol- 
lows more speedily; ninth, cys- 
tic degenerations in different 
parts of the neoplasm are quite 
common ; and, finally, the gen- 
eral health is broken more 
rapidly and the duration of the 
disease is comparatively short. 
With regard to rapidity in 
the progress of medullary car 
cinoma, it is not uncommon 
to meet with cases in which 
the whole life-history of the 
growth does not extend over 
ten or twelve months. 
The anatomical peculiarities 
observed in encephaloid carci- 
noma of the breast include color, 
consistence, and contents. The same section will exhibit a structure in color 
white, gray, and yellow, in consistence firm at one place and at another soft 
and brain-like, or perhaps honeycombed with cysts. In other parts of the 
same tumor blood-clots will be seen in various stages of degeneration. No 
encapsulating membrane exists in carcinoma of the breast. 
The vascularity of encephaloid carcinoma varies greatly. Sometimes the 
blood-vessels prevail to such a degree and are so intertwined wfith connec- 
tive tissue as to constitute a variety of the disease designated telangiectatic 
carcinoma. In other instances there are large, dilated veins, with thin walls, 
which have given way, crowding the growth with apoplectic clots, and 
forming a variety of carcinoma called hematoid. 
Fig. 2169. 
Encephaloid carcinoma of breast, with exuberant fungoid 
outgrowths. COLLOID CARCINOMA. 
709 
Medullary carcinoma and sarcoma are often confounded with each other. 
While the two growths possess points of common resemblance, they may be 
distinguished quite readily by attending to the following considerations: 
Occurs after thirty-eight and forty. 
Skin soon becomes adherent to the tumor. 
Superficial veins slightly enlarged. 
Nipple retracted. 
Strong tendency in the tumor to become ad- 
herent to the skin. 
Skin rarely attenuated with adhesions. 
Marked tendency to ulceration. 
Purple color of skin over points of adhesion. 
Axillary glands commonly affected. 
Ulceration early, without protruding granula- 
tions. 
Tendency to early metastasis strong. 
Local recurrence early. 
Duration of the disease seldom exceeding one 
year or fifteen months. 
Vascular. 
ENCEPHALOID CARCINOMA. 
Occurs before. 
Skin indisposed to adhere. 
Veins early enlarged. 
Not retracted. 
Slight tendency. 
May be thin as tissue-paper without adhesion. 
Tendency to ulceration slow. 
Reddish-brown color of skin when adherent. 
Axillary glands seldom affected. 
Ulceration late, and followed by a fungous out- 
growth of the neoplasm. 
Much less strong. 
Local recurrence later. 
May remain for several years. 
More vascular. 
SARCOMA. 
There is also an important anatomical distinction between the two neo- 
plasms : encephaloid is never encapsulated; sarcoma generally is circum- 
scribed by a wall of condensed connective tissue. 
The microscopic distinction between encephaloid carcinoma and sarcoma 
is quite decisive, and enables the pathologist to remove all conjecture in 
regard to the subject. This has been given in detail under the general head 
of tumors, and need not be repeated here. 
Colloid Carcinoma. 
Colloid carcinoma is rarely witnessed among mammary neoplasms. In its 
relation to age it does not conform either to carcinoma or to sarcoma, having 
been seen in women at all periods between twenty-eight and sixty-six. The 
average period of thirteen cases analyzed by Gross the younger is forty-five 
years. 
The leading clinical characters of this neoplasm are its tardy growth, 
irregularity of surface, soft, elastic consistence, absence of pain, indisposition 
to infect the axillary glands, and little terfdency to recurrence and to gen- 
eralization. Colloid carcinoma may continue eight or ten years, making 
very little progress, and never attaining any considerable bulk; eventually 
it will reveal its malignant nature by becoming adherent to the skin, causing 
retraction of the nipple, laying hold of the subjacent structures, ulcerating, 
poisoning the axillary glands, disseminating its elements among internal 
organs, inducing the cachexia following secondary deposits, and finally de- 
stroying the life of the patient. 
The anatomical peculiarities of colloid carcinoma of the breast consist in 
the presence through the gland of a grayish, tenacious, gelatinous, shining 
substance, made up of epithelial cells imbedded in an intercellular matrix of 
transformed protoplasm, and supported in very imperfectly-formed alveoli of 
connective tissue. 
In its clinical aspects colloid carcinoma most nearly approaches myxoma. 
So similar are the symptoms of the two neoplasms that it is impossible to 
distinguish between them with any degree of certainty. Some importance 
is attached, in attempting a differential diagnosis, to the more rapid course, 
the softer consistence, and the greater tendency in myxoma to reappear after 
operations; but, as the progress and general behavior of all varieties of soft 
cancer are extremely irregular, the surgeon will exercise great reserve in 
venturing any opinion merely on the existence of the above-mentioned 
phenomena. 710 
DISEASES OF THE MAMMARY GLAND. 
Melanotic carcinoma, an exceedingly rare form of the disease, does not 
differ histologically from melanotic cancer elsewhere, the dark color being 
due to the presence of pigment-granules. 
Melanotic Carcinoma. 
Epithelial Carcinoma. 
Epithelial carcinoma, or carcinoma commencing on the cutaneous surface 
of the mammary gland, is occasionally seen. In three cases, the histories of 
which I have been unable to follow, the disease originated near to and a 
short distance above and to the axillary side of the nipple. In each instance 
the progress was slow, extending in one case over twelve years, but in all 
gradually extending by infiltration into the glandular part of the organ, 
leaving deep, foul ulcers, with everted and irregular borders, in no way dif- 
fering in appearance, or in the offensive character of the discharges, from 
those which accompany either scirrhus or encephaloid ulceration. That the 
epithelial elements of the mamma became involved is more than probable 
from the infection of the axillary glands which finally ensued. The patients 
all were over sixty, and all perished from secondary deposits. In the early 
history of the disease it was painless, but after the penetration of the gland- 
tissue the suffering from this cause was far from unimportant. 
Prognosis.—In general it may be said that the prognosis in carcinoma is 
most discouraging, if not hopeless. The great question to be determined in 
any case of mammary carcinoma at the present state of surgery, in my 
judgment, is not how best to cure or eradicate the disease, but what course 
will give the patient the longest lease on life. This question can only be 
determined by the comparison and analysis of a large number of cases treated 
by tentative and operative means. 
Sibley makes the average duration of life, in cases not operated on, 32.25 
months, based on an analysis of 78 cases; and for those operated on, 53 
months, based on an analysis of 63 cases; a gain, therefore, of 21 months by 
operative measures. 
Gross the younger, after an analysis of 616 cases, 97 of which were allowed 
to take a natural course, and 519 were subjected to operations, concludes that 
operations add one year to life. The results obtained by Oldekop, Wini- 
water, and Henry, according to the same author, do not materially differ 
from the above, being respectively, in the order of their names, an average 
duration of life for those who did not undergo operation, 22.6 months, 26 
months, and 32.9 months; and for those who were operated on, 38.1 months, 
39.3 months, and 39.6 months. 
Now, there is no doubt that the generalizations which have been reached 
by these writers are strictly correct as deduced from the working data; yet 
it does not follow that they represent the real or bottom truth of this sub- 
ject. There are more than mathematical processes involved in striking the 
averages between the two different lines of treating the same disease. The 
cases which are to be the subjects of diverse methods of treatment must be 
as near as possible alike as to social position, hereditary transmission, tem- 
perament, age, and mental and moral conditions. For instance, it must be 
admitted that in carcinoma the patient whose circumstances are such as to 
command every comfort and appliance which friends and medical and sur- 
gical skill can supply enjoys an advantage over one less fortunate in these 
particulars, which, in many instances at least, tends to prolong life. It will 
not do to place these two classes on opposite sides in the race of life, and, when 
the death-goal is reached by each, to credit the difference of days or months to 
certain plans of treatment. Again, in a female suffering from carcinoma of the 
breast, whose antecedents on one or both sides have perished with a like 
disease, or possibly from pulmonary phthisis, and in whom in consequence the 
momentum of cancer is greatly increased, it is not fair to contrast the case with one occurring in a person with a good family history, and whose 
general system in other respects appears sound and vigorous. Again, the 
influence of temperament on a disease like carcinoma is by no means un- 
important. A melancholic patient is far less capable of resisting the inva- 
sions of cancer than one who possesses an ardent, sanguine organization. 
Age is no inconsiderable factor in the life-computation for carcinoma. The 
woman of sixty-five or seventy will be ill matched against the one of forty 
or forty-five years. Finally, in regard to mental or moral states, I know of 
nothing which precipitates the fatal issue of mammary carcinoma like the de- 
pression, distress, and anxiety which often accompany sudden and unlooked- 
for reverses in fortune, or the despondency and grief which settle over the 
mind of a mother from whom death has snatched some household idol. 
Again, it must be remembered that the prudent surgeon will exercise some 
elective judgment in the cases of mammary carcinoma which he consigns to 
the knife, selecting the most favorable for operation and relegating the more 
hopeless ones to the mercy of nature. Now, these are some of the elements 
which should enter into any comparison of the relative values of surgical with 
other methods; and, last, it is human to err, and therefore some of the cases 
accepted and tabulated as carcinoma may, in the absence of the more modern 
methods of pathological study, have been growths of a less malignant nature. 
As far as I can determine, no such detailed classification has been adopted 
by any surgical statistician working in the field of mammary carcinoma, and 
it is on this theory that I account for the results which have been recorded 
being different from my own experience. I am sure that of the very large 
number of carcinomatous mammae removed by myself during the last thirty 
years, so far as their subsequent histories are known to me, the permanent 
recoveries fall far short of 9.05 per cent.; indeed, I should hesitate, with my 
present experience, to claim a single case of absolute cure where the diagnosis 
of carcinoma had been verified by microscopic examination. The almost 
uniform history has been death from a return of the disease within two or two 
and a half years. The shortest period in which I have seen death follow car- 
cinoma of the breast, when left to nature, was six months, and the longest nine 
years in one case, seven years in a second, and in a third six and a half years. 
I do not despair of carcinoma being cured somewhere in the future, but 
this blessed achievement will, I believe, never be wrought by the knife of the 
surgeon. We may hope, however, for the discovery of some drug which, 
operating through the general system, will follow and destroy the vagrant 
cells and do for cancer what mercury and thb iodide of potassium have done 
for syphilis. 
The most common period of local recurrence is between the third and 
twelfth months. Gross the younger, in an analysis of 203 cases, found re- 
lapse to take place in three months in 63 per cent., and in only 11.65 per 
cent, after one year. 
When the disease does reappear, it may be in the cicatrix, or in the skin 
near the original site of the tumor, or in the axillary or cervical lymph- 
glands, or in some internal organ or structure, as the lungs, bronchial glands, 
liver, brain, or pleura. 
Frequently, when not a single evidence of the disease can be detected ex- 
ternally, the general health begins to suffer. There is loss of flesh, strength, 
and appetite, with shortness of breathing on making any exertion, the ap- 
pearance of a sallow color of the face, with other evidences of a pronounced 
cachexia, showing that the old enemy has become intrenched in the internal 
organs. 
If operations do not cure, do they serve to prolong life? This is a perti- 
nent inquiry. The profession is not agreed upon this subject. Among the 
surgeons of a past generation there were several eminent men who were un- 
favorable to operations. Kline the elder, Sir Everard Home, and Brodie, all 
were hostile to the use of the knife in mammary carcinoma. Sir Astley 
Cooper spoke very discouragingly of its success; and Leroy d’Etiolles, who 
EPITHELIAL CARCINOMA. 
711 712 
DISEASES OF THE MAMMARY GLAND. 
had investigated the subject statistically, inclined to the opinion that, except 
when the life of the patient was threatened by hemorrhages, operations were 
of little account. At the present time, however, there are few surgeons who 
entirely coincide in these views; and though I believe, from my own ex- 
perience and obseiwation, that these old sages, like the young man in Scrip- 
ture, were not far from the kingdom of truth, yet operations, with the 
qualification of the cases being well selected, do add greatly to the comfort of 
the patient and sensibly to length of life. 
The question has also been answered by the statistics already quoted, in 
which seven months, the lowest gain of life, and twelve months, the highest, 
are claimed for operative over other measures. The statistics bearing on 
this point have been tabulated and analyzed from the inmates of public 
institutions, where it is presumed the surgeons were men of the highest 
technical skill and maturest judgment, and therefore are entitled to confidence. 
But a large number of operations for carcinoma of the breast are per- 
formed over the country at large in which ablation is partial, or where indu- 
rated axillary glands are left undisturbed or unsound skin is not removed. 
Such imperfect procedures certainly shorten life; but, as these are defects of 
operators, and not of operations, it is not just to marshal them into coui’t as 
witnesses against the use of the knife. 
The fatality attending operations for carcinoma of the mamma? will be 
determined in a great measure by the extent of the procedure. Where the 
incisions are limited to the removal of the gland alone, it is extremely low, 
not exceeding one in thirty cases; but when it is necessary to clear the axilla 
of diseased glands, the death-rate is increased to about one in ten cases. 
The causes of death after these operations are erysipelas, pyaemia, pleuritis, 
pneumonia, and shock. 
The circumstances forbidding operations for carcinoma, specified under the 
head of treatment of malignant neoplasms, apply with equal force in cases of 
cancer of the breast. 
Treatment.—The treatment of carcinoma of the breast must be considered 
from two distinct stand-points: first, when the tumor is allowed to follow a 
natural course, being only opposed by those therapeutic measures, general 
and local, which lessen the march of the disease by sustaining the general 
vigor of the body, allaying pain, and conducing to the removal or neutrali- 
zation of offensive emanations from ulcerated surfaces; and, second, when 
an attempt is made to remove the disease operative measures. 
With regard to the first, the indications will be best fulfilled by correcting 
any derangement of the digestive organs which may occur by the occasional 
exhibition of a little blue mass, followed by a saline aperient; b}T regulating 
the diet so that the food shall be nutritious and at the same time easily 
digested, using milk, oatmeal, tea, eggs, stale bread, vegetables in season, 
when found to agree well with the stomach, fresh meat in moderation, 
together with regular exercise in the open air, and cheerful company. When 
the patient begins to lose flesh and to change color, benefit will be derived 
from the use of preparations of the extract of malt, cod-liver oil, iron, arsenic, 
extract of gentian, pepsin, etc. When the exhaustion becomes more pro- 
nounced, ale, the red wines, or milk-punch may be added to the diet. Pain, 
when severe, should be controlled by anodynes,—McMunn’s elixir of opium, 
or deodorized laudanum, or Dover’s powder, being the best. When the 
suffering is just sufficient to prevent sleep, the bromide of potassium, either 
alone or associated with chloral, will often answer in place of opiates. Fre- 
quently, if not too weak, a mercurial at night, and an active aperient of 
Rochelle salts in the morning, will secure a temporary exemption from pain. 
Local remedies are capable of affording no small degree of relief. The 
breast should be supported, and not allowed to drag, as the weight alone of 
the tumor excites pain. This may be done in various ways,—by adhesive 
plasters, by the suspensory bandage of the breast, by a corset from which 
the bones have been removed, and between which and the gland there is EPITHELIAL CARCINOMA. 
713 
interposed some soft cotton-wool, and also bypassing the centre of the body 
of a cravat handkerchief under the affected breast and securing the two 
ends about the neck, one end having been passed under the axilla and the 
other over the front of the chest. Sensibility and pain in the mamma may 
he alleviated by anodyne lotions, a very good one being composed of equal 
parts of tinctures of iodine and belladonna and laudanum, which will be 
best applied with a camel’s-hair brush. Another very excellent application 
of the same nature is one consisting of laudanum f£i, muriate of ammonia 
3ij, tincture of arnica fgi, and bay-water fgij. Cloths are to be wet with 
the liquid and laid over the breast from time to time, and covered with oiled 
silk. Ointments of belladonna, of cicuta, and of stramonium are frequently 
used over the mamma for the purpose of allaying pain. A plaster composed 
of belladonna alone, or of belladonna, opium, and iodoform, can be worn with 
great advantage for several weeks in succession without removal. It should 
be more than large enough to cover the breast, and should have a central 
opening for the reception of the nipple. 
When ulceration occurs, the surgeon has to contend with foul discharges, 
and in many cases with the tendency to hemorrhage. The odor is best neutral- 
ized by the use twice every twenty-four hours of a wash of dilute listerine, 
permanganate of potash, chlorinated soda, or Platt’s chlorides. After the 
ablutions have been completed, the surface of the ulcer should be dressed 
with a piece of lint moistened with cai*bolated oil, or spread with benzoated 
oxide of zinc ointment, and laid over the sore, with an additional protection 
of absorbent cotton. 
Hemorrhage is best controlled by sprinkling over the diseased surface the 
sulphate of iron, tannin, or powdered alum. Bleeding will often be arrested 
by apptying the solid crayon of nitrato of silver to the granulations, or by 
mopping the surface with phenol sodique. When the hemorrhage is threat- 
ening, it may be necessary, in addition to a hajmostatic, to secure a firm com- 
press over the ulcer. When the hemorrhages are repeated and profuse, the 
breast should be excised. Pain may frequently be relieved by sprinkling a 
little morphia over the exposed granulation-tissue of the ulcer. It should be 
used with discretion. 
Among the distressing complications which belong to the life-history of the 
disease are the great swelling and pain of the arm wThich follow the venous 
obstruction due to the pressure of indurated axillary glands. This condition 
can only be palliated by having the arm drawn away from the body and 
supported on a pillow, so as to relieve the vessels from pressure. A spiral 
reverse roller applied with an evenly-graduated pressure will also occasion- 
ally furnish some relief. The local application of cold, as ice, which may be 
used with advantage in cases of severe pain before ulceration has taken 
place, is not well suited after a sore is established. 
When the removal of the breast is determined on, there are two ways in 
which that object can be effected,—namely, by caustics and by the knife. 
Caustics have for the most part, with the profession, passed into desuetude, 
but, with the addition of an unlimited amount of ignorance, presumption, 
and brass, have become the trading capital of charlatans. The amount of 
suffering they occasion is inconceivable to any one who has not witnessed 
their use. Even were they free from the objection of causing atrocious pain, 
these agents possess no peculiar efficacy which renders their employment 
desirable in eradicating the morbid structures: indeed, in every sense the 
knife more certainly follows extensions of the disease and shortens immensely 
the time of recovery. 
The two modes of removing the mamma by the knife are excision and 
amputation. 
By excision a sufficient amount of integument can often be preserved to 
cover perfectly the wound left after the extirpation of the gland. Under no 
circumstance, however, should unsound skin be spared, even though its re- 
moval entail an open wound. If, therefore, the integuments are found adherent 714 
DISEASES OF THE MAMMARY GLAND. 
to the new growth, if its mobility is in the least diminished, if it is at all 
discolored or thickened, or contains little knots of indurated tissue, it should 
unhesitatingly be sacrificed. On the other hand, when the skin over the 
breast is uniformly soft, elastic, freely movable, its color normal, and it rests on 
a good cushion of healthy adipose tissue, there is no necessity for its removal. 
Another very important direction is with reference to the amount of gland- 
tissue to be excised. Of course nothing short of excision of the mamma in 
its entirety should be practiced. It matters not how small the tumor, or 
how isolated or circumscribed its apparent boundaries, the whole gland 
should be extirpated. 
Frequently the mamma in carcinoma is adherent to the underlying fascia 
and muscles, and when so these structures must be taken away with the gland. 
Amputation of the breast is an old operation, practiced by Galenzovsky 
and others, and, with a slight modification, recently recommended by the 
younger Gross. The skin is divided around the base of the gland and the 
organ dissected away from the pectoral fascia. A large, open wound is left, 
which is required to heal by granulation and cicatrization. When the skin 
is open to suspicion, there can be no objection to this method. 
Enlarged Axillary Glands.—In all operations for mammary carcinoma a 
very careful exploration of the axilla should be made for enlarged or indurated 
glands, and when such are discovered the entire group must be removed. It 
is trifling with the patient, under these circumstances, to extirpate the mam- 
mary gland and to allow even a single enlarged lymph-gland to remain. 
Recurrence.—When local recurrence follows the removal of a carcinomatous 
breast, the secondary tumors should be attacked with the knife, and, indeed, 
as often as they reappear, so long as there are no signs of internal deposits. 
Early operations.—As soon as the diagnosis of carcinoma has been estab- 
lished with reasonable certainty, the time has arrived for excision. Early 
operations, before the axillary glands have become contaminated or the 
neoplasm has approached too near the surface, and while the skin remains 
healthy, promise a longer exemption from recurrent symptoms of the disease 
than operations executed at a later period, though they give no security 
against a return sooner or later. . 
The mammary gland of the male, 
though rudimental in development, is 
liable, though not to the same extent, 
to the same diseases which affect the 
female breast. 
Among the congenital abnormalities 
of the mammae are supernumerary nip- 
ples and absence of one nipple. 
Some of the affections of the male 
mamma occur particularly about the 
age of puberty, and for some time there- 
after, when, in common with other 
changes, a certain degree of evolution 
in the gland-tissue takes place. These 
affections consist mainly in supersensi- 
tiveness, enlargement, and induration, 
and are entirely harmless, yielding read- 
ily to the local application of lead-water 
and laudanum. When more persistent, 
a belladonna plaster, with a central 
opening for the nipple, can be worn 
over the gland with decided benefit; and if the patient is pale and wanting 
Fig. 2170. 
DISEASES OF THE MALE MAMMA 
Ulcerating carcinoma of the male mamma, with 
numerous nodules on the surrounding skin. EXCISION OF THE MAMMA. 
715 
in constitutional vigor it may be necessary to administer tonics, the best 
being a combination of quinine, iron, and arsenic. 
The neoplasms of the gland belong to more mature or to advanced life, and 
embrace lipoma, fibroma, adenoma, cystoma, and carcinoma. (Fig. 2170.) 
The treatment of these different tumors is to be conducted on the same 
general principles as are applicable to similar growths in the female. 
Excision of the Mamma. 
Excision of the mammary gland is not an operation of any great difficulty, 
nor is it especially necessary that the patient should be subjected to any 
protracted preparatory treatment. Two or three days of quiet rest, the 
administration of an aperient, a plain, simple, and unirritating diet, constitute 
for the most part the regimen which should be prescribed. 
Preparatory measures.—The recumbent position is the only proper one for 
this as for most other severe operations. Some time previous to the hour 
of operation the breast and surrounding parts should be well cleansed with 
alcohol or ether, and covered with a pad of antiseptic gauze wet in a solu- 
tion of the bichloride of mercury (one to one thousand). After the admin- 
istration of the anaesthetic this is to be removed, and the parts subjected to 
another washing with the sublimate solution. The parts surrounding the 
seat of operation are to be guarded by towels wet in hot sublimate solution. 
These protective appliances can be adjusted after the patient has been brought 
under the influence of the anaesthetic. 
Assistants.—The surgeon will require two assistants,—one whose duty it 
will be to take charge of the anaesthetic, and one who shall attend to the 
sponges and aid in tying the vessels. The nurse will see to cleansing the 
sponges, and to emptying the basins and refilling them with clean antiseptic 
solutions. 
Operation.—When everything is ready, the arm of the patient is to be 
carried off from the body, the surgeon taking his stand or seat, as the case 
may require, on that side of the patient corresponding to the breast to be 
removed. If it is necessary, on account of the unhealthy character of the 
skin, the magnitude of the tumor, or from ulceration, to remove along with 
the tumor a portion of the integument, the latter should be included within 
elliptical incisions made in a direction parallel with the course of the fibres 
of the pectoralis major muscle. There are, qf course, conditions of the skin 
which render a strict conformity to this rule impossible, and when the in- 
cisions must be planned without reference to any particular form in order 
to secure a sufficient covering for the wound. The chief indication is to sacri- 
fice all skin which exhibits the slightest trace of being unsound, without 
the least reference to the future wound. It is infinitely better to allow the 
entire chasm left by the operation to heal by open granulation than to utilize 
a particle of integument which is in the least suspicious. Assuming, how- 
ever, that the elliptical incisions are permissible, there is an order which 
ought to be followed. The lower incision should be made first (Fig. 2171), 
and the integument dissected sufficiently far down to uncover the lower 
semicircumference of the gland, always observing to allow a good stratum 
of adipose tissue to remain over the latter. This completed, the upper in- 
cision is next to be made, and a similar dissection of the integument carried 
over the upper half of the gland. When the cellulo-adipose layer is abun- 
dant, after starting the flaps, the finger will often suffice, at least to some 
extent, to separate the tumor from the superincumbent tissues. 
The next step consists in raising a portion of the gland at its upper or 
inner circumference from the pectoral muscle, from which, unless adhesions 
have been previously contracted, the entire mass can be rapidly removed by 
making strong traction on the breast, while the subjacent connective tissue 
is touched with the knife at any point where it does not readily yield. In 
cases where the tumor has become adherent to the pectoral muscle, the 716 
DISEASES OF THE MAMMARY GLAND. 
latter, of preference, should be torn away by forcibly pulling on the breast 
rather than to employ the knife, as by the former plan the diseased structures 
are more likely to be removed. When the neoplastic infiltration has reached 
Fig. 2171. 
Lower incision made and gland being separated from the pectoral muscle. 
the base of the gland, though there may be no adhesion of the tumor to the 
pectoral fascia, it will be best to dissect the latter carefully away from the 
muscle along with the mamma. 
With regard to the hemorrhage which attends excision of the breast, it is 
generally not necessary to stop to take up the vessels, but rapidly to proceed 
and complete the excision first. The vessels as they spring can be seized 
with the haemostatic forceps, and after the removal of the gland each one 
can be tied, as these forceps not only control hemorrhage, but also take the 
place of the tenaculum, or artery-forceps, the ligature being applied before 
their removal. 
In all cases of excision of the breast the axillary glands should be care- 
fully removed, without reference to their being enlarged. These bodies can 
be most satisfactorily enucleated by the fingers, after extending the incision 
from the lower angle of the wound into the axilla. 
After the ligation of all bleeding vessels and a careful inspection to see 
that no diseased portions of tissue have been overlooked, the parts should 
be douched with the antiseptic solution, taking care to get rid of every little 
clot of blood, which, independently of the fact that each coagulum often 
conceals the mouth of a vessel which subsequently bleeds, undergoes decom- 
position later, and thus complicates the healing. 
Closing the wound.—The wound having been again washed with the subli- 
mate solution and a rubber drainage-tube introduced, the flaps are to be 
neatly adjusted and secured together by a sufficient number of silver or cat- 
gut sutures to make the coaptation perfect. The line of approximation is 
next to be dusted with iodoform, and covered with a strip of protective, over 
which the usual two pads of antiseptic gauze, one wet and the other dry, are 
to be laid, these to be reinforced by three or four layers of salicylized or sub- 
limate absorbent cotton, and the whole dressing secured in place by numerous 
turns of an aseptic roller. If a simple binder is used to retain the dressing, 
shoulder-straps must be added to prevent its slipping down. (Fig. 2172.) 
It is a good plan to perforate the lower flap with a large trocar near its 
axillary extremity and bring the drain-tubes through the opening. The 
forearm is now to be supported in a sling across the chest, and the upper arm 
made fast to the body by passing around it a broad strip of bandage, or, 
what is better, a roller bandage. EXCISION OF THE MAMMA. 
717 
Boro-glyceride has recently been brought forward and extolled as a valua- 
ble article in surgical dressing. It is to be poured freely into the wound 
after all bleeding has been arrested, before the flaps are approximated. 
Having used this material only twice, I am unable to form any opinion of 
its value; though in both cases, one an excision of the breast and the other 
of a diseased testicle, the wounds healed rapidly and with a trifling amount 
of pus. 
After-Treatment. —Generally, 
it is necessary to remove the dress- 
ing on the second or third day 
following the operation, as it be- 
comes soaked with bloody serum 
and if allowed to remain would 
cause some surgical fever, indi- 
cated by a rise of temperature. 
The removal and renewal of the 
soiled dressing must be conducted 
with the same strict precautions 
as to antisepsis as were observed 
in its original application. The 
drainage-tube can also be short- 
ened at this time, though, as a 
rule, it is best not to remove it 
altogether until the next dressing. 
At the third dressing, the sutures, 
if silver, may be cut out; if cat- 
gut, they will disappear spontane- 
ously. Three or four dressings 
are usually all that are required 
if the flaps are sufficiently ample to close the wound. A strip of carholized 
gauze smeared over with boracic ointment and laid over the line of union, 
after the antiseptic compresses have been laid aside, answers every purpose. 
Few, if any, drugs are required to be given during convalescence. An 
anodyne, if the pain should be sufficiently severe to prevent rest, can be 
administered, and quinine and iron when the patient is feeble or should the 
suppuration prove profuse from imperfect asepsis. 
The diet for the first three or four days sho.uld consist of milk, after which 
there may be added beef-essence, and in the course of six or eight days there 
can be no objection to the patient’s resuming her ordinary diet. 
The time required for the complete healing of the wound, if properly 
treated by antiseptic methods,will rarely exceed two weeks. There will be 
little or no surgical fever, and scarcely a drop of pus will be seen,—a striking 
contrast to the results of the old manner of treatment, in which ordinarily 
from four to six weeks were spent in almost the daily renewal of dressings 
and the pressing out of purulent matter. 
Fig. 2172. 
Bandage applied. CHAPTER XXXVIII. 
ELECTRICITY IN ITS APPLICATION TO SURGICAL THERA- 
PEUTICS. 
Electricity is employed in surgical practice both as a means of diagnosis 
and of treatment. It is used in three forms,—static, galvanic, and faradic 
electricity. The first form, sometimes designated as frictional or franklinic 
electricity, has a very limited application as a therapeutic measure; gal- 
vanism and faradism are the forms in which this agent is most generally 
employed. 
Galvanism is developed by immersing in an acidulated or exciting solution 
two plates, usually of metal, one electro-negative, the other electro-positive. 
The batteries used for the purpose are quite numerous. The ones com- 
monly employed are those of Grove, Weiss, Flemming, Elliot, Stohrer, Smee, 
Byrne, and of the Galvano-Faradic Company. (Fig. 2173.) 
Fig. 2173. 
Galvanic battery, ten to sixty cells. 
The galvanic current is applied in a continuous, unbroken stream (constant 
current), or by being broken into distinct installments (interrupted current). 
The faradic or induced electricity is developed both by the chemico-mag- ELECTRICITY IN SURGERY. 
719 
netic (Figs. 2174 and 2176) and the rotatory magnetic (Fig. 2175) batteries. 
The induction apparatus also has two currents,—primary, derived from the 
inner coil, and secondary, from the outer coil. 
Fig. 2174. 
Chemico-magnetic battery, provided with rheotome, interrupted counter-currents, etc. 
For the electrization of the body or any of its parts, electrodes of various 
forms are employed, adapted to the different parts to which they are to be 
applied. 
Generally the electrode consists of a cup, disk, or plate, bearing a piece 
of moist sponge, or covered with chamois 
leather, or the sponge may be wanting 
altogether. Sometimes the electrode ter- 
minates in a knob, or is armed with metal 
or with carbon points, or it may be formed 
of a bundle of fine wires (electric brush). 
The handles of the instruments are always 
Fig. 2176. 
Fig. 2175. 
Rotatory electro-magnetic battery. 
Faradic battery. 
insulated. The electrodes are connected with the poles of the battery by 
wires covered with silk or gutta-percha. 
For the electrization of cavities, as the rectum, urethra, vagina, uterus, 
pharynx, and larynx, electrodes of peculiar construction are required, some 
of them resembling catheters or bougies, and these are insulated almost to 
their extremities. The handles often are furnished with a lever, which can 
be worked with tho thumb of the operator, and by which he is able to cut 
off or turn on the current at pleasure. 
The continuous can be converted into the interrupted current by the hand 
of the operator, who, while he bolds the sponge of one electrode connected 
with one pole of the battery in contact with the surface, alternately makes 
and breaks the circuit by thrusting against the body, and as quickly raising 720 
that connected with the other pole; or the interruption may be more per- 
fectly effected by a mechanism connected with the batter}'-, consisting either 
of a vibrating wire watch-spring or a wheel the cogs of which possess 
unlike conducting properties; or by a simple hand-brake, which can be moved 
on and off a knob by one hand of the operator. 
In the use of electricity it is important to distinguish between electric 
irritability and electric contractility. Although the terms are often used as 
interchangeable, electricians recognize a radical difference, so radical that 
the latter (contractility) would be meaningless when applied to nerves unless 
the distinction were made. By electric irritability is meant the readiness 
with which a muscle responds to electric stimulation, and by electric con- 
tractility the capacity or power of the muscle for work or action. That the 
quickness of a muscle to recognize an electric current is no index of its 
power is readily demonstrated by testing, by means of a battery, the muscles 
of two limbs, one of which is paralyzed, when it will be found sometimes 
that those on the paralyzed side will be more easily affected by electric stim- 
ulation than those of its fellow, or the sound side. 
In testing the irritability of a muscle, the plan pursued is to diminish the 
strength of the current employed, whether galvanic or faradic, to the lowest 
degree capable of exciting contraction, then compare one muscle or group 
with corresponding muscles of another limb or another person. Again, in 
measuring muscular or nerve irritability, the direction of the current must 
enter into the estimate, the inverse current, that is, a current passing from 
the distal to the proximal part of a limb, from the nerve-periphery towards 
the nerve-centre, always increasing, and the direct, or a current passing in 
the reverse direction, always diminishing the irritability. 
The same currents are not always applicable to dissimilar affections of 
nerves or muscles. When the function of a nerve, either sensory or motor, 
has been diminished or lost, it may be best restored by the use of the faradic, 
or interrupted, galvanic current, provided there has not been complete de- 
struction of its substance. When instead of diminished there is exalted 
function of a nerve, as revealed in pain, spasm, or twitchings, and where 
the object is to reduce overaction, the galvanic continuous current will be 
indicated. 
In applying electricity to enfeebled or paralyzed muscles two methods are 
practiced, which may be distinguished as general and particular, or the direct 
and indirect methods. In the general plan, a muscle or an entii'e group of 
muscles is stimulated to contraction at the same time, the sponge of the elec- 
trodes having a large surface and being made to act through the overlying 
integument; in the particular plan, the electric excitation is communicated 
through the nerve or nerves supplying individual muscles. The latter method 
requires the operator to be familiar with the localities of the nerve-points. It 
is sometimes called the “ motor-point method.” 
Electricity may be advantageously employed by the surgeon as a means 
of diagnosis and as a therapeutic agent, including in the latter the stimula- 
tion of feeble, paralyzed, or wasting muscles, electrolysis, and the cautery. 
Diagnosis.—Paralysis of muscles results from a variety of causes. There 
are lesions affecting the brain, spinal cord, nerves, or the structure of the 
muscles. 
In resorting to electric tests with a view to trace paralysis to its proper 
source, the terms irritability and contractility assume important differential 
significance. 
Whenever a muscle is paralyzed in consequence of the communication be- 
tween its nerve and the spinal cord having been injured or destroyed, its 
electric irritability, whether galvanic or faradic, is soon diminished or abol- 
ished, and the same is true when the spinal marrow has suffered from some 
destructive lesion, traumatic or other, at the origin of the nerve-root destined 
for a certain muscle. 
When we find the electric contractility of a paralyzed muscle can be called 
ELECTRICITY IN SURGERY. ELECTRICITY IN SURGERY. 
721 
into activity, we may conclude that the communication between the nerve 
and the cerebral or spinal centre is unbroken, and also that the centre is free 
from any lesion at the origin of the nerve. 
In cases of loss of voluntary motion which follows paralysis of cerebral 
origin, the nerves and muscles show that they are sound, and that the nerves 
are in good vital connection with the cord, by retaining their normal reactions 
both to galvanic and faradic currents. A faradic current applied directly 
to a muscle and meeting with no response indicates either impairment or 
destruction of the intramuscular nerves, though it does not follow that the 
muscular fibres also are injured. 
In paralysis from destructive brain-lesions the contractility of the paralyzed 
muscles induced by electric stimulation is not diminished. 
In cases of hysterical paralysis the electric contractility of the implicated 
muscles remains unimpaired, or sometimes is exaggerated. Feigned paral- 
ysis may sometimes be detected by testing the muscles of the two limbs. If 
the electric irritability and contractility are unlike on the two sides, the paral- 
ysis may be assumed to be real, on the principles laid down : so far electricity 
will be helpful to the surgeon or to the medico-legal expert. The response, 
however, might be good on both sides and yet the paralysis be real, because, 
as has already been stated, a cerebral paralysis, or a spinal paralysis in which 
the nerve-roots or the nerves themselves escape, does not cause a loss of 
reaction. In such cases the diagnosis will have to be determined in other 
ways. 
In infantile paralysis there is wasting of the muscles, and also in progressive 
muscular atrophy; but in the former there is a rapid loss of electric con- 
tractility, while in the latter affection it is preserved, at least as long as any 
muscular tissue remains. It is not claimed, of course, that electricity alone 
enables the surgeon to make a differential diagnosis between these two dis- 
eases, as this can be established by the relation which subsists between the 
muscular atrophy and the loss of power,—the former in infantile paralysis 
succeeding the latter, while in progressive muscular atrophy the two advance 
side by side. 
In formulating rules for electric treatment in the various forms of paralysis 
it may be assumed,— 
First. That during the acute period of central lesions, whether cerebral or 
spinal, no form of electricity can be used without doing injury. 
Second. That in local paralysis resulting from traumatism of nerves, and in 
all cases in which electro-muscular contractility is defective, either faradism 
or interrupted galvanism should be used as a means for improving the cir- 
culation, restoring degenerated nerve and muscle, and preventing atrophy. 
Third. A good practical rule to follow in the selection of the form of cur- 
rent, faradic or galvanic, is to use that form which will give the best con- 
traction with the least discomfort to the patient. The rule to be observed 
in using electricity in the treatment of local paralysis is to apply one elec- 
trode over the trunk of the nerve, and the other over the course of the 
individual muscles or their motor nerve-points. The first electrode, when the 
current is galvanic, must be moved from place to place, thus interrupting 
the current, or the clock-work or other mechanical rheotome may be used. 
Fourth. When paralysis to the will (cerebral paralysis) continues absolute, 
while the contractility of the muscles remains undiminished, electricity can 
effect no great good. It should be used, however, at intervals to overcome 
the effects of disuse of the muscles. 
One of the great uses of electricity is, as will be seen, to maintain the 
nutrition of muscles when their communication with the central source of 
nerve-energy has been temporarily or permanently interrupted. 
The specific affections, independent of paralysis in general, for which this 
agent is employed, and which come within the domain of surgery, are as 
follows: 
Paralysis of the bladder.—When the defect consists in a simple atony of the 722 
ELECTRICITY IN SURGERY. 
organ with incontinence, often observed in aged persons, or in cases where 
the walls of the viscus have been overstretched by retention of urine, fara- 
dism often does good; but for vesical paralysis interrupted galvanism is to 
be preferred. The electrodes are to be applied, in cases of the above nature, 
the one against the perineum, the other above the pubes; or one may be ap- 
plied to the lumbar region of the spine and the other over the pubes or 
behind the scrotum. For paralysis of the sphincter of the bladder, a 
urethral electrode—a bougie insulated nearly to its tip—should be introduced 
into the sphincter. 
Insufficiency of the sphincter ani, allowing the faeces to escape involuntarily, 
is often improved by a nearly similar adjustment of the electrodes, or with 
a slight change of position of the perineal sponge, the latter being placed 
against the front of the anus, or a large cylindrical electrode may be intro- 
duced into the sphincter of the anus. 
Impotency.—In loss of sexual power, electricity is applied in the same 
manner as in the treatment of paralysis of the bladder, or by the application 
of one of the electrodes directly to the genitals. 
Paralysis of the arm following luxation of the shoulder, and due. to press- 
ure upon the axillary plexus of nerves, will sometimes be removed and 
the power of the limb recovered through the agency of galvanism, the elec- 
trodes being placed one over the bx-achial plexus, immediately above the clavi- 
cle, and the other over the different nerve-points of the limb, or this treatment 
may bo conjoined dii'ectly with applications to the paralyzed muscles. 
Paralysis of the deltoid muscle following blows upon the shoulder will be 
benefited by electric treatment. 
Facial paralysis arising from blows and fi-om exposure to cold di*aughts of 
air, after the inflammatoiy symptoms have disappeared, will be often removed 
by placing one electrode (sponge) over or just in front and below the mastoid 
pi'ominence behind the ear, while the other (a motor-point electi’ode) is ap- 
plied to the muscles or nei’ve-points of the side of the face, using that bat- 
tery, galvanic or faradic, to which the muscles will l'espond. Usually after 
a few days reaction to the faradic cui’rent is lost, but after weeks of treat- 
ment returns. 
Ptosis.—In treating ptosis, one electrode is applied over the temple and the 
other upon the eyelid, which may be held out from the ball. Either the 
galvanic or the faradic cuiTentcan be used, but it should not be strong. 
Strabismus.—When, after division of the intenial rectus muscle of the eye, 
the external rectus is found to be too feeble tocoi'rect the convei'gent squint, 
and in other cases of sti’abismus, fai’adization of the muscle at fault has been 
followed by a good i*esult. 
Aphonia.—Loss of voice, either from hystei’ical or other causes, is veiy 
successfully treated by fai*adization of the larjmx, one electrode being placed 
on the back of the patient’s neck, and the other either applied against the 
front of the larynx, or, under the guidance of the laryngoscope, conducted 
directly to the vocal cords. The current should be very weak. One appli- 
cation will often break the spell of silence. 
Torticollis.—A form of wry-neck is occasionally met with which seems to 
be induced by nervous exhaustion, and a number of cases have been success- 
fully ti’eated by galvanism. The positive electi’ode should be pi’essed into 
the space behind the angle of the jaw, and the negative one moved over the 
terminations of the spinal accessory neiwe along the outer border of the 
sterno-cleido-mastoid and over the ti’apezius muscles. 
Artificial respiration.—When life is thi-eatened from the poisonous action of 
chloroform, or in cases of suspended animation from drowning or suffocation, 
electricity constitutes a most valuable aid to other means of resuscitation by 
exciting the inspii*atory action of the diaphi’agm, the faradic cuiTent being 
transmitted thi’ough the phi-enic nerves, which can be reached by applying 
one electrode to the neck above the clavicle, or in the supra-clavicular space, 
and the other over the sixth intercostal space on the corresponding side of ELECTROLYSIS. 
723 
the chest, or at different points on a level with the cartilaginous border of 
the thorax. The current should be weak. 
Scrivener's cramp.—Some benefit has been derived from faradization of the 
affected muscles, and galvanism (continuous current), in cases of scrivener’s 
cramp. One of the best methods in this disorder is to apply a continuous 
galvanic current to the muscles affected with cramp or spasm, and an inter- 
rupted current to the paretic muscles. In this affection electricity should 
be used in connection with, but not to the exclusion of, other measures. 
Chorea.—Yery good results have been obtained by Addison and Golding 
Bird in the treatment of chorea by electricity. Static electricity was re- 
garded by these physicians as better adapted to cases of this nature than 
either the galvanic or the faradic current. It was applied to the spine by 
sparks. 
Neuralgia.—In neuralgia affecting the branches of spinal nerves the con- 
tinuous current, daily applied, often effects a cure, one electrode being placed 
over that portion of the spine nearest to the nerve affected, and the other 
over the painful parts. The sittings should not extend over ten or at most 
fifteen minutes, and the strength of the current should not be greater than 
is necessary to cause a little tingling, and, finally, warmth. 
Electrolysis. 
Electrolysis is a term used to express certain decompositions which occur 
at the positive and negative poles when a continuous current is passed 
through a compound liquid. When, for example, water is decomposed by 
the passage of an electric current, oxygen is found liberated at the positive 
and hydrogen at the negative pole. The parts of the substance decomposed 
which collect at the poles electricians designate as anions and cations, the 
former term being applied to those set free at the positive pole, the latter term 
to those set free at the negative pole. Any substance which admits of such 
decomposition is called an electrolyte. The value of an electrolyte is based 
on the amount of water and soluble saline matter which it contains. It is 
in view of the disintegrating effects of this kind of polar electricity that we 
have electrolysis applied to the treatment of tumors, aneurisms, inflammatory 
exudations, etc. 
When applied to the discussion of tumors, we require one or more steel 
gilt needles insulated with vulcanite to within'a very short distance of their 
points. These are to be passed into the morbid growth, and then connected 
with the negative pole of a battery, after which the sponge electrode attached 
to the positive pole is applied over the surface of the tumor, thus completing 
the circuit, and starting into activity the decomposing force by which the 
components of the neoplasm are disorganized and subsequently absorbed. 
Fatty tumors, sebaceous and hydatid cysts, goitres, nsevi, and hydroceles 
have been successfully cured by this plan of treatment. 
The time required for a sitting varies from five to fifteen minutes, and 
the current, at first moderate, should gradually be increased to the tension 
necessary to accomplish the full electrolytic effect, requiring a battery from 
ten to thirty cells strong. 
In the treatment of aneurism by electrolysis, a method which has received 
the special attention of Ciniselli, Nicolli, Petrequin, and others, one or more 
steel needles gilded, and insulated to protect the soft parts, are to be intro- 
duced into the aneurism, and connected with the positive and negative poles 
of a twenty-five- or thirty-celled battery. Care is taken that their points do 
not come in contact. Sometimes it is directed to introduce one needle into 
the aneurism and use a moist sponge electrode for the other pole; and when 
this plan is adopted the needle must always be connected with the positivo 
pole. 
The time required for the operation will vary from fifteen minutes to one 
hour, and its repetition may be required at intervals of three or four days. 724 
ELECTRICITY IN SURGERY. 
During the treatment the tumor will increase in size from the liberation of 
gas in its interior, will become quite red around the puncture of the positive 
needle, and the surface probably will vesicate under the moist sponge of the 
negative electrode when it is employed. The needles must be withdrawn 
with as little violence as possible, and the punctures covered at once with 
adhesive plaster, or with gauze and collodion. The operation is painful, and 
will require the patient to be placed under the influence of an anaesthetic. 
The chemical action of the current is to cause the coagulation of the con- 
tents of the aneurism and the occlusion of the sac, most probably without 
any separation of the fibrin. Of 126 cases of aneurism of different vessels 
treated by electrolysis and analyzed by Hamilton, 48 were accepted as 
cured, the remainder set down as doubtful or not cured. An unsuccessful 
effort to solidify an aneurism of the aorta was made in the medical ward of 
the hospital of the University of Pennsylvania on a patient under the care 
of Professor Pepper. After carefully reviewing the subject of electrotysis 
in its adaptation to the treatment of aneurism, it may be said that the plan 
can bo adopted in the early stage of internal aneurisms with a reasonable 
prospect of affording relief, but rarely with the result of permanently curing 
the disease. 
Electrolysis employed in the treatment of naevus has been attended with 
excellent success. Mr. Knott, of St. Mary’s Hospital, London, in 1875, 
reported forty cases cured by this plan. He employs either needles with 
each pole of an eight-celled zinc-carbon battery, or if needles are used only 
in connection with one pole, it must be the negative, while a carbon point is 
attached to the positive pole. 
Hydrocele, which has also been subjected to electrolysis, requires that the 
sac of the tunica vaginalis be punctured with an insulated needle and con- 
nected with the negative pole, the positive electrode being applied to the 
surface of the scrotum. Six or seven minutes will suffice for the sitting. 
The inflammation created by the currents constitutes, no doubt, the manner 
of cure. The facility and certainty with which hydrocele disappears after 
tapping and injection with the tincture of iodine render it very improbable 
that electrolysis will ever supplant the trocar and canula. 
Hydatid tumors have been successfully treated by Fogge, Durham, and 
Foster by the electrolytic method, the same course being pursued in regard 
to the details of the operation as in hydrocele. 
Maso-pharyngeal polypus has been attacked successfully by Bruns by this 
method. The needles used were composed of zinc, one being introduced into 
the tumor through the right nasal cavity, and the other through the mouth, 
both being protected by a gum Eustachian catheter. 
The use of zinc needles is believed by some operators to possess a peculiar 
value in the treatment of tumors by the electrolytic plan, as the chloride of 
zinc which is formed by the chemical action of the current exerts a cauter- 
izing effect on the tissues of the new formations. 
Electrolysis can also be used with advantage in alleviating the pain of 
malignant disease in persons who tolerate opiates badly. 
Electrolysis has been largely used by Tripier, Mallez, Brenner, and Hew- 
man in the treatment of stricture of the urethra. The electrode employed 
lor the canal resembles an ordinary catheter (Fig. 2177), and when prop- 
erly insulated and connected with the negative pole is conducted along 
the urethra until it comes in contact with the stricture; the circuit is com- 
pleted by bringing the other electrode—a button of carbon—in contact with 
the perineum, a piece of moist sponge or agaric being interposed between 
the two. 
It is claimed that the cicatrix resulting from the destructive action of the 
current is soft, pliable, and without tendency to conti’action, and therefore 
not likely to produce subsequent coarctation of the canal. The statement in 
regard to this alleged property of electrical scar-tissue has not been sufficiently 
verified to admit of its being accepted without challenge. The latest deliv- ELECTRO-CA UTERY. 
725 
erance on the use of the electrolytic method in the management of stricture 
is that of Dr. Newman, who has submitted to the profession a report of 
Fig. 2177. 
Electrode for stricture. 
one hundred cases treated in this way, and with very satisfactory results. 
Considering the outlay necessary to procure a battery and the technical 
skill required for manipulation, it is not probable that electrolysis will dis- 
place the metal bougie with the general practitioner in this department of 
surgery. 
Electro-Cautery. 
It is, however, as a cauterizing agent that electricity proves most valuable 
to the surgeon, and particularly in those operations where severe bleeding 
Fig. 2178. 
FIG I 
FIG 2 
FIG 3 
FIG 4- 
FIG 5 
F IG <5 
Electro-cautery instruments. 
is likely to be encountered: hence in the extirpation of the tongue, the 726 
ELECTRICITY IN SURGERY. 
removal of the cervix uteri and of uterine polypi, in amputation of the penis, 
the destruction of mevi, of epithelioma, of lupus, and of hemorrhoids, for the 
arrest of hemorrhage in cavities otherwise inaccessible, for fistulro and sinuses 
and phagedsenic ulcerations, the electro-cautery occupies a field of consider- 
able importance. Growths in the larynx and in the nasal cavities admit of 
being reached by this agent often with greater facility than by other means. 
Tracheotomy has also been performed by the electro-cautery knife, of which 
operation M. Burdon records eight cases. 
The instruments which are required to execute the various operations 
which come within the province of electro-cautery are platinum wire ecra- 
seurs, knives, cauteries (Fig. 2178), which consist of a conical shell of porce- 
lain surrounded spirally with platinum wire, and with electrodes containing 
two copper wires which at the handle connect with the poles of the battery, 
with trocar and canula designed to open a way for the passage of the plat- 
inum wire. These instruments, for convenience, are generally put up com- 
pactly in a box. (Fig. 2179.) The battery which I use is a Byrne, and 
Fig. 2180. 
Fig. 2179. 
answers admirably for all the purposes required in electro-cautery. (Fig. 
In using the ecraseur, the connection of the poles with the battery must 
not be made until the platinum-wire loop has been adjusted and tightened. 
The wire should not be heated above a dull-red heat; if greater than this it 
burns away the eschar which is made, and fails to close the divided vessels, 
in consequence of which hemorrhage follows. The screw of the ecraseur 
ought not to be turned too rapidly, as by so doing the wire may give way, 
or the tissues are divided so rapidly that there is not time given for the for- 
mation of a proper eschar; and, finally, as the loop near the completion of 
its task of course becomes hotter, the strength of the battery must be dimin- 
ished by utilizing a smaller number of cells. 
Case containing electro-cautery instruments, electrodes, etc. 
Byrne battery. CHAPTER XXXIX. 
OPERATIONS FOR NERVE-STRETCHING AND NERVE-EXCISION. 
Sufficient has been said when discussing the general subject of nerve- 
stretching to show that the operation should be accepted as a surgical 
means capable of affording relief in many cases of pain and spasm, and 
sometimes of effecting a perfect cure, when other measures have failed. 
The surgical relations and the methods of exposure of those nerves which 
are generally the subjects of stretching will constitute the contents of this 
chapter. 
Supraorbital Nerve.—The supraorbital nerve, or the terminal trunk of the 
first branch of the fifth pair of cranial nerves, passes through the supra- 
orbital notch, accompanied by the supraorbital artery and vein. Its point 
of exit is at the junction of the inner and middle thirds of the supraorbital 
arch, and a line drawn from the latter point to the frontal protuberance in- 
dicates the course of the nerve. (Fig. 2181.) It is covered by the skin, 
fascia, the mingled fibres of the orbicularis 
palpebrarum and anterior belly of the oceip- 
ito-frontalis and eorrugator supercilii mus- 
cles. 
Operation.—An oblique incision one inch 
in length should be made through the in- 
tegument over the junction of the inner and 
middle thirds of the supraorbital ridge (Fig. 
2181), exposing the muscular mass which 
enters into the structure of the eyebrow. 
The lower fibres of the orbicularis palpebra- 
rum are next to be raised on the director and 
divided in the line of the first incision, after 
which, by using the director to displace some 
fibres of muscular and connective tissue, the 
nerve will be exposed and can be stretched 
to the required degree. 
The subsequent treatment of the wound 
consists in bringing its edges together by adhesive straps or by sutures, and 
covering it with a pledget of lint moistened with carbolated oil and retained 
by an oblique roller bandage. 
The operation of stretching the supraorbital nerve may be deemed neces- 
sary in cases of severe neuralgia of its frontal branches arising idiopathically 
or induced by contusions. 
Fig. 2181. 
Supraorbital nerve exposed on the left side 
of the face, and the line of incision shown 
on the right. 
Infraorbital Nerve.—The infraorbital nerve, or the termination of the 
second branch of the fifth pair, enters the face through the infraorbital fora- 
men, and, descending, gives off’ in the canine fossa a considerable leash of 
branches destined to confer sensation on the muscles of the face. The nerve 
emerges from the infraorbital canal at a point corresponding to the junction 
of the inner and middle thirds of the infraorbital ridge, is accompanied by the 
infraorbital artery and vein, and is covered in front by the skin, the super- 728 
OPERATIONS FOR NERVE-STRETCHING AND NERVE-EXCISION. 
ficial fascia, containing considerable fat, the lower segment of the orbicularis 
palpebrarum, levator labii superioris, and levator labii superioris aleeque 
nasi muscles. (Fig. 2182.) A line dropped vertically from over the supra- 
orbital foramen will touch the surface 
below the orbit directly over the infra- 
orbital nerve and blood-vessels. 
Operation.—It is important that all 
incisions which are made upon the face 
should, as far as possible, run parallel 
with rather than across the muscles, 
and when feasible the latter should not 
be divided. The infraorbital nerve can 
be reached without violating either of 
these rules, by making a crescentic in- 
cision one inch in length, and one-quar- 
ter of an inch below the orbit, with its 
convexity downward. (Fig. 2182.) After 
dividing the skin and the cellulo-adipose 
tissue, the inferior border of the orbicu- 
laris palpebrarum muscle will be exposed. 
By turning its lower fibres upward, two other muscles, the levator labii supe- 
rioris and levator labii superioris alseque nasi, come into view. By entering 
the fissure between these two and separating them from each other, the 
nerve will be sufficiently exposed to admit of its being isolated from the blood- 
vessels and stretched by passing a director beneath it. 
The infraorbital nerve may require stretching in cases of neuralgia in- 
volving the upper part of the face and the teeth of the upper jaw. When 
the cause of the paroxysms is peripheral, or not seated farther back than the 
floor of the orbit, benefit may be expected from the operation; but when in 
the spheno-maxillary fossa or posterior to Meckel’s ganglion, excision of the 
nerve behind the latter should take the place of stretching. 
Fig. 2182. 
Infraorbital nerve exposed. 
Auricularis Magnus Nerve.—This nerve, destined to supply the posterior 
part of the auricle and the parts over and above the mastoid process of the 
temporal bone, is one of the ascending branches of the superficial cervical 
plexus : emerging at the posterior border of the steimo-cleido-mastoid muscle, 
near its middle, it ascends the neck resting on the latter muscle, becoming 
quite superficial half an inch posterior to the lower extremity of the lobe of 
the ear. (Fig. 2183.) 
Operation.—An incision 
one inch in length, made 
obliquely from below upward 
and backward, the middle of 
the incision being on a level 
with the free extremity of the 
lobe (Fig. 2184, A), and car- 
ried through the skin and 
superficial fascia, will expose 
the trunk of the nerve im- 
mediately below its division 
into two trunks, where it can 
be conveniently raised and 
stretched on the director. 
It is not common to meet 
with painful conditions of the 
region supplied by the termi- 
nal twigs of this nerve, but 
when these do occur, and no relief is obtained by ordinary measures, the 
operation can be performed without difficulty. 
Fig. 2183. 
Auriculaiis magnus nerve exposed. SPINAL ACCESSORY NERVE. 
729 
Great Occipital Nerve.—This is a branch of the second cervical nerve, and 
is destined to supply the integument of the scalp as far forward as the vertex. 
It pierces the eomplexus and trapezius muscles near the attachment of the 
latter to the cranium and to the occipital protuberance, and is accompanied 
by the occipital artery, dividing into several branches. (Fig. 2184.) 
Operation.—The surgeon feels for the occipital protuberance, and, having 
recognized that landmark, commences his incision three-quarters of an inch 
Fig. 2184. 
Lines of incision for exposing the occipital and auricular nerves; to the right of the cut, occipitalis 
magnus exposed; N, nerve; OA, occipital artery. 
above that prominence, and, carrying it downward and forward, passes to 
one side of the process, terminating the cut three-quarters of an inch below. 
(Fig. 2184, B.) Carefully raising the subcutaneous connective and adipose 
structures, the nerve will be exposed at the point where it pierces the 
trapezius. 
Severe neuralgic pain of the posterior half of the scalp is by no means un- 
common, and some persons are scarcely ever free from either acute suffering 
or extreme sensibility of this part of the bead. ]q jn case8 0f this kind 
that resort may be had to stretching, with a fair prospect of relief. 
Spinal Accessory Nerve.—This nerve, destined principally for the supply 
of the sterno-cleido-mastoid and trapezius muscles, enters the former muscle 
Fig. 2185. 
Fig. 2186. 
SC, sterno-cleido-ma8toi(i inward; N, spinal acces- 
sory nerve. 
Line of incision for exposing the spinal accessory 
nerve. 
nearly two inches below the mastoid process, and, after supplying its sub- 
stance with branches, passes outward to the trapezius. (Fig. 2185.)  OPERATIONS FOR NERVE-STRETCHING AND NERVE-EXCISION. 
730 
Operation.—An incision must be made along the posterior border of the 
sterno-cleido-mastoid muscle, beginning near the tip of the mastoid process 
of the temporal bone and terminating two and a half inches below. (Fig. 
2186.) After dividing the skin, superficial fascia, platysma myoides, and 
deep fascia, the posterior border of the sterno-cleido-mastoid muscle will be 
brought fairly into view, which, on being raised and turned inward towards 
the median line of the neck, leaves the nerve exposed at a point where it can 
be subjected to the required tension. 
Stretching the spinal accessory nerve may be called for in torticollis or in 
choreic movements of the head. Dandridge gives 4 cases of torticollis which 
were benefited by the operation. Richardson, of Cincinnati, has collected 
14 cases of excision of the spinal accessory, with 9 cures and 5 improved. 
Musculo-Cutaneous, Median, and Ulnar Nerves—These nerves lie along the 
inner edge of the coraco-brachialis muscle, in close relation with the axillary 
blood-vessels, the artery being embraced by the two branches of the median 
nerve. The external cutaneous trunk perforates the coracho-brachialis mus- 
cle. and the ulnar and internal cutaneous divisions of the axillary plexus lie 
along the inner side of the median 
nerve and axillary artery. (Fig. 
2187.) The superincumbent struc- 
tures consist of skin, superficial fas- 
cia, and deep fascia. 
Operation.—One incision will 
answer for the exposure of any 
branch of the axillary plexus of 
nerves: it does not differ from that 
employed for the purpose of liga- 
ting the third, or last, part of the 
axillary artery. (See Fig. 567, vol. 
i. p. 769.) The arm having been 
carried off from the body, the cut 
is made two and a half inches in 
length close along the .inner bor- 
der of the coraco-brachialis muscle, 
which can be readily distinguished 
as a tense cord under the pectoralis major muscle. After the division of the 
skin, the superficial and deep layers of fascia are raised and divided on the 
director, exposing the inner fleshy border of the coraco-brachialis muscle. 
If it is proposed to stretch the musculo-cutaneous nerve, it will be most 
accessible on the outer side of the muscle, while for operating on the median, 
musculo-spiral, or ulnar nerve, or, if necessary, on all of these at the same 
time, the isolation and raising must be done on the inner side of that muscle. 
The operation of stretching one or more branches of the axillary plexus 
of nerves may be required on account either of painful states of the arm or 
of spasmodic disturbances of certain groups of muscles. When such condi- 
tions are confined to definite limits, the stretching should be restricted to the 
particular nerve whose distribution falls within the affected area. 
Fig. 2187. 
Axillary nerves. MG, musculo-cutaneous ; M, median 
nerve; MS, musculo-spiral; U, ulnar nerve. 
Great Sciatic Nerve.—The great sciatic nerve, after leaving the great sacro- 
sciatic foramen below the pyriform muscle, passes down between the tuber 
ischii and the trochanter major of the femur, covered in by the glutseus maxi- 
mus muscle. It then passes beneath the hamstring muscles, and lower down 
descends between the latter after they diverge in order to reach the inner 
and outer sides of the leg (Fig. 2188), dividing at the lower part of the ham 
into popliteal and peroneal nerves, and covei’ed by the integuments and the 
posterior femoral fascia. 
Operation.—The great sciatic nerve can be reached in two localities,— 
viz., through the gluteo-femoral fold and, lower down, between the inner and PERONEAL NERVE. 
outer hamstring muscles. (Fig. 2188.) If the first locality is selected, an 
incision three inches and a half in length must be made in the gluteo-femoral 
told through the skin and fascia, bringing into view the lower border of the 
glutmus maximus muscle. By 
breaking up with the handle of 
the scalpel some loose cellulo- 
adipose tissue between the last- 
named muscle and the hamstring 
muscles the nerve will be exposed. 
By the second plan, which on 
account of its simplicity is to be 
preferred, the incision beginning 
at the gluteo-femoral crease is 
carried directly down the middle 
of the thigh, four inches in length, 
through the skin and subcuta- 
neous connective and adipose tis- 
sues. The deep fascia is next 
divided, and the fissure between 
the inner and outer hamstring 
muscles exposed, at the bottom 
of which lies the sciatic nerve. 
It must not be overlooked 
that not unfrequently the two 
nerves, the great sciatic and the 
external popliteal, originate independently from the sacral plexus, and descend 
the thigh separately side by side. 
This nerve, in sciatica and other painful conditions of the limb, has been 
stretched a large number of times, and often with very excellent results. 
731 
Fig. 2188. 
Great sciatic nerve exposed. Iff, inner hamstrings, or 
semitendinous and semimembranous; GM, gluttons maxi- 
mus; OH, outer hamstring, or biceps flexor cruris; N, N, 
nerve. On right side of figure, the two incisions for exposing 
the nerve. 
Peroneal Nerve.—The peroneal or external popliteal nerve passes around 
the outer aspect of the knee-joint, between the tendon of the flexor biceps 
cruris and the head of the fibula, and, 
piercing the origin of the peroneus 
longus muscle, divides into two branches, 
the anterior tibial and the peroneal cuta- 
neous. (Fig. 2189.) 
Operation.—The superficial position 
of the nerve just before it enters the 
peroneus longus muscle makes this point 
a desirable one for its exposure by oper- 
ation. For this purpose an incision two 
and a half inches long should be made 
obliquely downward and forward along 
the lower border of the flexor biceps 
cruris muscle, the leg being at the same 
time extended in order to give promi- 
nence to the tendinous edge of the ham- 
string as a guide. On the completion 
of the first cut, which should extend 
through the integument, the leg should 
be flexed, and the wound over the fibula 
cautiously deepened until the nerve is 
uncovered about one inch below the 
upper extremity of the fibula, where it is 
about to enter the peroneus muscle. 
Severe and protracted pain or spasm of the parts on the anterior or outer 
aspects of the leg, when not amenable to other means of treatment, will 
constitute the indication for stretching the external popliteal nerve. 
Fig. 2189. 
External popliteal nerve exposed. N, nerve; P, 
peronens longue muscle cut away to expose the 
nerve ; S, border of the soleus muscle. To the 
left, line of incision for exposing the external 
popliteal nerve. 732 
OPERATIONS FOR NERVE-STRETCHING AND NERVE-EXCISION. 
Anterior Crural Nerve.—The anterior crural nerve, the largest branch of 
the lumber plexus, leaves the pelvis by passing beneath the crural arch 
about three-quarters of an inch 
external to the femoral artery. 
(Fig. 2190.) At the point of 
exit the nerve lies in a groove 
between the psoas magnus and 
iliacus internus muscles, cov- 
ered by the integument, the 
superficial fascia, and the deep 
fascia, or fascia lata. Immedi- 
ately below Poupart’s ligament 
the nerve divides into a large 
number of branches, which are 
distributed to all the muscles 
on the anterior and inner por- 
tions of the thigh, except the 
tensor vaginae femoris. 
Operation.—To expose the 
main cord immediately below 
the crui*al arch, an incision 
should be made three inches 
in length directly over Poupart’s ligament, commencing one inch above it, 
and a little to the iliac side of its middle. After the division of the skin, 
superficial fascia, and adipose tissue, the deep fascia will be reached, when 
it only remains to open the latter and scratch away a film of iliac fascia, 
when the nerve will be brought into view, and by flexing the thigh some- 
what it can be raised from the groove between the iliac and psoas muscles. 
If any difficulty is experienced in finding the nerve, the operator will feel 
for the pulsation of the femoral artery, and, this recognized, the search must 
be made externally to the vessel. Very little bleeding will be encountered in 
the operation of uncovering the anterior crural nerve, and that little will 
come from the superficial external iliac artery, which may require to be tied. 
Stretching the anterior crural nerve may be required to relieve pain or 
spasm of the muscles on the front of the tliigh. It has been done 8 times, 
with rather negative results. 
Fig. 2190. 
Left side of body.—Dissection exhibiting the relation of the 
anterior crural nerve. N, nerve; dotted line, Poupart’s ligament; 
PI, psoas and iliac muscles ; S, sartorius; A, femoral artery. Eight 
side of body, line of incision. 
Anterior Tibial Nerve.—The anterior tibial nerve has the same surgical 
relations as the anterior tibial artery, and the line described for finding the 
latter, under the head of ligations, will be equally useful in a search for the 
nerve. 
Operation.—The middle third of the leg will be the best locality for ex- 
posing the anterior tibial nerve, requiring for the purpose an incision three 
inches long and in the course of a line already indicated. After the division of 
the skin, superficial fascia, and deep fascia, the space between the tibialis anticus 
and extensor longus digitorum muscles must be opened, when a third muscle 
will be brought into view, the extensor proprius pollicis, between which 
and the tibialis anticus muscle lie the artery, veins, and nerve, the last being 
either on the inner side or in front of the first. (Fig. 2191.) 
Though by stretching the peroneal or external popliteal nerve the anterior 
tibial participates in the effects of the tension, yet, as a particular case may 
demand that the group of muscles on the front of the leg shall alone be the 
subject of treatment, the necessity for stretching the anterior tibial indepen- 
dently of the peroneal cutaneous nerve will be evident. 
Excision of the Branches of the Trifacial Nerve.—Facial neuralgia incor- 
rigible to therapeutic measures is frequently relieved or cured by excision 
of the offending branch. 
First or supraorbital trunk.—If the pain is referred to the first branch, .this ANTERIOR TIBIAL NERVE. 
733 
latter can be readily exposed by an oblique incision one inch in length over 
the eyebrow, at the junction of the middle and outer thirds of the supraorbital 
ridge. After dividing the integument and the lower fibres of the orbiculus 
muscles, and tearing apart with the director some dense connective tissue, 
the nerve will appear as it leaves the supraorbital fora- 
men, when it may be dissected up and severed. 
Second or superior maxillary branch.—A vertical in- 
cision one inch in length, beginning at the junction 
of the middle and anterior thirds of the infraorbital 
ridge, with a second cut parallel with the same ridge, 
makes the readiest approach to the nerve. The flaps 
being reflected and the muscles displaced by the handle 
of the scalpel, the nerve will be exposed in the canine 
fossa, when it can be raised on a blunt hook, and 
with a director isolated up to the infraorbital foramen, 
below which it should be tied with a thread, with 
which to keep it on the stretch. The nerve being 
next cut, a section of the bone, including the infra- 
orbital foramen, is now made with the crown of a 
trephine. With the corner of a delicate chisel applied 
to the edge of the groove in the orbital plate of the 
upper maxillary bone the nerve can be exposed as 
far back as the posterior wall of the antrum, where 
it may be cut off with the scissors. If it becomes 
necessary to attack the nerve behind the orbit, in the 
spheno-maxillary fissure, and posterior to Meckel’s 
ganglion (the operation of Carnochan), the plan to 
pursue is to break away the posterior wall of the an- 
trum by gentle taps on a delicate metal punch and 
pick away the fragments of bone, after which the nerve can be severed 
close to the foramen rotundum with scissors curved on the flat. Langenbeck 
divided the nerve by a long delicate tenotome 
carried along the outer walls of the orbit into 
the spheno-maxillary fissure, and Pancoast 
the elder accomplished the same object by 
an operation through the zygomatic fossa. 
Third or inferior maxillary nerve.—The 
ramus of the lower jaw is exposed either by 
raising a semilunar flap (Fig- 2191*) or by 
a vertical incision two inches in length car- 
ried through the integument and the mas- 
seter muscle down to the lower border of 
the jaw and distant about one inch forward 
from its angle. The soft parts being displaced 
with the handle of the scalpel, the external 
wall of bone is cut out with the trephine 
three-eighths of an inch above the angle and 
about five-eighths of an inch behind the 
last molar tooth. The nerve, being exposed, 
should be removed to the full length of the 
opening made by the trephine. If the bleed- 
ing from the artery should prove troublesome, which is not common, it can 
be arrested by plugging the opening in the canal by a fragment of dentist’s 
cement, by a bit of wax, or by a point of the cautery. 
The dressing in all these operations consists in introducing a few threads 
of catgut into the wound and applying two or three stitches, and dressing 
antiseptically. 
Fig. 2191. 
Anteriortibial nerve. N,nerve; 
T, tibialis anticus muscle; E, ex- 
tensor longus digitorum ; P, ex- 
tensor proprius pollicis. 
Fig. 2191*. 
Author’s incision for exposing the inferior 
dental nerve. CHAPTER XL. 
MASSAGE. 
Massage may be defined to be manual therapeutics. The word is derived 
from a Greek word signifying “ to knead but the practice dates farther 
back than either Greece or the Greeks, possibly long prior to written his- 
tory. Whether the various procedures of massage were originally formu- 
lated on anatomical and physiological predicates, or were simply empirical 
devices introduced as a part of the machinery of Eastern astrology, it is 
impossible to determine. It is certain that in both ancient and modern 
times great virtue has been supposed to reside in the human hand. Naaman, 
when he visited Elijah at the instance of the little Syrian maid, expected 
certainly that the old prophet of Israel would come and “ strike his hand” over 
the leprous body. The laying on of hands was a therapeutic as well as a 
religious ceremonial act among the ancient Hebrews. Manipulations were 
not only employed among the arts of the Hindoos for charming away dis- 
ease, but from time immemorial have constituted a part of their system of 
legitimate medicine. Some of the miracles of healing wrought by Christ 
during his ministry on earth were accompanied by the touch of the hand; 
and at a comparatively late period the fingers of royalty were believed to 
exert a curative power over scrofulous glands. 
To see a nervously restless patient calmed into peaceful quietude by a 
few gentle strokes of the hand is a common experience ; and who that has 
suffered accidentally from a severe contusion has not experienced comfort 
and assuagement of pain from the pressure and rubbing which are instinct- 
ively practiced over the injured part? 
Like Simon Magus, there have always been persons who are ever ready to 
prostitute the useful to the basest purposes, and hence manual movements 
have been resorted to by charlatans and empirics to impose on the credulity 
of human nature by subsidizing them for the tricks of the exorcists, of 
animal magnetism, incantation, etc. 
References are made in the earliest records of the Chinese to special exer- 
cises or movements which were in use for the cure of certain affections of 
the body; and gymnastics, as hygienic measui’es among this people, have 
been made the subject of a special treatise by a native of China, Kong-Fau. 
Exhaustive treatises have been written by Beylier, Philippeaux, and Estra- 
dere on the literature of massage, to which I am indebted for much infor- 
mation in regard to the practice of ancient exercises. 
Originating in the East, the matrix, indeed, of much'curious lore, massage 
spread westward, and we next discover it associated with baths, more as a 
hygienic than as a therapeutic measure. 
The culture of the Greek was not limited to philosophy, art, and song, but 
comprehended also the highest possible development of the physical man. 
The Hellenist, who worshipped the beautiful, found his enjoyment not only 
in lingering about plane-trees and porticos listening to the utterances of 
philosophic sages, but also at the struggles of the Olympian games. What- 
ever ministered to the grace, beauty, and vigor of the body constituted a 
part of Greek education : hence the establishment of baths; and, as these 
were dedicated to Hercules, it is more than probable that they were associ- 
ated with exercises, and, from various allusions made by classical writers, 
that these exercises consisted in frictions, movements, and the use of oint- MASSAGE. 
735 
ments. The Greek physician was no indifferent spectator to what occurred 
among his countrymen, and it was not long until massage was introduced 
into medicine. Hippocrates* was quite familiar with its power to produce 
certain effects. In speaking of friction he says, “ It can relax, brace, incar- 
nate, and attenuate. Hard friction braces, soft relaxes, much attenuates, 
and moderate thickens.” 
Pauius iEginetaf speaks of friction, and uses very much the same language 
as Hippocrates. “ Hard friction,” says this writer, “ contracts, and soft re- 
laxes, so that those persons that are relaxed should be rubbed hard, and 
those that are immoderately constricted, softly; and again, hard rubbing 
diminishes the bulk of the body, whilst, on the other hand, little and soft rub- 
bing distends it.” He also divides the subject of frictions into three general 
heads, and under each describes three varieties. 
Similar directions in the use of friction are given by Celsus, Aetius, and 
Avicenna; also by Cselius Aurelianus, Praxagoras, and Philostratus, who 
seem, in addition to frictions, to have been familiar with other procedures, 
as kneadings, compression, passive, active, and extreme articular movements. 
Averroesj; gives a summary of the method as formulated by Galen, which 
practically, save in a few details, does not differ from that of Hippocrates 
and others of his predecessors. 
Oribasius, who lived in the third century, describes both massage and those 
movements which are known at present as Swedish movements. 
The Romans, though borrowing much from the art and customs of the 
Greeks, far outstripped them in magnificence, extravagance, and splendor, 
especially of their baths. The traveler to-day lingers with ever-increasing 
wonder about the baths of Caracalla, still magnificent even in their ruins, 
and where at one time the lavements were practiced on the most extended 
scale, in connection with frictions, kneadings, and unctions with fragrant 
ointment stored in costly vases. The thermae of Antoninus and Caracalla 
were furnished with marble seats for sixteen hundred persons, and those of 
Diocletian had three thousand seats and were adorned with costly mosaics 
and curious combinations of granite with Numidian marbles. Diocletian is 
said to have employed forty thousand Christian soldiers in the construction 
of his baths, all of whom, on their completion, were massacred. Champise, 
of Lyons,§ France, published a treatise in which special directions are given 
in regard to massage; and Fuchs, of Tubingen, in his Latin treatise on 
“ Motion and Rest,” makes allusion to similar procedures.|| Methods corre- 
sponding to those of massage are also spokeji of by Ambrose Pare. 
The practice of massage among the Egyptians is mentioned in a work 
by In the writings of Paulinus** reference is made to different 
manipulations which belong to the subject under consideration, as being 
of considerable importance. Still later, and at a period when anatomy was 
being cultivated by men like Fabricius ab Acquapendente, massage began to 
assume a scientific importance, based largely on the support which it re- 
ceived from the study of human anatomy. From the eighteenth century 
down to the present time a continuous line of authorities may be adduced as 
the advocates of manual therapeutics. Among these may be mentioned Hoff- 
mann,ff Sabatier,Tissot,§§ and Bonnet.|||| all of whom advocated strongly 
their use in anchylosis, sprains, and affections of the articulations. Larrey, 
on his return from the East, attempted to reduce all these procedures into an 
* Hippocrates, by Adams, rol. ii. p. 84. 
f Pauius iEgineta, by Adams, vol. i. p. 28. 
j Ibid., vol. i. p. 67. 
§ Cribratio Medicamentorum, 1530. 
|| De Motu et Quiete, 1560. 
Medicina iEgyptiorum, 1591. 
** Flagellum Salute, 1690. 
ff Dissertationes Physico-Medicae, 1708. 
jj Gymnastique Medicale, 1776. 
$$ Gymnastique Medicale et Chirurgicale, 1780. 
|||| Trait6 des Maladies des Articulations. 736 
MASSAGE. 
harmonious system. In Eussia, Sweden, and Denmark massage is associ- 
ated with certain exercises (Swedish movements) with which the name of 
Ling has been prominently connected. 
Among both the South Sea and the Sandwich Islanders massage was 
practiced both for the purpose of dissipating the effects of fatigue and for 
removing disease. 
In order that the full benefits of massage may be realized, it is absolutely 
necessary that the masseur shall have a good general knowledge of anatomy 
and physiology, that he may know not only the manner in which the manip- 
ulations and movements are to be made, but the reason why they are so 
made. Every city, I suppose, is filled with “ rubbers,” male and female, who, 
conceiving that the art consists only in frictions, believe that all that is 
required is muscular sti’ength, and, I might add, a reasonably good stock of 
“ brass.” The ignorance of most of these so-called professionals on all that 
concerns the scientific and art aspects of the subject is most palpable, and it 
is high time that the medical colleges should take this matter into their 
hands, furnish the necessary instruction to those who desire to engage in the 
calling, and confer such testimonials, after a practical examination, as the 
operators may merit, thus protecting the community against imposture and 
incompetence. 
Not every man or woman possesses the physical organization necessary 
for a masseur. For a big, fat, florid-faced man or woman, with a dumpy 
hand and short, claw-like fingers, to suppose that he or she is adapted for such 
a calling is the broadest farce conceivable. With such, a few minutes’ active 
employment ends the operation in perspiration and puffing. The masseur 
should be a person rather lean than obese, with firm, well-developed mus- 
cles, and of medium height, so as not to be inconvenienced by constrained 
postm*es or unusual attitudes, which must often be maintained for a consid- 
erable time. The hand should be of good size, the fingers broad, strong, 
muscular, and elastic, and on their palmar surface moderately soft. In fine, 
the masseur should be built for endurance, must exercise deftness or tact, 
and execute his work with precision, gentleness, and patience. He must, of 
course, be free from all cutaneous disease. 
Class of cases benefited by massage.—Massage has its place, and often no 
secondary one, both in medicine and in surgery. It is proper in cold, rough, 
flabby conditions of the surface, indicating imperfect innervation and a defec- 
tive capillary circulation,—a condition often present in convalescence from 
low fevers; in paralysis not due to central disease, where it will prove an im- 
portant aid to other measures in preventing atrophy of the disabled muscles; 
in constipation; in insomnia, when it frequently composes patients to rest after 
other means have failed : in club-foot; in sprains; in relaxation and rigidity 
of the joints; in inflammatory indurations and adhesions about the articu- 
lations and in the subcutaneous, muscular, and tendinous tissues, especially 
after fractures; and occasionally in neui-algia. 
Time for massage.—In general, massage should never be employed during 
the acute stage of a disease or immediately after an injury. The time to 
begin is after the inflammation has passed its zenith and when its decline is 
well advanced ; just how soon after the inflammatory declination it is difficult, 
short of a practical test, to determine. If on handling the part affected the 
manipulation is followed by tenderness, swelling, and increased heat, the 
effort has been premature. To determine the proper time, the masseur 
when beginning treatment should commence and proceed with great gentle- 
ness, and operate for only a few minutes at first, until the temper of the 
region is ascertained. 
Length of time.—This will depend somewhat on the proficiency of the mas- 
seur, some being able to do as much in ten or fifteen minutes as others would 
accomplish in half an hour or an hour. Barely will it be necessary to make 
the seance longer than from twenty to thirty minutes. 
General directions.—Manipulations should in every instance commence MASSAGE. 
737 
gently, become more rapid and forcible as the procedure progresses, and, 
when carried to the necessary degree, should lessen in vigor, ending in the 
same gradual and gentle manner as they began. 
The operator, or masseur, should utilize the largest extent of manual and 
digital surface consistent with the part to be massaged. When feasible, both 
hands are to be employed in the process of rubbing. 
Divisions.—There are six divisions of massage,—namely, friction, rolling, 
kneading, compression, percussion, and movements. 
All these procedures, excluding of course the movements, should bo made 
in gentle curves, and always in a direction upward. Transverse friction, or 
friction made at right angles with the long axis of an extremity, is not 
proper; and the same may be said of pinching: the former is anatomically 
objectionable, and the latter tends to bruise the tissues. 
Modus operandi.—The benefits to be derived from massage all result from 
impressions made on the blood-vessels, lymphatics, and nerves of the part 
treated, and also, in some instances, from the mechanical disruption or divul- 
sion of inflammatory products: hence the necessity of resorting to various 
manipulations according to the pathological or functional conditions which 
are to be corrected. 
In order that the fullest advantage may be obtained from the different 
procedures, the general course of the veins and lymph-vessels must be known. 
The radicles and main channels of the two systems run very much together. 
If these are studied on the lower extremity, the two sets of vessels are seen, 
not running vertically up or parallel with the long axis of the limb, but 
mainly obliquely upward and inclining to the inner and outer aspects of the 
extremity, where the main trunks, formed by the confluent tributaries of the 
two systems, are located. (Fig. 2192.) All of those situated on the outer, 
inner, and anterior portions of the extremity, whether lymphatics or veins, 
concentrate at the groin, at which point they enter the pelvis, joining the 
deep vessels of the same kind. Those on the posterior aspect of the thigh 
and gluteal region enter the pelvis chiefly through the great sacro-ischiatic 
foramen. On the anterior part of the abdomen the superficial lymphatics 
and veins converge to the inguinal region, where the former, with those of 
the anterior, inner, and outer portions of the lower extremity, enter the 
inguinal glands, while the latter empty into the saphenous vein. 
The two sets of superficial vessels of the upper extremity observe the 
same general course as those in the lower; that is, on the anterior aspect of 
the member the lymph-vessels accumulate in the greatest number along the 
course of the radial, ulnar, and median veins of the forearm, and on the 
upper arm converge from all sides towards the axilla, where, with other 
branches coming from the shoulder, the upper part of the abdomen, and the 
anterior portion of the chest, they empty into the axillary glands. 
Examining the face and neck, it will be seen that the veins and lymphatics 
continue to be companions, those lymphatics over the temple converging 
towards the lymph-glands in front of the auricle, those over the occipital 
part of the scalp concentrating towards the post-auricular and the occipital 
glands, which latter lie behind the sterno-cleido-mastoid muscle. The lym- 
phatics on the side of the face converge towards the glands which lie along 
the base of the jaw. 
On the neck, the lymphatics run downward and forward, clustering about 
the external jugular vein, and empty into the glands which lie in the supra- 
clavicular space, and also run along the posterior border of the sterno-cleido- 
mastoid muscle and the carotid. Some of the lymphatics which occupy the 
upper part of the chest, instead of descending to the axilla, pass over the 
clavicle and empty into the cervical glands. The practical lesson to be 
drawn from this anatomical statement is, that in the employment of mas- 
sage over the regions described, friction to be thorough must be made in 
these lines, that is, in the direction of or parallel with the course of the 
lymph-vessels and veins. 738 
MASSAGE. 
Fig. 2192, 
When friction is made in this 
manner, two effects follow, a me- 
chanical and a vital one. The 
mechanical one consists in urging 
forward the lymph in the lymph- 
vessels, and the blood in the veins, 
towards the two great representa- 
tive trunks, the thoracic duct and 
the vena cava; and now commences 
the vital part of the process. Not 
only are the currents in the two 
sets of vessels hastened onward, 
but a vacuum is formed in those 
portions of the canals subjected 
to pressure, which, when the latter 
is removed, are occupied by a sud- 
den rush of lymph and blood that 
tends to attract the effete or waste 
material lying outside of their 
walls with increased power, thus 
favoring its endosmosis and sub- 
sequent elimination. These effects 
are not peculiar to friction, but 
result from all the different manip- 
ulations included under massage. 
The lymph often lies sluggishly 
in the lymph-spaces, which are 
bounded by the warp and woof of 
the fasciie, and in other tissues, 
like pools of stagnant water, and 
whatever force can be brought to 
act on these receptacles will force 
the fluid into the lymph-vessels; 
and so with regard to the veins, 
friction, kneading, percussion, and 
movements all hurry the blood- 
current forward, and create in 
consequence a drift of effete mat- 
ter towards the various channels. 
Kneading or shampooing does 
good in another way, by breaking 
up the induration resulting from 
chronic inflammation and inducing 
those retrograde metamorphoses 
of the new tissue which render 
its disposal by the veins and lym- 
phatics an easy task. 
These manoeuvres increase the 
activity of the capillary circula- 
tion by stimulating the vaso-motor 
nerves, which regulate the lumen 
of the vessels, thus removing ob- 
structions, and improving the nu- 
trition of the parts by a rapid 
exchange of blood. 
Patients undergoing massage 
should be in the recumbent posi- 
tion, the temperature of the room 
about 70°, and they should during 
Direction of tlie lymphatics and veins. FRICTION. 
739 
the progress of the operation occasionally, about once in five minutes, make 
a few full, strong respiratory movements, which are calculated to hasten the 
return of the venous blood towards the heart. 
Females should have a female, and males a male, masseur. To ignore sex 
in a practice of this nature is both improper and indelicate. 
Friction.—Frictions are made with the thumbs, the fingers, or the entire 
hands, according to the extent of surface to be operated on, and may be 
divided into light, strong or heavy, dry and moist. 
Light frictions are designed to affect chiefly the nutritive processes of the 
skin and subcutaneous tissue. The rapidity of the movements should vary 
from sixty to one hundred and twenty strokes per minute. 
Strong or heavy frictions, which imply that a greater amount of pressure 
is employed than in the light ones, are designed to affect not only the skin 
and the subcutaneous tissue, but also the deep fascia and muscles which lie 
near the surface or are not covered in by strong aponeuroses. The greater 
the pressure made in this variety of friction, the less rapid will be the move- 
ments. 
Dry friction is made with the hand alone, and moist friction either with 
ointments, oils, or liquids. Benzoated lard with oil of bergamot, cocoanut 
oil to which some aromatic oil has been added, alcohol or soap liniment and 
laudanum, constitute the best of those articles used in moist frictions. 
Generally, unless the patient has been greatly reduced by previous illness, 
or unless the skin is rough and desquamating, dry friction is to be preferred. 
When general friction is practiced, without reference to local disorders, the 
masseur must proceed systematically, treating the body by installments, the 
extremities taking the precedence. In this apportionment, beginning with 
the lower extremities, a very convenient regional division is an anatomical 
one,—namely, the foot, including the ankle-joint, the leg, including the knee- 
joint, and the thigh, with the nates and lower two-thirds of the abdomen. 
The upper extremity can be divided in the same way, as follows: the hand 
and wrist-joint, the forearm with the elbow-joint, the arm with the shoulder, 
and the chest and upper third of the abdomen. On the posterior part of 
the body an upper and a lower region can be made, the former extending 
from the base of the skull to the spine of the scapula, and the latter or greater 
region including the remainder of the trunk down to the end of the spine. 
No more of the body should be exposed during the seance than the part 
or region immediately under treatment. 
First region.—The operator, commencing at the toes or the hands, uses 
both hands at the same time, the friction being made with the palmar sur- 
faces of the thumbs, the index and middle fingers being placed beneath, in 
order to oppose the action of the pressure above. (Fig. 2193.) Assuming 
that the lower extremity is the part to be treated, the movements are to be 
made lightly, uninterruptedly, and painlessly upward towards the meta- 
tarsus. On reaching the dorsal part of the foot, the strokes are to be con- 
tinued onward, the thumbs moving simultaneously, the one on the inner 
side upward and inward in gentle curves, and the other on the outer side 
upward and outward, while the sole of the foot is supported on the fingers. 
These frictions are to be continued at first around the inner and outer 
ankle, and last over the front of the articulation, but in curves towards the 
inner and outer aspects of the limb. The masseur now turns his atten- 
tion to the plantar surface of the foot, and, as the skin over this region is 
dense, the friction can most effectively be made by using the fleshy masses 
which form the balls of the thumbs. 
Second region.—On reaching the leg, or the arm, if the upper extremity is 
being treated, nearly the entire palmar surface of the hand or hands can be 
utilized, the direction of the strokes of the radial borders of the hands being 
still upward and moving in gentle curves towards the inner and outer sides 
of the leg, or towards the middle of the anterior face of the forearm (Fig. 740 
MASSAGE. 
2194), observing to lessen the pressure in gliding over the subcutaneous 
surface of the bones, in order to avoid doing violence to the soft parts. 
Fig. 2193. 
Position of thumb and fingers of the operator in applying friction to the fingers of the patient. 
As in the case of the ankle, so when the knee is reached the frictions are 
to be principally directed over the inner and outer surfaces of the joint. 
Fro. 2194. 
Position of the hand in friction of broad surfaces. 
Third region.—As the lymphatics and veins on the anterior surface of the 
thigh all run for the most part towards its inner side, the strokes should 
incline in the same general direction. The masseur will often find it conve- 
nient, when treating this region, to change his or her position, turning the 
back towards the face of the patient, and drawing the hands towards in- 
stead of, as in the other positions, pushing them away from his or her per- 
son. On reaching the groin, the lower two-thirds of the abdomen are next 
to be treated, the direction of the frictions being now changed and made KNEADING. 
741 
downward, converging towards the saphenous opening, thus making them 
correspond to the lymphatic and venous lines. The gluteal part of the 
region follows last in order, the strokes being made from the periphery of 
the nates towards the great sciatic foramen. 
One lower extremity being completed, the other is subjected to precisely 
the same treatment and in the same order. 
In applying friction to the upper extremities, the same rule is to be ob- 
served as in the treatment of the lower, the curvilinear movements of the 
hand towards the middle of the forearm being sufficiently indicated by a 
reference to the cut giving the track of the lymph-vessels. 
Frictions may be employed in all cases of feeble capillary circulation, in 
cold skin, in oedematous swellings, and in the dry, shrivelled skin which is 
so often seen during convalescence from fevers. This manoeuvre, when 
gentle, exercises a soothing, often anodyne effect, and in instances of nervous 
sleeplessness often produces a wonderful quieting effect. 
Rolling.—This procedure consists in planting the distal extremities of the 
four fingers upon the surface and rolling the integument by circular move- 
ments of the digits. (Fig. 2195.) As in friction, so in rolling, there are light 
Fig. 2195. 
Position of the fingers in rolling and kneading. 
and strong movements. By the former the pressure is only sufficient to 
cause the skin to glide over the deeper parts; by the latter the pressure is 
made sufficiently great to affect the deep structures of the region mas- 
saged. 
Rolling is admirably adapted for loosening tissues which have been matted 
together by adhesions following diffuse inflammation. 
Kneading.—Kneading differs from rolling only in the direction of the 
movements, the former being made nearly parallel with the longitudinal axis 
of the limb or of the trunk, while the latter are directed in circles. The 
power exerted in rolling and kneading movements must be obtained from 
the wrist and forearm. The two are often combined, and are particularly 
effective in reducing chronic inflammatory indurations, by breaking up or 
disintegrating the partially-organized lymph or new tissue and causing its 
resorption: hence in old sprains, in which the movements of the joint are 
abridged and the pliability of the extra-articular soft parts destroyed by the 
semi-organized infiltrate, or in the stiff, rigid, and painful conditions of joints 742 
MASSAGE. 
and muscles on being moved which result from long rest necessarily enforced 
during the treatment of fractures, rolling and kneading practiced together 
constitute the most effectual therapeutics for establishing painless motion 
and restoring the normal softness, mobility, and flexibility of the parts 
around the articulation. 
Compression.—I use this term to express a variety of massage in which 
ail the tissue-stratifications of a region are gripped between the fingers and 
the palmar surface of the hand and the thumb and subjected to rapid, in- 
termittent compression (Fig. 2196), at the rate of seventy-five or one hundred 
Fig. 2196. 
Position of hands in compression. 
movements or grasps per minute. When the size of the limb is considerable, 
both hands can be used at the same time, so as to embrace the entire circum- 
ference of the part, and while the grasp of one hand is being tightened that 
of the other can be relaxed, thus enabling the operator not only to cover 
more territory, but simultaneously to treat different groups of muscles. In 
all these procedures the masseur works from below upward, and the included 
tissues may receive two, three, or four compressions before being entirely 
relaxed from the grip. 
The degree of compression necessary to be exerted must be left to the 
judgment of the masseur. There is a very great difference in the elasticity 
of the tissues of different persons. In some individuals the skin will be found 
tightly stretched over the subjacent parts, the cellulo-adipose layer scanty, 
and the muscles beneath hard and fixed. In such a case hard compression 
is contra-indicated, at least during the first applications, but will be endured 
after a few treatments. The sensations of the patient should be consulted, 
and the manipulations not carried to the degree of causing severe suffering. 
This manipulation is well calculated to loosen up the muscles and to im- 
prove their nutrition by the large amount of blood which is invited into the 
parts, and by the acceleration of the capillary circulation. In executing these 
procedures, bony surfaces or salient processes of the skeleton must be pressed 
gently or entirely avoided. 
The applications, therefore, of compression are quite numerous. In all PERCUSSION. 
743 
cases of muscular wasting, as in club-foot, or that following fractures, it con- 
stitutes an important means of arresting atrophy of the muscles, and often 
of increasing their growth and action. Combined with friction and knead- 
ing, compression constitutes a valuable means of discussing serous swellings 
and of disposing of the indurated tissues found about old sprains. The 
order in which the different procedures are to be practiced when applied for 
the relief of the above conditions is as follows: first, compression; second, 
kneading; third, friction ; the first two reducing inflammatory exudates and 
indurations to a state of division or separation into particles, and the last 
forcing the contents into the lymph-vessels and veins, through which the 
products of the degenerated tissue are removed. Compression is admirably 
adapted to impart tonicity to flabby muscles, and to secure the free con- 
traction of their fasciculi when they have been bound together by adhesions. 
Bursal swellings may sometimes be dissipated by compression, and in like 
manner tendons glued to their sheaths may be rendered movable and supple. 
Percussion.—By percussion the parts are beaten either lightly or forcibly. 
There are several ways of applying percussion,—viz., by the hand or by 
muscle-beaters. Manual percussion is made by patting with the palmar sur- 
face of the open hand. When broad surfaces are treated, the extended fingers 
alone are used. It is an imitation of the interrupted electrical current, and 
constitutes an excellent stimulus to feeble muscles. Applied over the surface 
of the abdomen, either alone or with moderate kneading, percussion is an 
excitant of intestinal peristalsis, and accordingly aids in overcoming consti- 
pation ; so also in functional disorders of glands, as the liver, percussion 
stimulates secretion. 
Instrumental percussion is made either by balls, straps, or tubes. The 
first consists of an ordinary hollow gum ball attached to an elastic rod of 
Fig. 2197. 
Gum-ball muscle-beater. 
wood. (Fig. 2197.) The straps or tubes are also composed of gum, the best 
being formed of rubber tubes, three-eighths of an inch in diameter, placed 
side by side, and fastened to a handle. (Fig. 2198.) In using the hall or 
Fig. 2198. 
Muscle-beater made of gum tubing. 
the tubes the strokes should succeed one another with great rapidity, one 
hundred and twenty per minute, yet neither instrument must be allowed to 
strike the surface except in a gentle manner. When the ball is employed, 
the force of contact can be nicely regulated by the elastic handle, which 
admits of rapid and vigorous strokes, though the surface is at the same time 
lightly tapped. Instrumental percussion can be advantageously applied for 
twenty or twenty-five minutes at a time, and be repeated every day. In 
the evening before retiring is a proper time for such treatment. Under the 
use of the ball or tubes the skin soon becomes red and its capillaries well 
filled. By increasing the force of contact the muscles of a beaten part 
participate in the benefits of the blood-tide. 
Instrumental muscle-beating is very useful in cases of lateral curvature of 744 
the spine, by improving the nutrition and strength of the feeble muscles of 
the back, and thereby arresting the progress of the deformity. 
MASSAGE. 
Movements.—Though movements, active or passive, cannot in a strict 
sense be regarded as a variety of massage, yet, associated as they often are 
with the latter, there is a practical propriety in speaking of them in this 
connection. 
Movement or motion has a therapeutical value in several affections,— 
first, to prevent stiffness or anchylosis, true or false, in joints; second, to 
restore the functions of articulations which have been sprained ; third, to 
favor the absorption of fluid from joints after acute inflammatory symptoms 
have subsided ; fourth, to develop and strengthen wasting or unused muscles; 
fifth, to break muscular or tendinous adhesions; and, sixth, to relieve certain 
neuralgias depending on inflammatory attachments. 
It is sufficient to say that all movements are out of place—indeed, are 
decidedly injurious—so long as acute signs are present in a part. 
Movements are voluntary—that is, made by the will of the patient—or 
they are passive, being made by the masseur without any conscious resist- 
ance of the subject; and, finally, they are resistive, or executed in direct 
opposition to the will of the patient. 
Voluntary movements include the whole curriculum of the gymnasium. 
Passive movements are among the early duties of the surgeon in the 
management of fractures, and are specially designed to prevent rigidity of 
joints in the neighborhood of these injuries, and should always be introduced 
first with gentleness and afterwards with more energy. The pain is propor- 
tioned to the opposition which the surgeon encounters from the resistance of 
the patient. 
In false anchylosis,—that, for example, which follows dislocations, rheu- 
matism, etc.,—more can be accomplished in the way of restoring the func- 
tion of an articulation by patient and repeated movements of moderate 
power than by violent disruption of adhesions. The injury done by such 
force is sure to be resented by the joint; and before the inflammation which 
follows has sufficiently abated to admit of the manipulation being repeated, 
the articulating surfaces are as immovable as at first. 
Many old cases of synovitis, where the joint has been too long kept fixed 
and contains some fluid, only require motion to secure the absorption of the 
fluid. That this result is not improperly credited to the movements has 
been proved experimentally by introducing colored fluids into corresponding 
joints of animals. In the one subjected to motion the coloring matter was 
found in the extra-articular tissues, while in the other joint, allowed to 
remain fixed, no such result was observed. 
When motion is applied to joints in order to develop the muscles which 
move them, the operator, at the same time that he bids the patient flex or 
extend the joint, uses his own strength to resist the movements, and thus 
calls into vigorous action the flexors or extensors of the articulation. These 
trainings must be practiced with great judgment, and never be carried to 
the extent of exhaustion in the muscles under treatment. Indifference on 
this point may cause weakness, and subsequently atrophy, of the muscles, by 
too heavy drafts on the source of nerve-supply. 
Every masseur should thoroughly understand the anatomy and physi- 
ology of the articulations, so that he or she may not transcend the normal 
range of the movements or attempt those inconsistent with the form of the 
joints. 
Painful conditions of some nerves, more particularly the sciatic, are some- 
times due to adhesions between the nerve-cord and the surrounding parts; 
and it is possible in these cases, by forcible flexion or extension of the limb, 
to break up such attachments and remove the pain. INDEX TO VOLUME III. 
A. 
Abscess after tubercular laryn- 
gitis, 29. 
of areola, 682. 
of cornea, 206. 
of ear, 307. 
of eyelids, 154. 
of mamma, 687. 
of nose, 95. 
of palpebrae, 154. 
of thyroid, 491. 
Absence of fingers, 371. 
of toes, 365. 
Accommodation of eye, anoma- 
lies, 275. 
Achromatopsia, 248. 
Acne, 588. 
hypertrophica, 94. 
of eyelids, 154. 
rosacea, 93. 
syphilitic, 534. 
tarsi, 154. 
Acuity of hearing, 2S7. 
Addison’s keloid, 470. 
Adduction of thighs, 352. 
Adenitis, 451. 
after chancre, 512. 
chronic, 451. 
treatment of, 452. 
Adenocele, 700. 
Adenoid growth, 630. 
Adenoma, 629. 
diagnosis from carcinoma, 
673. 
follicular or tubular, 631. 
of eyelids, 169. 
of larynx, 63. 
of mamma, 700. 
Air-passages, foreign bodies in, 
44. 
apncea from, 90. 
changes undergone by, 46. 
diagnosis of, 47. 
during anaesthesia, 44. 
expulsion, prevention of, 
51. 
fatal hemorrhage from, 46. 
laryngotomy for, 49. 
morbid effects of, retained, 
46. 
passing from oesophagus, 
45. 
place of arrest of, 45. 
pleuritic adhesions after, 
46. 
prognosis in, 48. 
tracheotomy for, 49. 
non-expulsion after, 51. 
Air-passages, foreign bodies in, 
treatment of, 48. 
by inversion, 49. 
cautions in, 51. 
forceps in, 50. 
results of, 51. 
Albinism, 219. 
Albugo, 211. 
Albuminuric retinitis, 237. 
Alopecia, 481. 
areata, 482. 
of eyebrows, 151. 
syphilitic, 538. 
treatment of, 569. 
Alveolar carcinoma, 671. 
sarcoma, 638. 
Amaurosis, 245,246. 
Amblyopia, 245. 
hysterical, 248. 
treatment of, 246. 
varieties of, 246. 
Amyelinic neuroma, 622. 
Amyloid disease of conjunctiva, 
204. 
of eyelids, 169. 
of lymph-glands, 453. 
Anaesthesia, foreign bodies in 
air-passages from emesis 
during, 44. 
of larynx, 53. 
retinal, 247. ' • 
Anaesthetics in cataract opera- 
tions, 260. 
in iridectomy, 225. 
in strabotomy, 182. 
in tracheotomy for croup, 40. 
Anatomy of breast, 679. 
of corns, 465. 
of lachrymal passages, 174. 
surgical, of nerves, 727-733. 
Anchylosis of crico-arytenoid 
juncture, 59. 
Aneurism by anastomosis, 621. 
electrolysis for, 723. 
Angeioleucitis, 445. 
Angeiolithic sarcoma, 644. 
Angeioma, 621. 
electrolysis for, 724. 
of areola, 682. 
of auricle, 303. 
of conjunctiva, 203. 
of external auditory canal, 
309. 
of larynx, 62. 
of muscles, 389. 
Angina, syphilitic, 539. 
Animation, suspended, 84. 
Anions, 723. 
Ankle, weak, 362. 
Ankyloblepharon, 161. 
Anosmia, 134. 
Anterior crural nerve, stretch- 
ing of, 732. 
tibial nerve, stretching of, 
732. 
Antrum, inflammation of, 115. 
Anus, chancre on, 523. 
Aphonia after thyrotomy, 68. 
electricity in, 722. 
in laryngeal paralysis, 56. 
Apncea, 84. 
from foreign bodies in air- 
passages, 90. 
secondary, 90. 
Aponeurosis, affections of, 403. 
syphilis of, 555. 
Appendages of eye, affections 
of, 150. 
Arcus senilis, 212. 
Areola of nipple, diseases of, 682. 
Arteries of eye, 141. 
syphilis of, 563. 
Artery, posterior tibial,wounded 
in tenotomy, 350. 
Articular disease, deformity 
from, 337. 
genu valgum from, 355. 
Articulation, anchylosis of crico- 
arytenoid, 59. 
Articulations, syphilis of, 555. 
Artificial eyes, use of, 286. 
respiration,.87. 
electricity in, 722. 
methods of, 88. 
Aspergillus in ear, 306. 
Asphyxia, 84. 
death from, in laryngitis, 22. 
in goitre, 496. 
Aspiration of cataract, 269. 
Asthenopia, 280. 
Astigmatism, 280. 
diagnosis of, 281. 
forms of, 282. 
ophthalmoscope in, 284. 
treatment of, 282. 
Atomizer in laryngitis, 27. 
Atrophic nasal catarrh, 115. 
Atrophy from talipes, 340. 
of mamma, 683. 
of nerves, 439. 
optic, 244. 
Audiphone, 331. 
Aural vertigo, 327. 
Auricle, absence of, 299. 
angioma of, 303. 
calcareous formations in, 301. 
eczema of, 300. 
epithelioma of, 303. 746 
INDEX TO VOLUME III. 
Auricle, fibroma of, 302. 
malformations of, 299. 
nevus of, 303. 
othematoma of, 301. 
papilloma of, 303. 
sarcoma of, 303. 
supernumerary, 300. 
tumors of, 301. 
sebaceous, 303. 
warts of, 303. 
Auricularis magnus nerve, 
stretching of, 728. 
Auto-laryngoscopy, 20. 
Axillary glands enlarged in 
cancer, 714. 
B. 
Back, dislocation of muscles of, 
394. 
Back-knee, 361. 
Balanitis with chancroid, 517. 
Baldness, 481. 
localized, 482. 
Barbadoes leg, 473. 
Basedow’s disease, 492. 
Bellocq’s canula, 102. 
Bellows-inflation of lungs, 88. 
Benign tumors, 585. 
Biceps, rupture of long tendon 
of, 393. 
Blackboard for testing vision, 
144. 
Black eye, 151. 
Bladder, paralysis, electricity 
in, 721. 
syphilis of, 561. 
Blepharitis ciliaris, 154. 
Blepharospasm, 164. 
entropion from, 158. 
in phlyctenular ophthalmia, 
193. 
myotomy for, 165. 
Blindness, color-, 248. 
day-, 247. 
night-, 247. 
simulated, 249. 
snow-, 247. 
Blood cysts, 591. 
in chambers of eye, 227. 
in choroid, 233. 
retinal, lack of, 235. 
Bodies in air-passages, 44. 
Boil, Delhi, of India, 489. 
of nasal septum, 120. 
of nose, 95. 
Bones, syphilis of, 551. 
treatment of, 569. 
yielding, genu valgum from, 
355. 
Boro-glyceride as dressing, 716. 
Boucnemia tropica, 473. 
Bougies, Eustachian, 299. 
in Eustachian stricture, 317. 
Bow-leg, 359. 
Breast, diseases of, 679-717. 
Bright’s disease, retinitis in, 
237. 
Bronchi, syphilis of, 547. 
Bronchocele, 490. 
Bronchotomy, 75. 
by electro- and thermo-cau- 
tery, 84. 
Bubo, after hard chancre, 526. 
chancroidal, 512. 
treatment of, 517. 
in women, 513. 
Bubon d’embl6e, 513. 
Bullous syphiloderin, 535. 
Burns, club-hand after, 369. 
deformity from, 337. 
of eyelids, 152. 
Bursa, anterior femoral, 401. 
anterior to patella, 398. 
beneath crural muscles, 403. 
beneath tubers of ischii, 402. 
calcaneal, 403. 
carpal, anterior, 400. 
posterior, 399. 
contents of, 397. 
inflammation of, 396, 397. 
of extensors of thumb, 400. 
of tendon of peroneus longus, 
403. 
popliteal, 402. 
extra-articular, 402. 
subcutaneous, 395. 
subdeltoid, 401. 
tendinis patellas, 401. 
tendinous, 396. 
treatment of, 398. 
trochanteric, 402. 
Bursae mucosae, affections of, 
395. 
Bursitis, 396. 
treatment of, 398. 
Butyroid tumor, 692. 
C. 
Calcaneal bursa, 403. 
Calcaneo- valgus, 351. 
Calcareous deposit in auricle, 
301. 
in cornea, 212. 
goitre, 493. 
Calculus in frontal sinuses, 117. 
in tear-ducts, 175. 
nasal, 105. 
Calf-knee, 353. 
Callosities, 464. 
Canaliculi, obstructions of, 174. 
Cancer, 650. See Carcinoma. 
colloid, 671. 
cylinders, 651. 
encephaloid, 667. 
epithelial, 657. 
melanotic, 671. 
scirrhus, 663. 
“ Cancer en cuirasse,” 707. 
Cancroid, 657. 
Canula, misplaced in tracheot- 
omy, 82. 
Capsular cataract, 255. 
Capsulo-lenticular cataract, 255. 
Carcinoma, 650. 
alveolar, 671. 
causes of, 655. 
colloid, 671. 
of breast, 709. 
degenerations of, 672. 
diagnosis from adenoma, 673. 
from sarcoma, 672. 
of varieties of, 672. 
encephaloid, 667. 
of breast, 707. 
of conjunctiva, 202. 
of skin, 479. 
epithelial, 657. 
of breast, 710. 
extension of, 653. 
fatty, 671. 
hematoid, of breast, 708. 
hemorrhage in, 675. 
Carcinoma, hereditary, 655. 
medullary, 667. 
melanotic, 671. 
of breast, 710. 
metastasis of, 654. 
of breast, 704. 
of ear, 311. 
of iris, 223. 
of lachrymal gland, 172. 
of larynx, 70. 
of mamma, 704. 
caustics in, 713. 
diagnosis from fibroma, 699. 
enlarged axillary glands in, 
714. 
excision of, 713. 
operations, early, 714. 
result of, 710. 
prognosis of, 710. 
recurrence of, 706, 711, 714. 
treatment of, 712. 
of muscles, 390. 
of nasal fossae, 133. 
of nerves, 443. 
of thyroid gland, 503. 
operations forbidden in, 678. 
phthisis with, 656. 
scirrhous, 663. 
of breast, 705. 
of skin, 478. 
secondary deposits in, 654. 
soft, 667. 
telangiectatic, 669. 
of breast, 708. 
treatment of, 673. 
by caustics, 675. 
local, 674. 
operative, 677. 
varieties of, 671. 
Carcinomatous sarcoma of cho- 
roid, 233. 
Caries in syphilis, 552. 
Carpus, bursa anterior to, 400. 
posterior to, 399. 
Cartilage tumor, 607. 
Caruncle, lachrymal, diseases of, 
200. 
sinking of, after squint 
operations, 184. 
Cataract, 254. 
catoptric test for, 256. 
congenital, 270. 
division or discission for, 268. 
through sclerotic, 269. 
extraction of, 257. 
anesthetics in, 260. 
Daviel, 257. 
diet after, 263. 
dressing after, 262. 
flap, 259. 
lower, 264. 
upper, 261. 
Graefe, 258, 265. 
iritis after, 263. 
Jacobson, 258. 
Liebreich and Lebrun, 258, 
266. 
linear, 258, 265. 
modified, 258, 265. 
Mooren, 266. 
patient prepared for, 260. 
prolapse of iris after, 264. 
suppuration after, 264. 
Waldau, 266. 
Weber, 258. 
Wolfe, 267. 
from traumatism, 254. 
from senility, 254. INDEX TO VOLUME III. 
747 
Cataract, nystagmus with, 255. 
operations for, 257-273. 
conditions for, 259. 
contra - indications, 257, 
259. 
reclination or couching of, 
269. 
results of methods compared, 
271. 
secondary, 267. 
suction or aspiration of, 269. 
symptoms of capsular, 256. 
of cortical, 255. 
of lamellar, 256. 
of nuclear, 255. 
of traumatic, 256. 
terms descriptive of, 254. 
treatment of, 256. 
lamellar, zonular, or con- 
genital, 270. 
traumatic, 270. 
Catarrh, atrophic or dry, 115. 
hypertrophic, 111. 
nasal, 108. 
of accessory cavities, 115. 
of children, strumous, 110. 
of conjunctiva, 186. 
of lachrymal sac, 176. 
of larynx, 21. 
Catheter, Eustachian, 298. 
Cations, 723. 
Catoptric test for cataract, 256. 
Caustics to remove cancer, 675, 
713. 
Cautery, electro-, 725. 
Cellulitis after tracheotomy, 83. 
Centipedes in nose, 107. 
Cephalalgia, syphilitic, 557. 
Cerebral syphilis, 557. 
Cerumen, impacted, 304. 
Chalazion, 167. 
Chancre, 507, 518. 
anal, 523. 
bubo after, 526. 
complications of, 529. 
contrasted with chancroid, 
508. 
author’s views of, 509. 
diagnosis of, 524. 
digital, 524. 
hard, 507, 518. 
Hunterian, 507, 518. 
inoculability of, 524. 
kinds of, 507. 
mammary, 523. 
mixed, 509. 
number of, 524. 
on lips, 523. 
on nipple, 682. 
on tonsil, 523. 
prognosis of, 527. 
rectal, 524. 
soft, 510. 
treatment of, 528. 
urethral, 522. 
views concerning, 508. 
Chancroid, 510. 
balanitis with, 517. 
bubo after, 512. 
treatment of, 517. 
complications of, 515. 
contrasted with chancre, 508. 
development of, 511. 
diphtheritic, 517. 
gangrenous, 516. 
inflamed, 515. 
in women, 517. 
number of, 511. 
Chancroid, paraphimosis in, 517. 
pathology of, 513. 
phagedsenic, 515. 
phimosis in, 516. 
prophylaxis of, 514. 
seat of, 511. 
serpiginous, 517. 
treatment of, 514. 
Chemosis, 204. 
Chigoe, 480. 
Choked disk, 242. 
Chondritis after tubercular lar- 
yngitis, 29. 
of larynx, epi-, 29. 
peri-, 32. 
Chorea, electricity in, 723. 
from nerve-injury, 429. 
of eyelids, 165. 
Chorio-retinitis, 230. 
Choroid, blood in, 233. 
colloid disease of, 233. 
coloboma of, 232. 
detachment of, 232. 
inflammation of, 299. 
ossification of, 233. 
rupture of, 233. 
sarcoma of, 234. 
carcinomatous, 233. 
tuberculosis of, 232. 
tumors of, 233. 
Choroiditis, 229. 
circumscripta, 230. 
disseminata, 230. 
plastic, 230. 
retinitis with, 230. 
serous, 229. 
suppurative, 231. 
syphilitic, 549. 
hereditary, 574. 
Chylocele, 450. 
Chyloderma, 449. 
Cicatricial club-hand, 369. 
operation for, 369. 
Cicatrix from electrolysis, 724. 
Cilia, malposition of, 155. 
Ciliary arteries, 141. 
muscle, paralysis of, 276. 
paresis of, 275. 
spasm of, 276. 
Clavus, 465. , 
Cleft iris, 219. 
nose, 93. 
Clergyman’s sore throat, 26. 
Club-foot, 337-352. 
hand, 368. 
after burns or scalds, 369. 
Cochin leg, 473. 
Cold abscess, mammary, 690. 
in treating cancer, 674. 
Colloid carcinoma, 671. 
of breast, 709. 
disease of choroid, 233. 
Comedone, 588. 
Compression for cancer, 674. 
in massage, 742. 
Concretions in frontal sinuses, 
117. 
in Meibomian glands, 203. 
in nose, 105. 
Condyloid development, genu 
valgum from, 355. 
Condylomata, 540. 
Congestion of conjunctiva, 185. 
Coloboma of choroid, 232. 
of eyelid, 166. 
of iris, 219. 
Color-blindness, 248. 
dullness, 248. 
Conjunctiva, 185, 
amyloid, 204. 
angeioma of, 203. 
concretions of, 203. 
congestion of, 185. 
cysticercus of, 201. 
cystoma of, 201. 
dermoid tumor of, 201. 
ecchymosis of, 203. 
emphysema of, 204. 
encephaloid cancer of, 202. 
epithelioma of, 202. 
fibroma of,-202. 
herpes of, 192. 
inflammation of, 186. 
lipoma of, 200. 
membranous, 201. 
nsevus of, 203. 
oedema of, 204. 
pinguicula of, 200. 
polypus of, 201. 
sarcoma of, 202. 
stains of, 204. 
varix of, 203. 
warts of, 201. 
Conjunctivitis, catarrhal, 186. 
cleanliness in, 188. 
exanthematous, 194. 
gonorrhoeal, 190. 
granular, 194. 
keratitis during, 196. 
pannus during, 196. 
phlyctenular, 192. 
purulent, 188. 
Connective-tissue hypertro- 
phies, 464. 
Constitutional syphilis, 529. 
Contraction of fingers, 372. 
Contusions of eye, 216. 
of eyebrows, 151. 
of eyelids, 151. 
Cornea, abscess or suppuration 
of, 206. 
arcus senilis in, 212. 
calcareous deposit in, 212. 
conical, 213. 
fistula of, 211. 
inflammation of, 204. 
nebula of, 211. 
opacities of, 211. 
iridodesis for, 212. 
staphyloma of, 213. 
amputation of, 214. 
seton in, 215. 
strangulation of, 215. 
syphilis of, hereditary, 573. 
tumors of, 216. 
ulcers of, 208. 
crescentic or serpiginous, 
209. 
hernia of iris in, 210. 
inter- or postlamellar, pus 
in, 210. 
lead avoided in, 209. 
wounds of, 215. 
prolapse of iris after, 216. 
Corneous growth from ungual 
matrix, 485. 
Corns, 465. 
soft, 465. 
Cornua, 467. 
Corona Veneris, 533. 
Corps fibreux, 630. 
Cortical cataract, 254. 
Couching of cataract, 269. 
Cough, ear, 329. 
Crico-arytenoid articulation, 
anchylosis of, 59. 748 
INDEX TO VOLUME III. 
Crico-arytenoid muscle, paraly- 
sis of, 57, 58. 
Crico-thyroid, paralysis of, 56. 
Crico-thyrotomy, 68, 77. 
for laryngeal tumors, 68. 
Cross-knee, 353. 
Croup, 33. 
diagnosis from diphtheria, 33. 
from laryngitis, 23. 
false, 35, 54. 
spasmodic, 54. 
tracheotomy in, 36. 
Crural nerve, anterior, stretch- 
ing of, 732. 
Crystalline lens, absence of, 253. 
cataract in, 254. 
dislocation of, 253. 
after wounds of sclera, 217. 
Cuboid bone, excised for equino- 
varus, 350. 
Curvatures of leg, 361. 
of upper extremity, 368. 
Cutaneous cysts, 596. 
parasites, 479. 
redundancy, 469. 
syphilis, 531. 
Cylindrical epithelioma, 661. 
Cystic goitre, 493. 
sarcoma of mamma, 703. 
Cysticercus in conjunctiva, 201. 
in eye-chambers, 228. 
in eyelids, 169. 
in vitreous humor, 274. 
Cystoma, difference from cyst, 
585. 
of conjunctiva, 201. 
of ear, 308. 
of larynx, 63. 
of nerves, 443. 
of skin, 479. 
Cysts, 585. 
blood or venous, 591. 
cutaneous or dermoid, 596. 
of areola, 682. 
dentigerous, 596. 
difference from cystomata, 
585. 
extravasation or sanguineous, 
593. 
exudation, 591. 
formation of, 586. 
hemorrhagic, 593. 
hydatid or parasitic, 594. 
lactiferous, 591. 
mucous, 590. 
of iris, 223. 
of lachrymal gland, 172. 
of mamma, 691-695. 
of muscles, non-parasitie, 389. 
parasitic, 387. 
of retina, 241. 
of skin, 479. 
oil, 590. 
parasitic, in muscles, 387. 
piliferous, of eyelids, 168. 
proliferous, 596. 
salivary, 590. 
sebaceous, 587. 
seminal, 590. 
synovial, 591. 
vascular, 593. 
D. 
Dacrocystitis, 175. 
fistula after, 176. 
Dacryoadenitis, 170. 
Dacryoadenitis, hypertrophied 
gland after, 171. 
Dacryoliths, 175. 
Dacryops, 172. 
Dactylitis, 556. 
hereditary, 572. 
Dactylology for mutes, 332. 
Day-blindness, 247. 
Deaf-mutism, 331. 
Deafness, forms of, 324. 
instrumental aids for, 329. 
syphilitic, 557. 
Deformities, 333-380. 
conditions producing, 336. 
of extremity, lower, 337. 
upper, 368. 
of foot, 362. 
of toes, 365. • 
Delhi boil of India, 489. 
Deltoid muscle, paralysis of, 
electricity for, 722. 
Dentigerous cysts, 596. 
Dentition, strabismus during, 
181. 
Depilatories, 481. 
Dermatitis from Rhus, 463. 
Dermoid cysts, 596. 
of areola, 682. 
of conjunctiva, 201. 
Detached choroid, 232. 
retina, 239. 
Diabetic retinitis, 238. 
Digit, chancre on, 524. 
Digital nerves, compression of, 
407. 
Diphtheria, contrasted with 
croup, 33. 
deafness after, 326. 
diagnosis from laryngitis, 23. 
in tracheotomy wound, 83. 
Diphtheritic chancroid, 517. 
gonorrhoeal ophthalmia, 191. 
Discission for cataract, 268. 
Disk, choked, 242. 
Dislocations, deformity from, 
337. 
of crystalline lens, 253. 
of muscles, 384. 
of back, 394. 
of tendons, 393. 
Districhiasis, 155. 
Dracunculus, 480. 
Drainage-tube in excision of 
larynx, 72. 
Dropsy of eye-chambers, 227. 
Drowning, rigor mortis after, 86. 
Drum of ear, 292, 295. 
Dry nasal catarrh, 115. 
Duchenne’s apparatus, 369. 
paralysis, 387, 440. 
Dupuytren’s finger contraction, 
373. 
splint for valgus, 351. 
Dyschromatopsia, 249. 
Dyspepsia, laryngitis from, 26. 
E. 
Ear, affections of, 287. 
case, history of, 287. 
Eustachian catheter in, 298. 
fauces and post-palate ex- 
amined in, 299. 
otoscope for, 290. 
use of, 292. 
pain in, 290. 
tuning-fork in, 289. 
voice, test in, 288. 
Ear, auricle, affections of, 299. 
deafness in, 324. 
diagnosis of, 325. 
from quinia, 326. 
hysterical, 327. 
instrumental aids for, 329. 
labyrinthic, 324. 
nervous, 324. 
treatment of, 327. 
drum-head of, 292, 295. 
eczema of, 300. 
external canal, abscess of, 307. 
angioma of, 309. 
aspergillus in, 306. 
carcinoma of, 311. 
cystoma of, 308. 
examination of, 292. 
exostosis of, 311. 
fibroma of, 308. 
hyperostosis of, 311. 
impacted cerumen in, 304. 
insects in, 304. 
larvae of, 305. 
myxoma of, 309. 
polypus of, 308. 
sarcoma of, 311. 
syringing of, 290. 
foreign bodies in, 304. 
furunculus of, 307. 
hearing of, acuity, 287. 
fictitious dullness, 288. 
inflammation of external, 
307. 
middle, catarrhal, 312. 
non-suppurative, acute, 
313. 
chronic, 314. 
extension of, 315. 
incision of tympanum 
in, 318. 
necrosis in, 321. 
paracentesis in, 318. 
tenotomy in, 318. 
suppurative, acute, 319. 
chronic, 320. 
insects in, 304. 
internal, affections of, 324. 
membrana tympani, affections 
of, 312. 
appearance of, 295. 
examination of, 292. 
inflation of, 295. 
middle, diseases of, 312. 
speculum for, 292, 294, 296. 
syphilis of, 550. 
hereditary, 574. 
syringing of, 290. 
vegetable growths in, 306. 
Ear-ache, 329. 
Ear-cough, 329. 
Ear-trumpets, 330. 
Ear-vomiting, 329. 
Eburnated osteoma, 613. 
syphilitic bone, 552. 
Ecchymosisof conjunctiva, 204. 
Echinococcus, cysts from, 595. 
Ecthyma, syphilitic, 535. 
Ectropion, 159. 
operations for, 160. 
Eczema of auricle, 300. 
of nipple, 682. 
Egyptian ophthalmia, 188. 
Eiloid, 477. 
Electricity, 718. 
affections benefited by, 721. 
contractility and irritability 
of tissues to, 720. 
currents of, 718, 720. INDEX TO VOLUME III. 
749 
Electricity, diagnosis by, 720. 
for artificial respiration, 722. 
in treating cancer, 677. 
rules for treatment by, 721. 
Electrization of larynx, 59. 
Electro-cautery, 725. 
in tracheotomy, 84. 
Electrolysis, 723. 
affections treated by, 723. 
cicatrix from, 724. 
in goitre, 498. 
Elephantiasis Arabum, 473. 
treatment of, 475. 
Graecorum, 473. 
of eyelids, 169. 
tuberosa, 474. 
verrucosa, 474. 
Embolism of central retinal ar- 
tery, 250. 
Embryoplastic sarcoma, 637. 
Emphysema during trache- 
otomy, 82. 
of conjunctiva, 204. 
of eyelids, 152. 
Emprosthotonus, 432. 
Encanthis, 200. 
Encephaloid carcinoma, 667. 
diagnosis from scirrhus, 668, 
672, 708. 
from sarcoma, 709. 
of breast, 707. 
of conjunctiva, 202. 
of skin, 479. 
Encephaloma, 667. 
Enchondroma, 607. 
of lachrymal gland, 172. 
of larynx, 63. 
of muscles, 390. 
of nasal region, 131. 
Endothelial sarcoma, 645. 
Enostosis, 612. 
Entropion, 157. 
due to blepharospasm, 158. 
operations for, 158. 
Enucleation of eyeball, 284. 
Epicanthus, 167. 
Epichondritis in tubercular lar- 
yngitis, 29. 
Epidermic accumulations, syph- 
ilitic, 539. 
treatment of, 569. 
Epiglottis, dislocated, causing 
suffocation, 45. 
Epilepsy from nerve-injury, 
428. 
Epistaxis, 101. 
rhineurynters in, 103. 
tampon for, 102. 
when to remove, 103. 
transfusion in, 103. 
Epithelial cancer, 657. 
Epithelioma, 657. 
cylindrical, 661. 
lymph injection in, 659. 
of areola, 682. 
of auricle, 303. 
of breast, 710. 
of conjunctiva, 202. 
of eyelids, 170. 
of larynx, 70. 
of nose, 98. 
squamous, 660. 
tubular, 663. 
Epulis, 641. 
Equino-valgus, 351. 
Equino-varus, 348. 
excision of cuboid for, 350. 
of tarsal wedge for, 350. 
Erectile tissue, 621. 
Erysipelas, 454. 
after tracheotomy, 83. 
causes of, 455. 
contagion and infection, 
456. 
epidemic influences, 456. 
local conditions, 455. 
sex, 455. 
wounds, 457. 
character of materies morbi 
of, 457. 
course and duration of, 459. 
diagnosis of, 459. 
from lymphangitis, 446. 
local signs of, 458. 
mode of spreading, 460. 
morbid appearances of, 459. 
of internal organs, 461. 
cedematous, 454. 
phlegmonous, 454. 
prognosis in, 461. 
tissues invaded by, 454. 
treatment of, 461, 
local, 462. 
varieties of, 454. 
Erythema, mucous, 539. 
syphilitic, 547. 
Erythematous syphiloderm, 
532. 
Erythropsine, 249. 
Ethmoidal sinuses, inflamma- 
tion of, 115. 
Eustachian bougies, 299. 
catheter in ear-disease, 298. 
Exanthemata, laryngitis from, 
22. 
cedema of larynx during, 24. 
ophthalmia from, 194. 
tumors of larynx after, 60. 
Excision of breast, 715. 
of carcinoma, 677. 
of cuboid for talipes, 350. 
of larynx, 72. 
partial, 75. 
of tarsal wedge for talipes, 
350. 
Excurvation of eyelids, 163. 
Exophthalmic goitre, 492. 
Exostoses, 612. , 
of ear, 311. 
under nails, 486. 
External popliteal nerve, 
stretching of, 731. 
Extirpation of lachrymal gland, 
172. 
of larynx, 72. 
of thyroid gland, 499. 
Extravasation cysts, 593. 
of blood in choroid, 233. 
Exudation cysts, 591. 
Eye, 141-286. 
amblyopic, 245. 
anomalies of accommodation 
in, 275. 
appendages, affections of, 150. 
artificial, 286. 
astigmatic, 280. 
black, 151. 
blood in, 227. 
blood-supply of, 141. 
choroid, diseases of, 229. 
ciliary troubles in, 275. 
contusions of, 216. 
cysticercus in, 228. 
deportment in disease of, 142. 
disk or optic nerve of, 149. 
dropsy of, 227. 
Eye, emmetropic, 277. 
enucleation of, 284. 
examination of, 142. 
by inverted image, 149. 
by oblique illumination, 
143. 
by upright method, 148. 
interior of, 146. 
foreign bodies in, 227. 
fundus of, 149. 
fovea in, 150. 
hare-, 163. 
hydatids in, 228. 
hypermetropic, 279. 
lens and capsule, diseases of, 
253. 
meridians of, 280. 
muscles of, affections, 180. 
myopic, 278. 
optic nerve or disk, 149. 
diseases of, 242. 
physiological functions of, 
141. 
presbyopic, 276. 
punctum proximum of, 275. 
remotum, 275. 
pupil of, 221. 
refraction in, 277. 
syphilis of, 548. 
hereditary, 573. 
tension of, 143. 
vision, acuity of, 144. 
field of, 146. 
test-types for, 144. 
vitreous, diseases of, 273. 
Eyeball, enucleation of, 284. 
Eyebrows, 151. 
contusions of, 151. 
loss of hair from, 151. 
wounds of, 151. 
Eyelids, 151. 
abscess of, 154. 
acne of, 154. 
adenoma of, 169. 
adhesions of, 161. 
amyloid, 169. 
burns of, 152. 
chalazion of, 167. 
chorea of, 165. 
cilia, malposition of, 155. 
contusions of, 151. 
cysticercus of, 169. 
elephantiasis Graecorum of, 
169. 
emphysema of, 152. 
eversion of, 159. 
excurvation of, 163. 
fibroma of, 168. 
fissure of, 157. 
congenital, 166. 
hordeolum on, 153. 
horns of, 169. 
inflammation of, 186. 
inversion of, 157. 
lepra of, 169. 
lice on, 157. 
lipoma of, 169. 
millet-grains of, 168. 
molluscum of, 168. 
muscular defects of, 163. 
naevus of, 169. 
nictitation of, 165. 
oedema of, 152. 
piliferous cysts of, 168. 
ptosis of, 165. 
pustules of, 154. 
redundancy of, 167. 
scalds of, 152. 750 
INDEX TO VOLUME III. 
Eyelids, stings of, 152. 
stye on, 153. 
tumors of, 167. 
malignant, 170. 
sebaceous, 168. 
turning of, 185. 
warts of, 169. 
wounds of, 152. 
F. 
Facial paralysis, electricity in, 
722. 
Fallopian tubes, syphilis of, 561. 
Far-sighted, 276. 
Fatty carcinoma, 671. 
Fauces, spasm of, in laryngos- 
copy, 19. 
Felon, 487. 
Femoral bursas, 407. 
Fibro-cystic goitre, 493. 
Fibro-lipoma, 598. 
Fibroma, 600. 
cavernous, 603. 
glio-, 648. 
hard, 601. 
keloid as, 603. 
nasal, 125. 
of areola, 682. 
of auricle, 302. 
of conjunctiva, 202. 
of ear, 308. 
of eyelids, 168. 
of larynx, 62. 
of mamma, 696. 
of muscles, 389. 
of nerves, 442. 
soft, 602. 
Fibrous goitre, 493. 
polypi, nasal, 125. 
Filaria medinensis, 480. 
Fingers, absence of, 371. 
chancre on, 524. 
hypertrophy of, 372. 
locked, 375. 
supernumerary, 370. 
webbed, 371. 
Finger-flexion, 372. 
diagnosis of contracted palmar 
fascia variety from con- 
tracted flexor muscles, 374. 
Dupuytren’s, 373. 
Fissures of eyelids, 157. 
of nipple, 681. 
Fistula after tracheotomy, 83. 
of cornea, 211. 
of lachrymal gland, 171. 
of larynx or trachea, 44. 
Flat-foot, 363. 
Flexion of thighs, 353. 
of thumb and fingers, 372. 
of toes, 367. 
Follicular adenoma, 631. 
inflammation of nose, 95. 
Foot, deformity of, 362. 
multiple ulceration of, 364. 
normal impress of, 362. 
splay- or flat-, 363. 
Foreign bodies in air-passages, 
44. 
apnoea from, 90. 
in ear, 304. 
in eye-chambers, 227. 
in frontal sinuses, 117. 
in lachrymal passages, 175. 
in nasal passages, 105. 
Fovea of optic disk, 150. 
Fractures, deformity from, 336. 
genu valgum after, 355. 
Framboesia, 477. 
French rhinoplasty, 139. 
Frictions in massage, 739. 
Frog-face, 126. 
Frontal sinuses, foreign bodies 
in, 117. 
calculi in, 117. 
inflammation of, 116. 
chronic, 115. 
tumors of, 118. 
wounds of, 117. 
Functions, suspended, of glottis, 
56. 
of laryngeal occlusion, 55. 
Fundus of eye, 149. 
examination of, 148. 
Fungoid inflammatory neo- 
plasm, 649. 
syphilitic laryngeal growths, 
30. 
Fungus htematodes, 669. 
of lachrymal ducts, 180. 
Furunculus of ear, 307. 
of nose, 95. 
G. 
Galactocele, 691. 
Galvanism, 718. 
Galvano-cautery for laryngeal 
tumors, 64. 
in cancer, 677. 
Ganglions, 395. 
Gangrene of chancroid, 516. 
of nose, 95. 
Gastric tinnitus, 328. 
Gelatinoid polypus, 620. 
Genu extrorsum curvatum, 359. 
shoe for, 360. 
Genu valgum, 353. 
author’s view of etiology of, 
356. 
produced by articular disease, 
355. 
condyloid development, 
355. 
fractures, 355. 
hereditary influence, 354. 
muscular rigidity, 355. 
paralysis, 355. 
rachitis, 354. 
rheumatism, 355. 
yielding bones, 355. 
treatment of, 356. 
by apparatus, 357. 
by manual pressure, 356. 
by operations, 358. 
Giant-celled sarcoma, 641. 
Gland, lachrymal, affections of, 
170. 
mammary, diseases of, 679. 
thyroid, diseases of, 490. 
Glandular hypertrophy, 629. 
of larynx, 26. 
Glaucoma, 250. 
excavated disk in, 251. 
operations for, 252. 
Glio-fibroma, 648. 
Glioma, 648. 
of retina, 241. 
Glio-myxoma, 648, 
Glio-sarcoma, 648. 
of nerves, 443. 
Globes 6pidermiques, 660. 
Glossitis, syphilitic, 546. 
Glottis, functional disorders of, 
55. 
oedema of, 23. 
sub-, 24. 
Goitre, 490. 
aneurismal, 493. 
calcareous, 493. 
cystic, 493. 
differential diagnosis of, 495. 
exophthalmic, 492. 
fibrous, 493. 
retropharyngeal, 503. 
treatment of, 496. 
operative, 497. 
Gonorrhoeal ophthalmia, 190. 
Gracilis, bursae under, 403. 
Graefe cataract extraction, 265. 
Granular conjunctivitis, 194. 
ophthalmia, 194. 
Granulation-celled sarcoma, 637. 
Graves’s disease, 492. 
Great occipital nerve, stretch- 
ing of, 729. 
sciatic nerve, stretching of, 
730. 
Green’s astigmatic diagram, 281. 
Guinea-worm, 480. 
Gumma, 545. 
cutaneous, 536. 
in larynx, 547. 
of heart, 562. 
of nerves, 443. 
treatment of, 569. 
H. 
Haemophthalmos, 227. 
Hair, avulsion of, 481. 
lost from eyebrows, 151. 
redundancy of, 481. 
wild, 155. 
Hammer-toes, 367. 
Hand, club-, 368. 
Hare-eye, 163. 
Head, spasmodic extension of, 
379. 
Healing of nerves, 409. 
Hearing, acuity of, 287. 
dullness of, 324. 
Heart, syphilis of, 562. 
Hematoid cancer of breast, 708. 
Hemeralopia, 247. 
Hemiopia, 245. 
Hemorrhage after avulsion of 
nasal polypus, 129. 
after enucleation of eye, 285. 
arrest of, in tenotomy, 350. 
fatal, from bodies in air-pas- 
sages, 46. 
from cancer, 675. 
in retinitis, 236. 
in tracheotomy, 81. 
secondary, 82. 
into vitreous, 274. 
nasal, 101. 
Hemorrhagic glaucoma, 251. 
Hereditary influence in deformi- 
ties, 337. 
in genu valgum, 354. 
Hernia of iris after staphyloma, 
214. 
Herpes of conjunctiva, 192. 
Homonymous hemiopia, 245. 
Hordeolum, 153. 
difference from abscess, 154. 
Horns, 467. 
of eyelids, 169. INDEX TO VOLUME III. 
751 
Horse-foot, 345. 
House-maid’s knee, 398. 
Howard’s artificial respiration, 
89. 
Hyalitis, 273. 
Hydatid cysts, 594. 
electrolysis for, 724. 
in eye-chambers, 228. 
of mamma, 695. 
Hydrocele, electrolysis for, 724. 
of neck, 591. 
Hydrophthalmos, 227. 
Hygromata of neck, 591. 
Hyperaesthesia of larynx, 54. 
of mamma, 685. 
Hypermetropia, 279. 
Hyperostosis of ear, 311. 
Hypertrophic naso-pharyngeal 
catarrh, 111. 
paralysis, pseudo-, 387, 440. 
Hypertrophy, dermoid, 464. 
from nerve-injury, 429. 
glandular, 629. 
of fingers, 372. 
of larynx, 26. 
of mamma, 682. 
of nasal integument, 94. 
of thyroid gland, 493. 
of toes, 367. 
subdermoid, 464. 
Hypopyon, 207. 
keratitis, 210. 
ulcer, 210. 
Hysterical amblyopia, 248. 
deafness, 325. 
I. 
Impacted cerumen, 304. 
Impetigo, syphilitic, 535. 
Impotency, electricity in, 722. 
Incurvated toe-nail, 486. 
India, Delhi boil of, 489. 
mycetoma of, 489. 
Indian rhinoplasty, 136. 
Infantile paralysis, 441. 
muscular atrophy after, 387. 
Inflammation of aponeuroses, 
404. 
of bursae, 396, 397. 
of chancroid, 515. 
of choroid, 229. 
of conjunctiva, 186. 
of cornea, 204. 
of ear, external, 307. 
middle, 312. 
of ethmoidal sinuses, 115. 
of frontal sinuses, 115, 116. 
of iris, 221. 
of lachrymal gland, 170. 
sac, 175. 
of larynx, 21. 
of lymphatics, 445. 
of lymph-glands, 451. 
of mammae, 685. 
of mastoid cells, 322. 
of muscles, 384. 
of nasal cavities, 108. 
of nerves, 405. 
of nose, follicular, 95. 
of optic nerve, 242. 
of retina, 235. 
of sclerotica, 218. 
of sphenoidal sinuses, 115. 
of tendons, 394. 
of ungual matrix, 484. 
of vitreous humor, 273. 
Inflammatory fungoid neo- 
plasm, 649. 
Inflation of lungs by bellows, 
88. 
by mouth, 87. 
Infraorbital nerve, stretching of, 
727. 
Infra-thyroid laryngotomy for 
tumors of larynx, 69. 
Ingrown toe-nail, 486. 
Inhalations in laryngitis, 27. 
Injections into cancer, 676. 
In-knee, 353. 
Insects in ear, 304. 
Insufflator, 28. 
Interstitial keratitis, 207. 
Intestines, syphilis of, 551. 
Intra-uterine pressure, deform- 
ity from, 337. 
Iridectomy, 224. 
anaesthetics in, 225. 
Critchett’s plan of, 226. 
for foreign bodies, 228. 
in glaucoma, 252. 
Iridermia, 219. 
Irido-choroiditis, 228. 
Irido-cyclitis, 228. 
Iridodesis, 226. 
in corneal opacities, 212. 
Iridodialysis, 227. 
Iridonesis, 220. 
Iris, 219. 
carcinoma of, 223. 
congenital imperfections of, 
219. 
contraction of, 220. 
cysts of, 223. 
dilatation of, 220. 
hernia of, after staphyloma, 
214. 
in keratitis, 210. 
inflammation of, 221. 
lepra of, 223. 
membrana pupillaris remain- 
ing to, 219. 
naevus of, 223. 
operations on, 224. 
prolapsed, after corneal 
wounds, 216. 
pupil in, 221. 
sarcoma of, 223. 
sphincter of, 221. 
tremulous, 220. 
Iritis, 221. 
plastic infiltration in, 221. 
posterior synechia after, 223. 
rheumatic, 222. 
sequels of, 223. 
syphilitic, 222, 548. 
hereditary, 573. 
treatment of, 569. 
traumatic, 221. 
Ischaemia, 235. 
Italian rhinoplasty, 138. 
J. 
Javal’s astigmatic apparatus, 
284. 
Joints, syphilis of, 555, 572. 
swollen, after nerve-injury, 
411. 
K. 
Keloid, 469, 603. 
Addison’s, 470. 
Keratitis, 204. 
fascicular, 206. 
hypopyon, 207, 210. 
interstitial, 207. 
pannus in, 205. 
suppurative, 206. 
ulcerative, 210. 
with granular lids, 196. 
Keratoglobus, 213. 
Keratonyxis, 269. 
Kidney disease, oedema of lar- 
ynx during, 24. 
syphilis of, 561. 
Kneading in massage, 741. 
Knee, back, 361. 
house-maid’s, 398. 
knocked, 353. 
out-, 359. 
Knock-knee, 353. 
L. 
Labial chancre, 523. 
Labyrinthic deafness, 324. 
Laceration of muscles, 382. 
of nerves, 408. 
Lachrymal caruncle, diseases of, 
200. 
sinking of, after squint op- 
erations, 184. 
ducts, dilatation of, 177. 
stricture of, 176. 
fistula, after dacrocystitis, 
176. 
gland, altered secretions from, 
170. 
cyst of, 172. 
dermoid or hydatid, 172. 
extirpation of, 172. 
fistula of, 171. 
inflammation of, 170. 
hypertrophy after, 171. 
morbid growths of, 171. 
obstruction, syphilitic, 569. 
passages, affections of, 173. 
anatomy of, 174. 
foreign bodies in, 175. 
probes, 177. 
punctum, deviations of, 173. 
obliteration of, 175. 
sac, catarrh of, 176. 
fungus of, 180. 
inflammation of, 175. 
stricture, 176. 
intractable, 179. 
probes for, 177. 
style introduced for, 178. 
Lachrymation, disordered, 170. 
overflow of, 173. 
Lacteal cysts, 691. 
obstruction, 695. 
Lagophthalmus, 163. 
Lamellar cataract, 254. 
Large spindle-celled sarcoma, 
641. 
Larvae in ear, 305. 
Laryngeal brush, 28. 
knife, 25. 
occlusion, suspended func- 
tions of, 55. 
syringe, 28. 
Laryngismus stridulus, 54. 
Laryngitis, 21-29. 
acute, 21. 
death from asphyxia in, 22, 
in children, 22. 
mirror view of, 22. 752 
INDEX TO VOLUME III. 
Laryngitis, acute, treatment of, 
23. 
catarrhal, 21. 
diagnosis from croup, 35. 
chronic, 25. 
after hypertrophic catarrh, 
111. 
common or simple, 26. 
diagnosis from tuberculous, 
26, 28. 
treatment of, 27. 
hypertrophic, 26. 
laryngo-tracheitis, after, 21. 
parenchymatous, 23. 
syphilitic, 30, 546. 
fungoid or warty growths 
in, 30. 
necrosis after, 30. 
paresis in, 30. 
treatment of, 31, 569. 
tuberculous, 28. 
appearances in, 29. 
chondritis after, 29. 
diagnosis from chronic, 26, 
28. 
treatment of, 29. 
Laryngoscope, history of, 17. 
used in tracheotomy wound, 
21. 
Laryngoscopy, auto-, 20. 
by artificial light, 20. 
by sunlight, 18. 
laryngitis from, 22. 
obstacles to, 19. 
structures seen by, 21. 
Laryngotomy, 75. 
for foreign bodies, 49. 
for tumors of larynx, 68. 
inferior, 77. 
infra-thyroid, 69. 
median, 76. 
superior, 77. 
Laryngo-pharyngotomy for tu- 
mors, 68. 
Laryngo-tracheitis, 33. 
diagnosis of, 33, 35. 
from laryngismus stridulus, 
54. 
diphtheria compared with, 33. 
from laryngitis, 21. 
lymph-glands in, 34. 
pathology of, 34. 
prognosis in, 35. 
symptoms of extension of, 39. 
tracheotomy in, 36. 
accidents during, 40. 
after-treatment of, 41. 
anaesthetics in, 40. 
canula, when to remove, 41. 
causes influencing success 
of, 37. 
fatal result after, 41. 
form of opening in, 40. 
indications for, 36, 40. 
statistics of, 36. 
treatment of, 35. 
Laryngo-tracheotomy, 83. 
for tumors, 68. 
Larynx, 17-91. 
adenoma of, 63. 
anaesthesia of, 53. 
angeioma of, 62. 
carcinoma of, 70. 
cystoma of, 63. 
electrization of, 59. 
enchondroma of, 63. 
epithelioma of, 70. 
extirpation of, 72. 
Larynx, extirpation of, drain- 
age-tube in, 72. 
partial, 75. 
results of, 73. 
false bands in, 67. 
fibroma of, 62. 
fistula in, 44. 
blind, 44. 
foreign bodies in, 44. 
functional disorders of, 53-59. 
glandular hypertrophy of, 26. 
hyperaesthesia of, 54. 
inflammation of, 21. 
lepra of, 31. 
lipoma of, 63. 
lupus of, 31. 
malignant growths of, 70. 
myxoma of, 62. 
necrosis of, syphilitic, 30. 
neuroses of, 53. 
oedema of, 23. 
chronic, 24. 
pathology of, 25. 
spasmodic, 24. 
subglottic, 24. 
treatment of, 25. 
operations forbidden in, 67. 
papilloma of, 62. 
paralysis of muscles of, 55. 
perichondritis of, 32. 
spasm of, 54. 
stenosis or stricture of, 42. 
oedematous, 43. 
surgical relations to trachea, 
75. 
syphilis of, 30, 546. 
treatment of, 569. 
tuberculous ulcers in, 29. 
tumors of, 60. 
evulsion of, 65. 
prognosis in, 62. 
treatment of, 63. 
operative, 68. 
Lead avoided in corneal ulcers, 
196, 209. 
Leech in air-passages, 45. 
in nose, 108. 
Leg, curvatures of, 361. 
Leiomyoma, 606. 
Leontiasis, 601. 
Lepra of eyelids, 169. 
of iris, 223. 
of larynx, 31. 
Leptothrix, 180. 
Leucaemic retinitis, 238. 
Leucoma, 211. 
Lice on eyelids, 157. 
Liebreich cataract operation, 
266. 
Ligature, contusing nerves, 407. 
in treating cancer, 677. 
Linear cataract extraction, 265. 
Lip, chancre on, 523. 
Lipoma, 597. 
fibro- or mixed, 598. 
of conjunctiva, 200. 
membranous, 201. 
of eyelids, 169. 
of larynx, 63. 
of mamma, 696. 
Lipomatous sarcoma, 643. 
Lithiasis, 203. 
Liver, syphilis of, 564. 
hereditary, 573. 
Local syphilis, 518. 
Lock-finger, 375. 
Lockjaw, 432. 
Loring’s ophthalmoscope, 147. 
Lucilia hominivorain nose, 107. 
Lues venerea, 504. 
Lungs, artificial inflation of, 87. 
syphilis of, 548. 
hereditary, 573. 
Lupus of larynx, 31. 
of nose, 96. 
erythematosus, 99. 
Luxation of crystalline lens, 217, 
253. 
of muscles, 384. 
Lymphadenoid sarcoma, 639. 
Lymphangiectosis, 449. 
Lymphangioma, 618. 
Lymphangitis, 445. 
Lymphatic system, 444-453. 
anatomy and physiology of, 
444. 
Lymphoma, 615. 
differential diagnosis of, 617. 
hard, 616. 
soft, 615. 
Lymphorrhagia, 449. 
Lymph-glands, affections of, 
450. 
amyloid disease of, 453. 
in croup, 34. 
syphilis of, 564. 
Lymph-oedema, 448. 
Lymph-scrotum, 449. 
Lymph-vessels, varices of, 448. 
wounds of, 447. 
M. 
MacEwen’s osteotomy for genu 
valgum, 358. 
Macrochilia, 618. 
Macro-glossia, 618. 
Macromelia, 618. 
Main en griffe, 387. 
Malformations, 333-380. 
factors producing, 336. 
Mamma, abnormalities of, 680. 
abscess of, 687. 
cold, 690. 
interlobular, 688. 
post-, 690. 
subcutaneous, 688. 
treatment of, 688-691. 
adenoma of, 700. 
affections of areola of, 682. 
nipple of, 680. 
anatomy of, 679. 
atrophy of, 683. 
carcinoma of, 704-714. 
prognosis of, 710. 
treatment of, 712. 
chancre on, 523. 
chronic tumor of, 630. 
colloid cancer of, 709. 
cysts, hydatid, 695. 
lacteal, 691. 
multilocular, 694. 
non-lacteal, 692. 
retention, 691. 
diseases of, in female, 682. 
in male, 714. 
encephaloid cancer of, 707. 
epithelioma of, 710. 
excision of, 715. 
after-treatment of, 717. 
fibroma of, 696. 
diagnosis from cancer, 699. 
hyperaesthesia of, 684. 
hypertrophy of, 682. 
inflammation of, 685. INDEX TO VOLUME III, 
753 
Mamma, lipoma of, 696. 
melanotic cancer of, 710. 
milk obstructed in, 695. 
myxoma of, 699. 
neuralgia of, 684. 
sarcoma of, 701. 
diagnosis of, 704. 
prognosis of, 704. 
treatment of, 704. 
scirrhus of, 705. 
syphilis of, 564. 
tumors of, 691. 
Mammary abscess, 687. 
gland, diseases of, 679. See 
Mamma. 
Marriage, syphilis debarring, 
575. 
Marshall Hall’s artificial respi- 
ration, 88. 
Massage, 734. 
cases benefited by, 736. 
compression in, 742. 
directions for, 736. 
divisions of, 737. 
frictions in, 739. 
history of, 734. 
kneading in, 741. 
modus operandi of, 737. 
movements in, 744. 
percussion in, 743. 
regions for, 739. 
rolling in, 741. 
time lor, 736. 
Masseur, qualifications for, 736. 
Mastitis, 685. 
Mastoid, inflammation of, 322. 
periostitis of, 322. 
trephining of, 322. 
Maternal impressions, deformity 
from, 337. 
Matrix of nail inflamed, 484. 
Matrixitis, 484. 
Median nerve, stretching of, 730. 
Medullary cancer of breast, 707. 
Meibomian glands, concretions 
in, 203. 
Melanosis of skin, 478. 
Melanotic carcinoma, 671. 
of breast, 710. 
sarcoma, 641. 
Membrana pupillaris remaining 
to iris, 219. 
tympani, affections of, 312. 
appearance of, 295. 
artificial, 330. 
examination of, 292. 
inflation of, 295. 
Meningeal syphilis, 557. 
Middle ear, diseases of, 312- 
321. 
Millet-grains, 588. 
of eyelids, 168. 
Moles, 468. 
Molluscum fibrosum, 470. 
of eyelids, 168. 
sebaceum, 470. 
Mooren cataract operation, 266. 
Morphoea, 470. 
Mother's mark, 621. 
Mouth-inflation of lungs, 87. 
Movements in massage, 744. 
Mucocele, 176. 
Mucous cysts, 590. 
membranes, syphilis of, 539. 
patches, hereditary, 571. 
in larynx, 547. 
treatment of, 544. 
Muscse carnariso in nose, 107. 
Muscse volitantes, 275. 
Muscles, 381. 
angeioma of, 389. 
atrophy, forms of, 386. 
with infantile paralysis, 
387, 400. 
bursae of, 399, 403. 
carcinoma of, 390. 
contracture of, from nerve- 
injury, 429. 
cysts of, non-parasitic, 389. 
parasitic, 387. 
deformity from spasm of, 337. 
degeneration of, 386. 
developed by massage, 744. 
Duchenne’s paralysis of, 387, 
440. 
enchondroma of, 390. 
fibroma of, 389. 
inflammation of, 384. 
laceration of, 382. 
luxation of, 384. 
erector spinse, 394. 
myxoma of, 389. 
neuralgia of, 386. 
of larynx, paralysis of, 55. 
osteoma of, 390. 
parasites in, 387. 
paresis of, 384. 
pseudo-hypertrophic paraly- 
sis of, 387, 440. 
rupture of, 382. 
sarcoma of, 390. 
spasm of palpebral, 164. 
syphilis of, 555. 
tensile resistance of, 381. 
trichina spiralis in, 388. 
tumors of, 389. 
wounds of, 381. 
Muscular defects of eyelids, 163. 
neuralgia, 386. 
rigidity, genu valgum from, 
355. 
Musculo-cutaneous nerve, 
stretching of, 730. 
Myalgia, 386. 
Mycetoma of India, 489. 
Mydriasis, 220. 
Myelinic neuroma, 622. 
Myeloid sarcoma, 641. 
Myodesopia, 275. • 
Myoma, 605. 
leio-, 606. 
of skin, 479. 
rhabdo-, 606. 
Myopia, 278. 
Myo-sclerosis, 440. 
Myosis, 220. 
Myositis, 384. 
Myotomy for blepharospasm, 
165. 
in glaucoma, 253. 
Myxoma, 619. 
glio-, 648. 
of ear, 309. 
of larynx, 62. 
of mammae, 699. 
of muscles, 389. 
of nerves, 443. 
Myxo-sarcoma, 643. 
N. 
Naevus maternus, 621. 
electrolysis for, 724. 
of auricle, 303. 
of conjunctiva, 203. 
Naevus of eyelids, 169. 
of iris, 223. 
Nails, alterations in, 484. 
avulsion of, 484. 
exostosis under, 486. 
incurvated, of toe, 486. 
syphilis of, 537. 
wounds of, 483. 
Nasal bones, syphilis of, 554. 
calculi, 105. 
catarrh, 108. 
atrophic or dry, 115. 
hypertrophic, 111. 
post-nasal syringe in, 110. 
simple chronic, 108. 
strumous of children, 110. 
Thudichum douche in, 109. 
douche, 109. 
fibromata, 125. 
polypus, 121. 
avulsion of, 123. 
diagnosis from rhinoliths, 
106. 
fibrous, 125. 
avulsion of, 128. 
hemorrhage after, 129. 
differential diagnosis of, 
127. 
osteoplastic operations 
for, 129. 
strangulation of, 130. 
treatment of, 128. 
soft or gelatinous, 121. 
diagnosis from fibrous, 
127. 
treatment of, 123. 
Naso-pharyngeal catarrh, 111. 
image, 105. 
polypus, electrolysis for, 724. 
region, enchondroma in, 131. 
in ear-disease, 315. 
Near-sighted, 278. 
Nebula of cornea, 211. 
Neck, wry-, 376. 
Necrosis after perichondritis of 
larynx, 32. 
after tubercular laryngitis, 29. 
in syphilis, 553. 
hereditary, 572. 
of larynx, 30. 
of temporal bone in ear-dis- 
ease, 321. 
Neoplasms, benign or typical, 
597. 
inflammatory fungoid, 649. 
Nephritic retinitis, 237. 
Nerves, affections of, 405-443. 
atrophy of, 439. 
carcinoma of, 443. 
central affections from periph- 
eral irritation of, 428. 
compression of digital, 407. 
cystoma of, 443. 
excised for neuralgia, 413. 
fibroma of, 442. 
force needed to rupture, 428. 
glio-sarcoma of, 754. 
gumma of, 443. 
healing of, 408. 
hypertrophy of, 440. ' 
inflammation of, 405. 
of optic, 242. 
injury of, 710. 
evil effects after, 410. 
of special sense, 408. 
laceration of, 408. 
ligation of, 407. 
myxoma of, 443. 754 
INDEX TO VOLUME III. 
Nerves, sarcoma of, 443. 
spinal accessory, division and 
stretching of, for torticollis, 
380. 
stretching of special, 727. 
cases tabulated, 413. 
tumors of, 442. 
wounds of, 407. 
skin-changes after, 411. 
treatment of, 409. 
Nerve-section for elephantiasis, 
476. 
Nerve-stretching, 727-733. 
by forcible flexion and exten- 
sion, 428. 
diseases employed in, 413. 
of anterior crural, 732. 
of anterior tibial, 732. 
of auricularis magnus, 728. 
of external popliteal, 731. 
of great occipital, 729. 
of great sciatic, 730. 
of infraorbital, 727. 
of median, 730. 
of musculo-cutaneous, 730. 
of peroneal, 731. 
of spinal accessory, 729. 
of supraorbital, 727. 
of ulnar, 730. 
statistics on, 414-428. 
Nerve-tumor of skin, 624. 
Nervous deafness, 324. 
system, syphilis of, 557, 573. 
Neuralgia, 411. 
diagnosis from neuritis, 412. 
electricity in, 723. 
of mammary gland, 684. 
syphilitic, 557. 
treatment, 412. 
operative, 413. 
Neuritis, 405. 
diagnosis from neuralgia, 412. 
extension of, 406. 
optic, 242. 
Neuroma, 622. 
cutis, 472, 624. 
of nasal fossae, 133. 
special forms of, 442. 
Neuro-retinitis, 242. 
syphilitic, 550. 
Neuroses of larynx, 53. 
of nasal passages, 133. 
Nictitation of eyelids, 165. 
Night-blindness, 247. 
Nipple, abnormalities of, 680. 
eczema of, 682. 
fissure of, 681. 
neoplasms around, 682. 
psoriasis of, 682. 
retracted, 681. 
syphilis of, 682. 
ulceration of, 681. 
Nodes, syphilitic, 552. 
Non-lacteal cyst, 692. 
Nose, 92-140. 
abscess of, 95. 
acquired contraction of, 92. 
affections of cavities of, 101. 
of septum of, 118. 
of soft parts of, 93. 
carcinoma in, 133. 
catarrh of accessory cavities 
to, 115. 
cleft, 93. 
congenital defects of, 92. 
deformities of, 93. 
enchondroma in, 131. 
epithelioma of, 98. 
Nose, epithelioma of, treatment 
of, 100. 
examination of passages of, 
103. 
by finger and probe, 103. 
by rhinoscope, 104. 
follicular inflammation of, 95. 
foreign bodies in passages of, 
105. 
from without, 106. 
functions of, 92. 
furuncle of, 95. 
gangrene of, 95. 
hypertrophy of integument 
of, 94. 
inflammation of cavities of, 
108. 
leeches in, 108. 
lupus of, 96. 
diagnosis of, 97. 
erythematosus, 99. 
exedens, 96. 
treatment of, 99. 
morbid growths in, 121. 
neuroma in, 133. 
neuroses of, 133. 
osseous tumors of, 131. 
papilloma in, 132. 
parasites in, animal, 107. 
vegetable, 108. 
polypus in, 121, 631. 
rodent ulcer of, 98. 
treatment of, 100. 
sarcoma of, 133. 
ossifying, 131. 
sebaceous tumors of, 95. 
septum, abscess of, 120. 
blood - extravasations of, 
120. 
deviations of, 118. 
furuncles of, 120. 
inflammation of, 119. 
perforating ulcer of, 120. 
steatoma of, 95. 
stenosis of, 92. 
sudden oedema of lining of, 
135. 
syphilis of, 100, 550. 
wounds of, 101. 
Nuclear cataract, 255. 
Nutrition after nerve-injury, 
410. 
Nyctalopia, 247. 
Nystagmus with cataract, 255. 
0. 
Oblique illumination of eye, 143. 
Occipital nerve, stretching of, 
729. 
(Edema, lymph-, 448. 
of conjunctiva, 204. 
of eyelids, 152. 
of glottis, 23. 
tubes in, 43. 
of larynx, 23. 
tubes in, 43. 
of lungs after partial drown- 
ing, 91. 
(Edematous erysipelas, 454. 
(Esophagus, syphilis of, 551. 
Ogston osteotomy for genu val- 
gum, 358. 
Oil cysts, 590. 
Olfactory syphilis, 550. 
Onychia, 484. 
syphilitic, 537. 
Onychia, syphilitic, treatment 
of, 508. 
Opacities of cornea, 211. 
of vitreous humor, 274. 
Ophthalmia, catarrhal, 186. 
contagiosa, 188. 
Egyptian, 188. 
exanthematous, 194. 
gonorrhoeal, 190. 
diphtheritic, 191. 
ptosis after, 192. 
secondary or metastatic, 
190. 
treatment of, 192. 
granular, 194. 
neonatorum, 189. 
phlyctenular, 192. 
blepharospasm during, 193. 
pannus herpeticus in, 193. 
purulent, 188. 
isolation during, 189. 
tarsal, 154. 
Ophthalmoscope, 146. 
principles of, 146. 
Opisthotonus, 432. 
Optic disk or nerve, 149. 
atrophy of, 244. 
excavated in glaucoma, 251. 
inflammation of, 242. 
Optic neuritis, 242. 
descending, 242. 
peri-, 243. 
Orbicularis palpebrarum, spasm 
of, 164. 
Ossification of choroid, 233. 
Osteitis, syphilitic, 552. 
Osteoid sarcoma, 643. 
Osteoma, 612. 
dura, 613. 
eburnatum, 613. 
enostoses as, 612. 
exostoses as, 612. 
in nose, 131. 
of muscles, 390. 
spongiosum, 614. 
Osteo-periostitis, syphilitic, 552. 
Osteo-sarcoma, 612. 
Osteotomy for genu valgum, 358. 
Otalgia, 329. 
Othasmatoma, 301. 
Otitis, 312-321. 
external, 307. 
media, 312-322. 
Otoscope, interference-, 290. 
use of, 292. 
Out-knee, 359. 
Ovary, syphilis of, 561. 
Overlapping toes, 366. 
P. 
Palate, hard, syphilis of, 554. 
Palpebral arteries, 141. 
Palsy, scrivener’s, 430. 
Pancreas, syphilis of, 564. 
Pannus, 205. 
crassum, 205. 
herpeticus in phlyctenular 
ophthalmia, 193. 
in granular conjunctivitis, 
196. 
tenuis, 205. 
Papillitis, 242. 
Papilloma, 625. 
hard, 625. 
of auricle, 303. 
of larynx, 62. INDEX TO VOLUME III. 
755 
Papilloma of nares, 132. 
of nose, 93. 
soft, 625. 
Papular syphiloderm, 533. 
Papulo-squamous syphiloderm, 
533. 
Paquelin cautery in cancer, 677. 
Paracentesis of tympanum, 318. 
Paralysis, deformity from, 337. 
facial, electricity in, 722. 
from syphilis, 557. 
genu valgum from, 355. 
infantile, 441. 
atrophy after, 387. 
nutrition innerve-injury with, 
410. 
of arm, electricity for, 722. 
of bladder, electricity in, 721. 
of deltoid, electricity for. 722. 
of muscles, ciliary, 276. 
crico.arytenoid, 57, 58. 
crico-thyroid and thyro- 
arytenoid, 56. 
laryngeal, 55. 
levatores alse nasi, 92. 
thyro-epiglottic, 55. 
of upper extremity, 368. 
pseudo-hypertrophic, 387, 
440. 
Paraphimosis with chancroid, 
517. 
Parasites in muscles, 387, 389. 
in nose, 107. 
on skin, 479. 
of scalp, 483. 
vegetable, in ear, 306. 
Parasitic cysts, 594. 
in muscles, 387. 
Parenchymatous atrophy of op- 
tic nerve, 244. 
iritis, 221. 
Paresis of muscles, 384. 
ciliary, 275. 
Paronychia, 487. 
Patella, bursa of tendon of, 401. 
rupture of tendon of, 393. 
Pearly tumor, 590. 
Pemphigus, syphilitic, 535. 
hereditary, 571. 
Percussion in massage, 743. 
Pericardium, syphilis of, 562. 
Perichondritis of larynx, 32. 
necrosis after, 32. 
Perimeter for testing vision, 145. 
Perionyxis, syphilitic, 538. 
Periostitis, mastoid, 322. 
syphilitic, 551. 
hereditary, 572. 
Peroneal nerve, stretching of, 
731. 
Peroneus longus, bursae of ten- 
don of, 403. 
Pes equinus, 345. 
Phagedaenic chancroid, 515. 
Pharyngitis, laryngitis after, 26. 
Pharyngotomy for laryngeal 
tumors, 69. 
Pharynx, syphilis of, 551. 
Phimosis with chancroid, 516. 
Phlebectasia, 203. 
Phlebitis, diagnosis of, from 
lymphangitis, 446. 
Phlegmonous erysipelas, 454. 
Phlyctenular ophthalmia, 192. 
Phthisis, laryngitis during, 28. 
with cancer, 656. 
Pigmentous retinitis, 238. 
Piliferous cyst of mamma, 693. 
Piliferous cysts of eyelids, 168. 
Pinguicula, 200. 
Pityriasis capitis, 483. 
syphilitic, treatment of, 569. 
Plastic operations, rules for, 
136. 
Pleurosthotonus, 432. 
Plexiform cylindrical neuroma, 
622. 
Plica polonica, 483. 
Pneumonia after tracheotomy, 
83. 
Podelcoma, 364. 
Poisoning from Rhus, 463. 
Polish plait, 483. 
Politzer bag, 296. 
Polyadenoid tumor of mamma, 
700. 
Polydaetylism, fingers, 370. 
toes, 365. 
Polypus, nasal, gelatinoid or 
soft, 121, 631. 
nasal, fibrous, 125. 
naso-pharyngeal, 126. 
electrolysis for, 724. 
of conjunctiva, 201. 
soft, 620, 625, 631. 
rectal, 631. 
uterine, 631. 
Position, deformity from, 336. 
Post-mammary abscess, 690. 
Presbyopia, 276. 
in glaucoma, 250. 
Proliferous cysts, 596. 
Prostitution, 577. 
Psammoma, 644. 
Pseudo-hypertrophic muscular 
paralysis, 387, 440. 
Psoriasis of nipple, 682. 
syphilitic, 533. 
Pterygium, 197. 
forms of, 198. 
operations for, 198. 
Ptosis, 165. 
after gonorrhoeal ophthalmia, 
192. 
electricity in, 722. 
Punctum lacrymale, deviations 
of, 173. 
obliteration of, 175. 
rules for passing prdbes into, 
173. 
Pupil of eye, 221. 
Purulent ophthalmia, 188. 
Pustular syphiloderm, 534. 
Q. 
Quinia, deafness from, 326. 
tinnitus aurium from, 328. 
R. 
Rachitis, curvatures from, 368. 
genu valgum from, 354. 
Receptaculuin chyli, rupture of, 
447. 
Reclination of cataract, 269 
Rectum, chancre in, 524. 
polypus in, 631. 
syphilitic stricture, treatment 
of, 569. 
Redressement brusque of De- 
lore, 358. 
Redundancy of skin, 469. 
Reel-footed, 348. 
Reeves’s osteotomy for genu val- 
gum, 358. 
Refraction in eye, 277. 
Repair of tendons, 391. 
Respiration, artificial, 87. 
electricity in, 722. 
in tetanus, 433. 
Retina, absence of blood in, 
235. 
anaesthesia of, 247. 
central artery of, 141. 
embolism of, 250. 
congestion of, arterial, 234. 
venous, 235. 
cysts of, 241. 
detached, 239. 
glioma of, 241. 
inflammation of, 235. 
sarcoma of, 241. 
tuberculosis of, 242. 
tumors of, 241. 
vascular growths of, 242. 
Retinitis, 235. 
albuminurica, 237. 
chorio-, 230. 
diabetic, 238. 
hemorrhagic, 236. 
leucaemic, 238. 
nephritica, 237. 
pigmentosa, 238. 
suppurative, 236. 
syphilitic, 238, 549. 
Retracted nipple, 681. 
Retropharyngeal goitre, 503. 
Rhabdomyoma, 606. 
Rhagades, 539. 
Rheumatic iritis, 222. 
Rheumatism, genu valgum from, 
355. 
Rhineurynters, 103. 
Rhinitis, 108. 
Rhinoliths, 105. 
Rhinoplasty, 136. 
French method of, 139. 
Indian plan of, 136. 
modifications of, 137, 138. 
Italian or Taliacotian method 
of, 138. 
rules for, 136. 
Rhus dermatitis, 463. 
Rickets, deformity from, 337. 
Rigor mortis after drowning, 
86. 
Ringworm, 479. 
Rodent ulcer of nose, 98. 
Rolling in massage, 741. 
Round-celled sarcoma, 637. 
large, 639. 
of mamma, 703. 
Run-round, 484. 
syphilitic, 538. 
Rupia, syphilitic, 535. 
Rupture of aponeuroses, 404. 
of choroid, 233. 
of muscles, 382. 
of tendons, 392. 
of thoracic duct, 446. 
S. 
Salivary cysts, 590. 
gland, syphilis of, 564. 
Sand-flea, 480. 
Sanguineous cysts, 593. 
Sarcocele, syphilitic, treatment 
of, 570. 
Sarcoma, 633. 756 
INDEX TO VOLUME III. 
Sarcoma, alveolar, 638. 
angeiolitbic, 644. 
central, 643. 
course of, 646. 
diagnosis of, 647. 
from carcinoma, 672. 
from epcephaloid, 709. 
embryoplastic, 637. 
endothelial, 645. 
forms of, 634. 
giant-colled, 641. 
glio-, 648. 
lipomatous, 643. 
lymphadenoid, 639. 
melanotic, 641. 
myeloid, 641. 
myxo-, 643. 
of auricle, 303. 
of conjunctiva, 202. 
of ear, 311. 
of iris, 223. 
of mamma, 701. 
of muscles, 390. 
of nerves, 443. 
glio-, 443. 
of nose, 133. 
ossifying, 131. 
of retina, 241. 
of skin, 478. 
osteoid, 643. 
prognosis of, 646. 
round-celled or granulation, 
637. 
large, 639. 
spindle-celled, 640. 
large, 641. 
treatment of, 648. 
Sarcomatous carcinoma of cho- 
roid, 233. 
Sartorius, bursa under, 403. 
Scald, club-hand after, 369. 
of eyelids, 152. 
Schneiderian membrane, ca- 
tarrh of, 108. 
sudden swelling of, 135. 
Sciatic nerve, stretching of, 730. 
Scirrhus, 663. 
atrophic or withering, 664. 
diagnosis from encephaloid, 
668, 672. 
of mamma, 705. 
atrophy of, 706. 
compared with encephaloid, 
708. 
treatment of, 712. 
of skin, 478. 
pathology of, 666. 
Scleroderma, 477. 
Scleronyxis, 269. 
Sclerotica, inflammation of, 218. 
staphyloma of, 217. 
tumors of, 219. 
wounds of, 217. 
luxated lens after, 217. 
Sclerotitis, 218. 
Sclerotomy for glaucoma, 252. 
Screatus, 135. 
Scrivener’s palsy, 430. 
electricity in, 723. 
Scrofula of nose, diagnosis from 
lupus, 97. 
Sebaceous cysts, 587. 
of areola, 682. 
of auricle, 303. 
of eyelids, 168. 
of nose, 95. 
Secondary cataract, 267. 
Seminal cysts, 590. 
Semitendinosus, bursas under, 
403. 
Serpiginous ulcer, syphilitic, 
treatment of, 569. 
with chancroid, 517. 
Silvester’s artificial respiration, 
88. 
Simulated blindness, 249. 
Skin, callosities of, 464. 
cancer of, 657. 
parasites on, 479. 
redundancy of, 469. 
syphilis of appendages of, 
537. 
tumors of, 478. 
Smell, loss of, 134. 
Sneezing, 134. 
Snellen test-types, 144. 
Snow-blindness, 247. 
Soft carcinoma, 667. 
of breast, 707. 
chancre, 510. 
corns, 465. 
Sore throat, clergyman’s, 26. 
Spasm of ciliary muscle, 276. 
of larynx, 54. 
of muscles, deformity from, 
337. 
of palpebral muscles, 164. 
of upper extremity, 368. 
Spasmodic croup, 54. 
extension of head, 379. 
Spastic conditions, deformity 
from, 337. 
Spermatic cord, syphilis of, 561. 
Sphenoidal sinuses, inflamma- 
tion of, 115. 
Sphincter ani, paresis of, elec- 
tricity for, 722. 
Spinal accessory nerve, divis- 
ion and stretching, for 
torticollis, 380. 
accessory nerve, stretching of, 
729. 
cord, syphilis of, 558. 
Spindle-celled sarcoma, 640. 
of mamma, 702. 
Splay-foot, 363. 
as a form of valgus, 351. 
Spleen, syphilis of, 566. 
hereditary, 573. 
Splint for adducted thighs, 353. 
for talipes, 342. 
Spongy osteoma, 614. 
Spray for chronic laryngitis, 27. 
Squamous epithelioma, 660. 
Squint-eye, 180. 
Stains of conjunctiva, 204. 
Staphyloma after chorio-retini- 
tis, 231. 
of cornea, 213. 
of sclerotica, 217. 
posterior in myopia, 278. 
Steatoma, 588. 
of nose, 95. 
Stenosis after tubercular laryn- 
gitis, 29. 
after tracheotomy, 83. 
of larynx and trachea, 42. 
of nares, 92. 
Sterno-mastoid muscle, tenot- 
omy of, 379. 
Stings of eyelids, 152. 
Stomach, Syphilis of, 551. 
Strabismometer, 181. 
Strabismus, 180. 
convergent, 180. 
divergent, 184. 
Strabismus, electricity in, 722. 
tenotomy for, 182. 
sinking of caruncle after, 
184. 
tests for, 181. 
Stricture of canaliculus, 174. 
of Eustachian tube, bougies 
for, 317. 
of larynx and trachea, 42. 
of tear-ducts, 176. 
Stridulus, laryngismus, 54. 
Strumous nasal catarrh of 
children, 110. 
Stye, 153. 
Style for tear-ducts, 178. 
Subcutaneous fibroma of nerves, 
442. 
myotomy for blepharospasm, 
165. 
wounds, healing of, 334. 
Subdeltoid bursae, 401. 
Suction of cataract, 269. 
Suffocation from dislocated epi- 
glottis, 45. 
in tracheotomy, 82. 
Supernumerary fingers, 370. 
toes, 365. 
Suppuration of cornea, 206. 
Supraorbital nerve, stretching 
of, 727. 
Suprarenal capsule, syphilis of, 
562. 
hereditary, 573. 
Suspended animation, 84. 
apncea from accidents in, 91. 
secondary, 90. 
artificial respiration in, 88. 
length of time to continue, 
90. 
evil effects after, 91. 
precautions in, 90. 
post - mortem appearances 
after, 85. 
symptoms of, 85. 
treatment of, 87. 
Symblepharon, 161. 
operations for, 162. 
Synechia, anterior, after staphy- 
loma, 214. 
posterior, after iritis, 223. 
Synovial cysts, 591. 
Syphilides, 531. 
Syphilis, 504. 
acne in, 534. 
acquired, 506. 
alopecia in, 538. 
angina in, 539. 
author’s divisions of, 506. 
bubo with, chancroidal, 512, 
517. 
indurated, 526. 
caries in, 552. 
cephalalgia in, 557. 
cerebral, 557. 
chancres in, 507, 518. 
diagnosis of, 524. 
choroiditis in, 549. 
condyloma in, 540. 
constitutional, 529. 
fever in, 530. 
dactylitis from, 556. 
deafness from, 326, 557. 
doctrines concerning, 508. 
early, 518. 
ecthyma in, 535. 
epidermic accumulations in, 
539. 
eruptions in, 531. INDEX TO VOLUME III. 
757 
Syphilis, eruptions in, hered- 
itary, 571. 
erythema in, 539, 547. 
exanthemata in, 539. 
glossitis in, 546. 
gumma in, 536, 545, 547, 569. 
hereditary, 570. 
bones in, 572. 
signs of, 571. 
skin appendages in, 571. 
special organs in, 573. 
teeth in, 572. 
treatment of, 574. 
history of, 504. 
impetigo in, 535. 
infantile, 570. 
iritis from, 222, 548. 
laryngitis after, 30, 569. 
late, 545. 
local, 518. 
marriage related to, 575. 
meningeal, 557. 
mucous patches in, 539. 
hereditary, 571. 
of larynx, 547. 
myositis from, 384. 
necrosis in, 553. 
of larynx, 30. 
neuralgia in, 557. 
nodes in, 552. 
of aponeuroses, 555. 
of articulations, 555. 
of bladder, 561. 
of blood-vessels, 563. 
of bones, 551. 
abscess in, 553. 
nasal, 554. 
of bronchi, 547. 
of ear, 550. 
of encephalon, 557. 
of eye, 548. 
of hard palate, 554. 
of heart and pericardium, 562. 
of intestines, 551. 
of kidney, 561. 
of larynx, 546. 
of liver, 564. 
of lungs, 548. 
of lymph-glands, 564. 
of mammae, 564. 
of mucous membranes, 539. 
of muscles, 555. 
of nipple, 682. 
of nose, 100, 550, 554. 
diagnosis from lupus, 97. 
of oesophagus, 551. 
of olfactory organs, 550. 
of pancreas, 564. 
of periosteum, 551. 
of pharynx, 551. 
of salivary glands, 564. 
of spermatic cord, 561. 
of spinal cord, 558. 
of spleen, 566. 
of stomach, 551. 
of suprarenal capsule, 562. 
of tendons, 555. 
of testes, 559. 
of trachea, 547. 
of uterus and appendages, 
561. 
onychia in, 537. 
osteitis in, 552. 
eburnation in, 552. 
osteo-periosdds in, 552. 
paralysis from, 557. 
prevention of, by local treat- 
ment, 528. 
Syphilis, primary, 506. 
prostitution related to, 577. 
retinitis from, 238, 549. 
neuro-, 550. 
rhagades in, 539. 
rupia in, 535. 
sarcocele in, 570. 
secondary, 506, 529. 
stages or order of, 506. 
stricture of rectum in, 569. 
tertiary, 506. 
treatment of, 528. 
constitutional, 541. 
locally, 528, 544. 
mineral waters in, 575. 
of alopecia in, 569. 
of bone-disease in, 569. 
of early, 541. 
by mercurial hypoder- 
mics, 544. 
by vapor baths, 543. 
locally, 544. 
of hereditary, 574. 
of late, 566. 
locally, 568. 
of laryngitis in, 31, 569. 
of mucous patches in, 544. 
of onychia in, 568. 
of pityriasis in, 569. 
tubercular, 537, 553. 
ulcerations in, 517, 545. 
of larynx, 30, 569. 
of nose, 100. 
virus of, 509. 
entrance into system, 510. 
Syphilitic iritis, 222. 
laryngitis, 30. 
Syphilization, 541. 
Syphilodermata, 531. 
bullous, 535. 
erythematous, 532. 
general characters of, 531. 
gummatous, 536. 
hereditary, 571. 
papular, 533. 
pustular, 534. 
tubercular, 537. 
vesicular, 534. 
Syringing external auditory 
canal, 290. , 
T. 
Taenia solium, cysts from, 594. 
Taliacotian rhinoplasty, 138. 
Talipes, 337-352. 
apparatus for, 341. 
atrophy with, 340. 
calcaneus, 346. 
causes of, 338. 
equinus, 345. 
non-paralytic, length of 
treatment in, 346. 
excision of tarsus for, 350. 
foot-stretcher for, 343. 
manipulation in, 341. 
night splint for, 342. 
operation for, 343. 
cases for, 334. 
period when, 344. 
time necessary to restore 
limb at, 344. 
pathological changes in, 340. 
statistics of, 338. 
treatment of, 340. 
varieties of, 338. 
mixed or sub, 352. 
Talipes valgus, 350. 
calcaneo-, 351. 
Dupuytren’s splint for, 351. 
equino-, 351. 
splay-foot as form of, 351. 
varus, 348. 
equino-, 348. 
Talon-toes, 367. 
Tarsal ophthalmia, 154. 
Tarsus, excision of wedge from, 
for equino-varus, 350. 
Tear-ducts, stricture of, 176. 
Tears, overflow of, 173. 
Teeth, syphilitic, 572. 
Telangiectasis, 621. 
Telangiectatic carcinoma, 669. 
of breast, 708. 
Temperature in tetanus, 433. 
reduced after nerve-injury, 
410. 
Tenasynite crepitante, 394. 
Tendo Achillis, division of, 
346. 
patellae, bursa of, 401. 
Tendons, 391. 
bursae with, 396. 
of peroneus longus, 403. 
dislocation of, 393. 
inflammation of, 394. 
repair of, 391. 
rupture of, 393. 
biceps, 393. 
rectus femoris or tendo- 
patellae, 393. 
syphilis of, 555. 
wounds of, 391. 
Tenotomy, 333. 
accidents following, 336. 
anaesthetics in, 346. 
artery wounded in, 350. 
entrance of air avoided in, 
335. 
for finger-flexion, 375. 
for strabismus, 182. 
history of, 333. 
in ear-disease, 318. 
of extensor longus digitorum, 
• 347. 
proprius pollicis, 347. 
of flexor longus digitorum, 
349. 
of peroneus tertius, 347. 
of plantar fascia, 346. 
of sterno-mastoid, 379. 
of tendo Achillis, 335. 
of tibialis anticus, 347. 
posticus, 349. 
steps of operation, 334. 
subcutaneous, 334. 
healing of wound in, 334. 
operations suggested by, 
334. 
Testis, syphilis of, 559. 
Test-types, 144. 
Tetanus, 431. 
age affecting mortality of, 
435. 
causes of, 434. 
atmospheric changes as, 
434. 
circulation in, 433. 
climate affecting, 434. 
diagnosis from hydrophobia, 
437. 
from strychnia-poison, 437. 
duration of, 433. 
influence of particular inju- 
ries on, 435. 758 
INDEX TO VOLUME III. 
Tetanus, mortality of, conditions 
affecting, 435. 
general, 436. 
nerve-stretching for, 417. 
pathology of, 437. 
period of development after 
injury, 435. 
reflex irritability in, 433. 
respiration in, 433. 
secretions in, 433. 
symptoms of, 432. 
temperature in, 433. 
treatment of, 438. 
varieties of, 431. 
Thecitis, 394. 
Thermo-cautery in tracheotomy, 
84. 
Thighs, adduction of, 352. 
flexion of, 353. 
Thompson’s astigmatic detector, 
283. 
Thoracic duct, absence of, 444. 
dilatation and rupture of, 447. 
irregularities of, 444. 
wounds of, 446. 
Thudichum douche, 109. 
Thumb, bursae of, 400. 
Thymus gland displaced in 
tracheotomy, 82. 
hereditary syphilis of, 573. 
Thyroid gland, abscess of, 491. 
carcinoma of, 503. 
extirpation of, 499. 
goitre in, 490. 
hypertrophies of, 493. 
vascular enlargement of, 492. 
veins, in tracheotomy, 79. 
Thyroiditis, suppurative, 491. 
Thyro-arytenoids, paralysis of, 
56. 
Thyro-epiglottic muscles, paral- 
ysis of, 55. 
Thyrotomy, 76. 
crieo-, 68, 77. 
for tumors of larynx, 68. 
Tibial nerve, anterior, stretch- 
ing of, 732. 
Tinea circinata, 479. 
Tinnitus aurium, 327. 
gastric, 328. 
toxic, 328. 
Toe-nail, incurvated, 486. 
Toes, absence of, 365. 
flexed, hammer, or talon, 367. 
hypertrophy of, 367. 
overlapping of, 366. 
supernumerary, 365. 
webbed, 365. 
Tongue, fleshy, obstructing lar- 
yngoscopy, 19. 
Tonsil, chancre on, 523. 
enlarged, obstructing laryn- 
goscopy, 19. 
Torticollis, 376. 
apparatus for, 378. 
carious, 379. 
choreic, 379. 
electricity in, 722. 
from muscular atony, 379. 
paralytic, 379. 
posterior, 379. 
rheumatic, 377.1 
spinal accessory nerve, divis- 
ion for, 380. 
stretching for, 380. 
sternum and clavicle changed 
by, 377. 
tenotomy for, 379. 
Torticollis, treatment of, 377. 
typical, 378. 
Toynbee’s ear speculum, 294. 
Trachea, fistula in, 44. 
after tracheotomy, 83. 
foreign bodies in, 44. 
leeches in, 45. 
opening the, 78. 
stenosis or stricture of, 42. 
surgical relations to larynx, 
75. 
syphilis of, 547. 
tumors of, 70. 
Tracheal canula in bronchi, 45. 
catheters in stenosis, 43. 
tubes in oedema of glottis, 43. 
Tracheo-laryngotomy for tu- 
mors, 68. 
Tracheotomy, 78. 
after-treatment of, 83. 
by electro- and thermo-cau- 
tery, 84. 
complications and difficulties 
in, 81. 
for foreign bodies in air-pas- 
sages, 49. 
emphysema in, 79, 82. 
hemorrhage in, 81. 
secondary, 82. 
incision, form of, 81. 
length of, 80. 
in croup, 36. 
in laryngitis, 23. 
syphilitic, 31. 
in laryngo-tracheitis, 36. 
in stenosis of larynx and 
trachea, 42. 
instruments for, 78. 
introduction of tube in, 80. 
in tubercular laryngitis, 29. 
mirror used in wound of, 21. 
misplaced canula in, 82. 
rapid method of, 81. 
suffocation in, 82. 
Trachoma, 194. 
Transfusion for epistaxis, 103. 
Tremulous iris, 220. 
Trephining of mastoid, 322. 
Trichiasis, 155. 
Trichina spiralis in man, 388. 
Trichinosis, 388. 
Trismus, 432. 
nascentium, or neonatorum, 
432, 434. 
Trumpets for ear, 330. 
Tubercle, painful subcutaneous, 
624. 
Tubercular laryngitis, 28. 
syphilis, 537, 553. 
treatment of, 569. 
Tuberculosis of choroid, 232. 
of retina, 242. 
Tubular adenoma, 631. 
epithelioma, 663. 
Tumors, adenomata as, 629. 
angeiomata as, 621. 
article on, 579. 
benign, 585. 
typical, 597. 
carcinomata as, 650. 
classification of, 580, 585. 
cystic, 585. 
differentiation of benign and 
malignant, 580. 
enchondromata as, 607. 
epitheliomata as, 657. 
fibromata as, 600. 
gliomata as, 648. 
Tumors, inflammatory fungoid, 
649. 
lipomata as, 597. 
lymphangiomata as, 618. 
lymphomata as, 615. 
myomata as, 605. 
myxomata as, 619. 
neuromata as, 622. 
of auricle, 301. 
sebaceous, 303. 
of choroid, 233. 
of conjunctiva, 200. 
of cornea, 216. 
of external auditory canal, 
308. 
of eyelids, 167. 
sebaceous, 168. 
of frontal sinuses, 118. 
of iris, 223. 
of larynx, 60. 
of mammae, 691. 
of nerves, 442. 
of nose, osseous, 131. 
sebaceous, 95. 
of retina, 241. 
of sclerotica, 219. 
of skin, 478. 
of trachea, 70. 
osteomata as, 612. 
papillomata as, 625. 
sarcomata as, 633. 
scirrhus, 663. 
theories of origin of, 582. 
author’s, 583. 
Tuning-fork in ear-disease, 289. 
Tutamina, affections of, 151. 
Tympanum incised in ear-dis- 
ease, 318. 
involved in ear-disease, 315. 
mirrors for, 321. 
paracentesis of, 318. 
Typical tumors, 597. 
U. 
Ulcer, hypopyon, 210. 
of cornea, 208. 
of foot, multiple, 364. 
perforating, 365. 
of nipple, 681. 
of nose, perforating the sep- 
tum, 120. 
rodent, 98. 
syphilitic, 100. 
Ulcus ulcerans, 98. 
Ulnar nerve, stretching of, 730. 
Ungual matrix, corneous growth 
from, 485. 
inflamed, 484. 
Upper extremity, paralysis of, 
368. 
rachitic curvatures of, 368. 
spasm of, 368. 
Urethra, chancre in, 522. 
electrolysis for stricture of, 
724. 
Uterus, polypus of, 631. 
syphilis of, 561. 
y. 
Varicelliform syphilide, 534. 
Varix of conjunctiva, 203. 
of lymph-vessels, 448. 
Vascular cysts, 593. 
enlargement of thyroid, 492. INDEX TO VOLUME III. 
759 
Vascular growths of retina, 242. 
Vegetations, syphilitic, in lar- 
ynx, 30. 
Venous cysts, 591. 
Verruca, 466. 
Vertigo, aural, 327. 
Vesicular syphiloderm, 534. 
Vitiligo, 482. 
Vitreous humor, cysticercus in, 
274. 
hemorrhage into, 274. 
inflammation of, 273. 
muscse volitantes formed in, 
275. 
opacities of, 274. 
Vomiting, ear-, 329. 
W. 
Waldau cataract operation, 266. 
Warts, 466. 
of auricle, 303. 
of conjunctiva, 201. 
Warts of eyelids, 169. 
of nose, 93. 
syphilitic, of larynx, 30. 
Weak ankle, 362. 
Webbed fingers, 371. 
toes, 365. 
Wen, 588. 
Whitlow, 487. 
Wild hairs, 155. 
Wilde’s ear speculum, 292. 
Windpipe, opening of, 75. 
Wolfe cataract operation, 267. 
Woman, bubo in, 513. 
chancroid in, 517. 
Worm, Guinea-, 480. 
Wounds of aponeuroses, punc- 
tured, 404. 
of eyebrows, 151.* 
of eyelids, 152. 
of frontal sinuses, 117. 
of lymph-vessels, 447. 
of muscles, 381. 
of nails, 483. 
of nerves, 407. 
Wounds of nose, 101. 
of sclerotica, 217. 
of tendons, 391. 
of thoracic duct, 446. 
Wry-neck, 376. 
X. 
Xerophthalmia, 199. 
Xerosis, 199. 
Y. 
Yaws, 477. 
Yielding bones, genu valgum 
from, 355. 
Z. 
Zonular cataract, 254. 
treatment of, 270. GENERAL INDEX. 
THE VOLUMES ARE INDICATED BY ROMAN NUMERALS. 
A. 
Abdomen, contusions of, i. 265, 
430. 
diseases of, i. 475. 
dropsy of, i. 476. 
T-bandage of, i. 58. 
tapping of, i. 478. 
uterus removed through, ii. 
780. 
wounds of, i. 429, 431, 440. 
Abdominal aorta, aneurism of, 
i. 718. 
ligation of, i. 786. 
dropsy, i. 476. 
nephrectomy, ii. 714. 
nephrotomy, ii. 713. 
section, i. 429. 
in extra-uterine pregnancy, 
ii. 834. 
spaying, ii. 785. 
tourniquet, i. 225. 
walls, rupture of, i. 433. 
weakness of, i. 552. 
Abortion in renal colic, ii. 707. 
Abrasion, i. 169. 
Abscess, acute, ii. 90, 96, 100. 
alveolo-dental, ii. 928. 
article on. i. 157. 
cervical, ii. 881. 
chronic, i. 157, 165. 
cold, i. 165. 
constitutional effects of, i. 167. 
diagnosis of, i, 157. 
from aneurism, i. 157, 657, 
697. 
from encephaloid, i. 158. 
from fatty tumor, i. 158. 
from hernia, i. 158, 159. 
gluteal and femoral, ii. 882. 
iliac, ii. 882. 
lumbar, i. 156, ii. 882. 
metastatic, i. 127. 
of antrum, ii. 957. 
of areola, iii. 682. 
of auricle, iii. 307. 
of bladder, ii. 532. 
of bone, i. 1055. 
of breast, iii. 687. 
of cornea, iii. 206. 
of eyelid, iii. 153. 
of jaw, ii. 924, 950. 
of kidney, ii. 701. 
of labium, ii. 717. 
of liver, i. 451. 
of nasal septum, iii. 120. 
of ovary, ii. 783. 
of palate, hard, ii. 978. 
soft, ii. 983. 
of parotid, ii. 997. 
Abscess of prostate, ii. 497. 
of thyroid gland, iii. 491. 
of tongue, ii. 909. 
of tonsil, ii. 992. 
palmar, i. 611. 
palpebral, iii. 154. 
peri-anal, i. 535. 
perinephritic, ii. 701. 
from wounds, i. 460. 
peri-rectal, i. 535. 
peri-urethral, ii. 468. 
phlegmonous, i. 161. 
psoas, ii. 882. 
pulmonary spinal, ii. 882. 
retro-oesophageal, ii. 1018. 
retropharyngeal, ii. 1008. 
scrofulous, i. 165, ii. 160, 881. 
spinal, ii. 872, 881. 
sublingual, ii. 909. 
Absorption in abscess, i. 155. 
in bone, i. 824, 1085. 
of callus, i. 851. 
of pus, i. 155. 
Accidents during and after oper- 
ations, ii. 276. 
Accommodation, anomalies of, 
iii. 275. 
Acetabulum, fractures of, i. 968. 
diagnosis of, i. 970, ii. 93. 
necrosis of, ii. 186. 
perforation of, ii. 167, 170. 
Achromatopsia, iii. 248. 
Acne, iii. 588. 
rosacea, iii. 93. 
tarsi, iii. 154. 
Acromio-clavicular joint, arthri- 
tis of, ii. 198. 
Acromion, fractures of, i. 913. 
Acupressure, i. 228, 231, 706. 
for aneurism, i. 563. 
Acupuncture, ii. 264. 
Addison’s keloid, iii. 470. 
Adduction of thighs, iii. 352. 
Adenitis, iii. 451. 
Adenocele, iii. 700. 
Adenoid growth, iii. 630. 
of uterus, ii. 774. 
Adenoma, iii. 629. 
follicular or tubular, iii. 631. 
of eyelid, iii. 169. 
of larynx, iii. 63. 
of lip, ii. 893. 
of mamma, iii. 700. 
of rectum, i. 521. 
of soft palate, ii. 983. 
of spermatic cord, ii. 558. 
papillary, of bladder, ii. 548. 
Adeno-sarcoma of submaxillary 
gland, ii. 995. 
Adhesions in phimosis, ii. 428. 
Adhesions, ruptured, in anchy- 
losis, ii. 143. 
Adhesive inflammation, i. 316. 
plaster, i. 224. 
for fractured clavicle, i. 
906. 
for fractured ribs, i. 894. 
for ulcers, i. 183. 
for umbilical hernia, i. 600. 
for wounds, i. 244. 
Adipose tumor, i. 158. 
diagnosis from hernia, i. 589, 
597, 600. 
of back, ii. 838. 
of scrotum, ii. 520. 
of vulva, ii. 722. 
Adynamia of bladder, ii. 540. 
.ZEsthesiometer, i. 38. 
Air, entrance of, into veins, i. 
395, 626. 
organisms in, i. 44, 45. 
Air-passages, foreign bodies in, 
iii. 44. 
wounds of, i. 394. 
Albinism, iii. 219. 
Albugo, iii. 211. 
Albumen in urine, ii. 618. 
Albuminuria, retinitis in, iii. 
237. 
Alcohol causing aneurism, i. 
653. 
atheroma, i. 644. 
Alopecia, iii. 481. 
areata, iii. 489. 
Alveolar sarcoma, iii. 638. 
A1 veolo-dental abscess, ii. 928. 
Alveolus broken away, ii. 936. 
fracture of. i. 879. 
Amaurosis, iii. 246. 
Amblyopia, iii. 245. 
hysterical, iii. 248. 
Amputation, ii. 293. 
after-dressing of, ii..316. 
after excision, ii. 212. 
after hospital gangrene, i. 196, 
antiseptics in, ii. 315. 
artificial limbs after, ii. 327 
371. 
circumstances demanding, ii, 
293. 
comparison of methods of, ii, 
307. 
complications after, ii. 317. 
drainage-tube in, ii. 314. 
for aneurism, i. 668, ii. 296. 
for compound luxations, ii 
29, 66, 76, 80, 115, 120. 
for deformities, ii. 296. 
for frost-bite, ii. 422. 
for gunshot wounds, i. 306. 762 
GENERAL INDEX. 
Amputation for mortification, 
i. 196, ii. 30, 296. 
for strumous joints, ii. 152, 
190, 203. 
hemorrhage after, ii. 318, 320. 
history of, ii. 298. 
intra-uterine, ii. 326. 
musculo-tegumentary, ii. 304. 
quadrangular, ii. 306. 
semi-, ii. 305. 
operation of, ii. 309. 
period, intermediary, ii. 297. 
primary, ii. 296. 
secondary, ii. 297. 
re-, ii. 326. 
simultaneous, ii. 324. 
statistics of, ii. 315, 328. 
tegumentary, ii. 300. 
Amputations, special, ii. 333. 
above shoulder, ii. 350. 
at ankle-joint, ii. 358. 
at elbow-joint, ii. 342. 
for shot wound, i. 310. 
at hip-joint, ii. 372. 
at knee-joint, ii. 365. 
for shot wound, i. 314. 
at shoulder-joint, ii. 346. 
for shot wound, i. 307. 
author’s, of foot, ii. 356. 
Chopart’s, ii. 357. 
Dupuytren’s, ii. 347. 
Hey’s, ii. 356. 
Larrey’s, ii. 346. 
Lisfranc’s, ii. 348. 
metacarpo-phalangeal, ii. 335. 
metatarso-phalangeal, ii. 352. 
of arm, ii. 344. 
for shot wound, i. 307. 
of cancerous breast, iii. 714. 
of fingers, ii. 333. 
of foot, ii. 353. 
of forearm, ii. 341. 
for shot wound, i. 310. 
of hand, ii. 338. 
of leg, ii. 362. 
of little finger, ii. 337. 
of metacarpal bones, four of, 
ii. 337. 
with digits, ii. 336. 
of thigh, ii. 368. 
of thumb, ii. 336. 
and metacarpal bone, ii. 
336. 
of toes, ii. 352. 
of tongue, ii. 916. 
of uterus, inverted, ii. 765. 
Pirogoff’s, ii. 360. 
Syme’s, ii. 358. 
Teale’s, ii. 306. 
Vermale’s, ii. 304. 
Wharton’s, ii. 306. 
Amyelinic neuroma, iii. 622. 
Amyloid disease of arteries, i. 
641. 
of conjunctiva, iii. 204. 
of eyelid, iii. 169. 
of lymph-glands, iii. 453. 
Anaesthesia of larynx, iii. 53. 
of pharynx, ii. 1003. 
respiratory, ii. 290. 
retinal, iii. 247. 
Anaesthetics, article on, ii. 280. 
compared, ii. 290. 
contra-indications for, ii. 283. 
general, ii. 283. 
in croup, iii 40. 
local, ii. 291. 
precautions with, ii. 282. 
Anal fistula, i. 536, 540. 
speculum, i. 503. 
Anasarca of scrotum, ii. 518. 
Anastomosis of arteries, i. 775. 
Anatomical tubercle, i. 271. 
Anatomy, morbid, of. traumatic 
fever, ii. 389, 391. 
of joints, ii. 130. 
of lachrymal passages, iii. 
174. 
surgical, of axillary artery, i. 
767, 769. 
of femoral hernia, i. 593, 
786. 
Anchylosis, ii. 140. 
after burns, ii. 416. 
after fractures, i. 817, 821, ii. 
141. 
false, ii. 141. 
massage in, iii. 744. 
in coxalgia, ii. 170, 174. 
in Pott’s disease, ii. 877. 
of crico-arytenoid juncture, 
iii. 59. 
operations for, ii. 145. 
Aneurism, i. 647. 
amputation in, i. 668, ii. 
296. 
arterio-venous, i. 647, 684, 
713, ii. 367. 
by anastomosis, i. 647, iii. 
621. 
circumscribed, i. 683. 
cirsoid, i. 615, 647. 
compression in, i. 662, 669, 
671, 674, 699. 
diagnosis from abscess, i. 157, 
657, 697. 
from encephaloid, i. 659. 
diffused, i. 681, 717. 
direct, i. 647, 684. 
dissecting, i. 639> 647, 680. 
electrolysis for, iii. 723. 
false, i. 647, 680. 
circumscribed, i. 683. 
fusiform, i. 648. 
hernial, i. 647. 
intermediate, i. 647. 
interparietal, i. 639. 
intraorbital, i. 709, 713. 
ligation in, i. 662, 664, 669, 
694, 700. 
mortification of, i. 667. 
rupture of, i. 666. 
sac of, i. 648. 
sacculated, i. 648, 651. 
traumatic, i. 647, 681. 
treatment of, i. 661, 683. 
methods compared, i. 679. 
true, i. 647. 
varicose, i. 647, 684. 
Aneurism of special vessels, i. 
686, 733. 
aorta, i. 680. 
abdominal, i. 718. 
thoracic, i. 686. 
axillary, i. 713. 
brachial, i. 717. 
carotid, i. 696. 
femoral, i. 727. 
gluteal, i. 779. 
iliacs, i. 723. 
innominate, i. 690. 
intracranial, i. 707. 
intraorbital, i. 709. 
ischiatic, i. 779. 
palmar arch, i. 718. 
plantar, i. 733. 
Aneurism, popliteal, i. 730. 
subclavian, i. 703. 
tibial, i. 732. 
vertebral, i. 707. 
Aneurismal goitre, iii. 493. 
varix, i. 647, 684. 
Angeioleucitis, iii. 445. 
diagnosis from erysipelas, ii. 
408. 
Angeiolithic sarcoma, iii. 644. 
Angeioma, i. 615, iii. 621. 
arterial, i. 615. 
electrolysis for, iii. 724. 
of areola, iii. 682. 
of auricle, iii. 303. 
of back, ii. 839. 
of conjunctiva, iii. 203. 
of external auditory canal, 
iii. 309. 
of gums, ii. 922. 
of labium, i. 624. 
of larynx, iii. 62. 
of lip, ii. 892. 
of muscle, iii. 389. 
of tongue, i. 624, ii. 911. 
treatment of, i. 616, 620, 
venous, i. 618. 
Animal ligatures, i. 236. 
in amputations, ii. 313. 
in ovariotomy, ii. 807. 
Animals, foot and mouth dis- 
ease of, i. 275. 
poisoning from, i. 271. 
Animation, suspended, iii. 84. 
Anions, iii. 723. 
Ankle, amputation at, i. 314, ii. 
358. 
disease of, ii. 190. 
dislocations of, ii. 116. 
excision of, i. 314, ii. 241. 
reflex, ii. 848. 
Ankles, weak, iii. 362. 
Ankyloblepharon, iii. 161. 
Anodynes in exhaustion, ii. 277. 
Anomalies of accommodation, 
iii; 275. 
Anosmia, iii. 134. 
Anteflexion of uterus, ii. 759. 
Anterior crural nerve, stretch- 
ing of, iii. 732. 
tibial nerve, stretching of, iii. 
732. 
Anteversion of uterus, ii. 758. 
Anthrax, ii. 399. 
bacteria, i. 272. 
from animals, i. 271. 
of lip, ii. 892. 
Antiseptics in amputations, ii. 
315. 
in excisions, ii. 212. 
in ovariotomy, ii. 806. 
in wounds, i. 302. 
of joints, ii. 135. 
ligatures in, i. 236. 
Antracele, ii. 958. 
Antrum, affections of, ii. 957. 
cysts in, ii. 939. 
Anus, abscess about, i. 535. 
artificial, i. 448, 462, 464. 
condyloma, of, i. 509, iii. 540. 
diseases of, i. 502. 
fissure of, i. 512. 
fistula in, i. 536. 
itching of, i. 509. 
loss of co-ordination of mus- 
cles of, i. 511. 
malformations of, i. 504. 
prolapse of, i. 516. GENERAL INDEX. 
763 
Anus, pruritus of, i. 509. 
ulcers of, i. 522. 
wounds of, i. 472. 
Aorta, aneurism of, i. 686, 690, 
718, 721, 783. 
wounds of, i. 422. 
Aphasia from brain-injury, i. 
374. 
Aphonia, i. 402. 
electricity for, iii. 722. 
Aphthous ulcer of tongue, ii. 
910. 
Aplastic lymph, i. 111. 
Aponeuroses, affections of, iii. 
403. 
Approximation of wounds, i. 
498. 
Arachnoid, clot in, i. 355. 
Aranese, wounds by, i. 284. 
Arcus senilis, iii. 212. 
Areola, affections of, iii. 682. 
Arm, amputation of, i. 308, ii. 
344. 
avulsion of, ii. 351. 
wounds of, i. 610. 
Arrest of hemorrhage, i. 215, 
219, 255, 259, 264. 
from stump, ii. 318. 
Arrow-wounds, i. 364. 
Arsenical poisoning, ii. 1033. 
Arterial varix, i. 615. 
Arteries, affections of, i. 638. 
amyloid change in, i. 646. 
aneurism of, i. 647, 653. 
angeioma of, i. 615. 
atheroma of, i. 642. 
calcified, i. 643. 
inflammation of, i. 640. 
ligation of, i. 232, 734. 
mortification of, i. 656. 
syphilis of, iii. 563. 
torsion of, i. 226. 
ulceration of, i. 645. 
wounds of, i. 639. 
Arterio-venous aneurism, i. 647, 
684, 713. 
Arteritis, i. 640. 
Arthritis, ii. 150. 
constitutional, ii. 154. 
dry or osteo-, ii. 154. 
rheumatoid, ii. 154. 
strumous, ii. 154. 
of ankle-joint, ii. 190. 
of calcaneo- and scapho-as- 
tragaloid joint, ii. 193. 
of elbow-joint, ii. 200. 
of hip-joint, ii. 162. 
of knee-joint, ii. 186. 
of metatarso - phalangeal 
joints, ii. 194. 
of occipito-atloid and atlo- 
axoid joints, ii. 195. 
of sacro-iliac joint, ii. 196. 
of shoulder-joint, ii. 199. 
of sterno- and acromio-cla- 
vicular joints, ii. 198. 
of tarso-metatarsal joints, 
ii. 194. 
of wrist and carpal joints, 
ii. 202. 
suppuration in, ii. 152. 
tissue-changes in, ii. 149, 152. 
Articulation after ablation of 
tongue, ii. 919. 
fractures of, i. 820. 
new, after luxations, ii. 21. 
Artificial anus, i. 448, 464. 
in hernia, i. 462. 
Artificial eyes, iii. 286. 
limbs, ii. 327, 371. 
respiration, i. 626, iii. 87. 
electricity for, iii. 722. 
teeth in stomach, i. 435. 
Ascarides, pruritus from, i. 509. 
urine, incontinence of, from, 
ii. 545. 
Ascites, i. 476. 
diagnosis from ovarian drop- 
sy, i. 477, ii. 704. 
Asphyxia, i. 395, 867, ii. 288, 
290, iii. 84. 
Aspiration of abdomen, i. 478. 
of abscess, i. 168. 
of cataract, iii. 269. 
of joints, ii. 162, 188, 202. 
of pericardium, i. 426. 
of retained menses, ii. 735. 
of spinal abscess, ii. 883. 
of thorax, i. 419. 
Astigmatism, iii. 280. 
Astragalo-scaphoid arthritis, ii. 
193. 
Astragalus, ablation of, ii. 29, 
123. 
dislocation of, ii. 121. 
excision of, i. 1041, ii. 255. 
fracture of, i. 1040. 
Atheroma, i. 642, 644. 
aneurism from, i. 653. 
consequences of, i. 645. 
Atlo-axoid arthritis, ii. 195. 
dislocations, ii. 44. 
Atomization, i. 132. 
Atony of bladder, ii. 540. 
Atresia of vagina, ii. 733. 
Atrophy after luxations, ii. 21, 
32. 
after spine-injury, ii. 857. 
in osteo-arthritis, ii. 156. 
of bladder, ii. 534. 
of bone, i. 1084. 
of cranial bones, i. 327. 
of mamma, iii. 683. 
of muscles, iii. 386. 
in club-foot, iii. 340. 
of neck of femur, i. 978. 
of nerves, iii. 439. 
of optic nerve, iii. 244v 
of ovaries, ii. 783. 
of testicle, ii. 597. 
of tongue, ii. 906. 
of tonsil, ii. 991. 
of veins, i. 631. 
Atropia-poisoning, ii. 1034. 
Aural vertigo, iii. 327. 
Auricle, affections of, iii. 299. 
tumors of, iii. 301. 
Auricularis magnus nerve, 
stretching of, iii. 728. 
Auscultation, i. 656. 
Auto-laryngoscopy, iii. 20. 
Avulsion of arm, with scapula 
and clavicle, ii. 351. 
Axillary artery, aneurism of, i. 
713. 
ligation of, i. 765, ii. 65. 
pad, i. 906. 
veins, rupture of, ii. 65. 
B. 
Bacillus, forms of, i. 45, 272. 
of anthrax, i. 272. 
Back, affections of tissues of, ii. 
837. 
Back, contusions of, ii. 850. 
tumors of, ii. 838. 
Bacteria, forms of, i. 45. 
in anthrax, i. 272. 
in gonorrhoea, ii. 461. 
of urea, i. 45. 
Balanitis, ii. 425, 462, 467. 
Balano-posthitis, ii. 467. 
Baldness, iii. 481. 
Balls, i. 291. 
deflection of, i. 293. 
removal of, i. 299, 302. 
slow, i. 295. 
windage of, i. 295. 
Bandages, i. 56, 65, 72, 75. 
Barton’s, i. 74, 883, ii. 37. 
Esmarch’s, i. 674. 
Gibson’s, i. 74. 
handkerchief, i. 78. 
mortification from tight, i. 
193. 
recurrent, i. 76. 
roller, i. 62. 
spica, i. 69. 
Velpeau’s, i. 78, ii. 47. 
Bandy-leg, iii. 359. 
Barbadoes leg, iii. 473. 
Barton’s bandage, i. 74, 883, ii. 
37. 
fracture, i. 943. 
handkerchief, i. 87. 
Basedow’s disease, iii. 492. 
Battey’s operation, ii. 785. 
Bavarian splint, i. 1034. 
Bed, fracture-, i. 810-812. 
Bedbug-bites, i. 289. 
Bed-sores, i. 188, ii. 45, 856. 
Bee-stings, i. 289. 
Belladonna-poisoning, ii. 1034. 
Biceps cubiti, rupture of long 
tendon of, iii. 393. 
Bichloride of methylene, ii. 289. 
Bilateral lithotomy, ii. 688. 
Bile in urine, ii. 623. 
Bilharzia haematobia, ii. 538. 
Biliary fistula, i. 461. 
Binders’- board splint, i. 812, 
813, 1030, ii. 86. 
Bites of animals, i. 280. 
of insects, i. 284. 
of reptiles, i. 286. 
of spiders, i. 284. 
Bladder, abscess of, ii. 532. 
adynamia of, ii. 540. 
atrophy of, ii. 534. 
catarrh of, ii. 528. 
congenital defects of, ii. 609. 
exstrophy of, ii. 611. 
fistulas of, ii. 536. 
gangrene of, ii. 533. 
hemorrhage from, ii. 537. 
hernia of, i. 608, ii. 610. 
hypertrophy of, ii. 533. 
inflammation of, ii. 526. 
inversion of, ii. 611. 
irritable, from gonorrhoea, ii. 
475. 
in female, ii. 828. 
neurosis of, ii. 534. 
paralysis of, ii. 540. 
electricity in, iii. 721. 
perforated in lithotrity, ii. 
661. 
stammering, ii. 511. 
supernumerary, ii. 610. 
suppuration of, ii. 532. 
syphilis of, iii. 561. 
tapping, ii. 512. 764 
GENERAL INDEX. 
Bladder, tubercle in, ii. 550. 
tumors of, ii. 546. 
ulceration of, ii. 532. 
varices of, ii. 537. 
wounds of, i. 468. 
Blebs, ii. 404, 418. 
Blepharitis ciliaris, iii. 154. 
Blepharospasm, iii. 164. 
Blindness, color-, iii. 248. 
simulated, iii. 249. 
Blind piles, i. 541. 
Blood, clot of, as haemostatic, i. 
215. 
concretions in kidney, ii. 640. 
cysts, iii. 591. 
dyscrasia, i. 188. 
extravasated in skull, i. 346. 
on nasal septum, iii. 120. 
in chambers of eye, iii. 227. 
in choroid, iii. 233. 
in inflammation, i. 92, 110. 
transudation of, i. 150. 
in urine, ii. 619. 
pus in, ii. 387. 
tumors, i. 371, ii. 837. 
Blood-vessels, affections of, i. 
615. 
closed by nature, i. 215. 
ligation of, i. 734. 
torsion of, i. 226. 
Bodies in air-passages, iii. 44. 
movable, in joints, ii. 127. 
Boil, ii. 397, 837. 
Bond’s splint, i. 950. 
Bone, abscess of, i. 1055. 
syphilitic, iii. 553. 
absorption of, i. 824. 
bulbous, ii. 321. 
death of, i. 189, 1050, 1060. 
excision of, ii. 206. 
inflammation of, i. 114, 1050. 
refracture of, i. 849. 
reproduced from periosteum, 
ii. 208. 
separation of dead, i. 1062. 
syphilis of, iii. 551, 569, 572. 
Bones, disease of, i. 615, 1046. 
fragile, i. 795, 1081. 
injuries of, i. 899. 
necrosis of, i. 189, 1060. 
soft, i. 1077. 
Boucneinia tropica, iii. 473. 
Bougie, oesophageal, ii. 1022. 
rectal, i. 526, 529. 
Bowels in spine-injury, ii. 855. 
obstruction of, i. 481. 
Bow-leg, iii. 359. 
Brain, abscess of, i. 328, 385. 
compression of, i. 349, 354. 
concussion of, i. 343. 
urine retained in, ii. 510. 
foreign bodies in, i. 364. 
fungus of, i. 369. 
inflammation of, i. 367. 
injured by fractures, i. 331. 
laceration of, i. 347. 
vibration of, i. 343. 
Bran dressing, i. 815, ii. 30. 
Breast, diseases of, iii. 679. 
See Mamma. 
Broad ligament, cyst in, ii. 812. 
hydrocele of, ii. 814. 
Bronchi, syphilis of, iii. 547. 
Bronehocele, iii. 490. 
Bronchotomy, iii. 75. 
by electro- and thermo-cau- 
tery, iii. 84. 
Bruises, i. 261. 
Bruit de soufflet, i. 697. 
in aneurism, i. 650, 719. 
in erectile growths, i. 659. 
Brush-burn, i. 257. 
Bubo in gonorrhoea, ii. 469, 739. 
with chancre, iii. 526. 
with chancroid, iii. 512, 517. 
Bubon d’einblee, iii. 513. 
Bulbous bone, ii. 321. 
Bullets, i. 291. 
of charpie, i. 53. 
Burns, ii. 412. 
anchylosis after, ii. 416. 
duodenal ulcer in, ii. 415. 
from sun, ii. 423. 
of eyelids, iii. 152. 
shock in, ii. 414. 
skin-grafting in, ii. 419. 
Bursa, article on, iii. 395. 
diagnosis from aneurism, i. 
730. 
of back, ii. 840. 
of special parts, iii. 398. 
on stump, ii. 323. 
over vertebra, ii. 840 
subcutaneous, iii. 395. 
tendinous, iii. 396. 
Bursitis, iii. 396. 
diagnosis from arthritis, ii. 
173, 200. 
Buttock, T-bandage of, i. 59. 
Button suture, i. 249. 
Butyroid tumor, iii. 692. 
C. 
Caecal hernia, i. 550. 
Caesarean section, ii. 820. 
hernia after, i. 604. 
Calcaneo-astragaloid arthritis, 
ii. 193. 
Calcaneum, bursa of, iii. 403. 
excision of, ii. 256. 
luxations of, ii. 124. 
Calcareous deposits in arteries, 
i. 643. 
in auricle, iii. 301. 
in testis, ii. 594. 
in urine, ii. 629. 
goitre, iii. 493. 
Calcification of penis, ii. 437. 
Calculus, biliary, i. 453. 
in parotid, ii. 998. 
in submaxillary gland, ii. 
996. 
in tonsil, ii. 985. 
nasal, iii. 105. 
salivary, i. 391, ii. 998. 
urinary, i. 469, ii. 629. 
construction of, ii. 632. 
diagnosis of, ii. 644. 
extraction of, ii. 650. 
in bladder, ii. 629. 
in females, ii. 693. 
in kidney, ii. 705. 
in prostate, ii. 505. 
in scrotum, ii. 520. 
in urethra, ii. 453. 
origin of, ii. 629. 
renal, ii. 705. 
sacculated, ii. 644. 
sounding for, ii. 642. 
spontaneous expulsion of, 
ii. 650. 
treatment of, ii. 648. 
vesical, i. 469, ii. 629. 
Callosities of skin, iii. 464. 
Callus, i. 803. 
in eoxalgia, ii. 170. 
in dislocations, ii. 22. 
in excisions, ii. 208. 
morbid changes of, i. 851. 
redundant, i. 851. 
sensitive, i. 852. 
union of adjacent bones by, i. 
803, 850. 
Canaliculi, obstructions of, iii. 
174. 
Cancer, article on, iii. 650. See 
Carcinoma. 
cylinders, iii. 651. 
epithelial, iii. 657. 
scirrhous, iii. 663. 
“ Cancer en cuirasse,” iii. 707. 
Cancroid, iii. 657. 
Cancrum oris, i. 192. 
Cantharides, urine retained 
from, ii. 511. 
Capillaries, varicose, i. 120. 
Capillary angioma, i. 617. 
varix, i. 617. 
Caput succedaneum, i. 323. 
Carbolic acid as a local anaes- 
thetic, ii. 292. 
Carbolized gauze, i. 48. 
ligature, i. 47, 48. 
Carbuncle, i. 271. 
article on, ii. 399. 
of lip, ii. 892. 
Carcinoma, article on, iii. 650. 
causes of, iii. 655. 
caustics in, iii. 675, 713. 
colloid, iii. 671. 
diagnosis of varieties of, iii. 
672. 
encephaloid, iii. 667. 
epithelial, iii. 657. 
excision of, iii. 677, 713. 
extension of, iii. 653. 
fatty, iii. 671. 
hemorrhage from, iii. 675. 
melanotic, iii. 671. 
metastasis in, iii. 654. 
of bladder, ii. 548. 
of choroid, iii. 233. 
of conjunctiva, iii. 202. 
of external auditory canal, iii. 
311. 
of iris, iii. 223. 
of jaw, lower, ii. 957. 
upper, ii. 961. 
of kidney, ii. 710. 
of labium, ii. 721. 
of lachrymal gland, iii. 172. 
of larynx, iii. 70. 
of lip, ii. 894. 
of mamma, iii. 704. 
early operations in, iii. 714. 
enlarged axillary glands in, 
iii. 714. 
excision of, iii. 713. 
prognosis in, iii. 710. 
recurrence of, iii. 706, 711, 
714. 
treatment of, iii. 712. 
of muscle, iii. 390. 
of nerves, iii. 443. 
of nose, iii. 133. 
of oesophagus, ii. 1019, 1025. 
of ovary, ii. 814. 
of parotid gland, ii. 998. 
of penis, ii. 432. 
of prostate, ii. 506. 
of rectum, i. 526, 532. 
of skin, iii. 478. GENERAL INDEX. 
765 
Carcinoma of soft palate, ii. 984. 
of spermatic cord, ii. 558. 
of submaxillary gland, ii. 995. 
of testicle, ii. 590. 
of thyroid gland, iii. 503. 
of tongue, ii. 912. 
of tonsil, ii. 993. 
of uterus, ii. 777. 
of vagina, ii. 737. 
operations forbidden in, iii. 
678. 
scirrhous, iii. 663. 
soft, iii. 667. 
telangiectatic, iii. 669. 
treatment of, iii. 673. 
Caries, amputation for, ii. 295. 
article on, i. 1050. 
in joint-disease, ii. 166, 190, 
192, 200, 202. 
of cranial bones, i. 327. 
of spine, ii. 869, 876. 
of teeth, ii. 927. 
syphilitic, iii. 552. 
Carnification, i. 1056. 
Carotid artery, common, aneu- 
rism of, i. 696. 
ligation of, i. 700, 740, ii. 
972. 
externa], aneurism of, i. 701. 
ligation of, i. 749, ii. 1001. 
internal, aneurism of, i. 702. 
ligation of, i. 755. 
Carpus, arthritis of, ii. 202. 
dislocation of, ii. 78, 80. 
fractures of, i. 702. 
ganglion of, iii. 399. 
Cartilages, degenerated, in 
joints, ii. 147. 
fracture of, i. 889. 
costal, i. 895. 
of ribs, dislocation of, ii. 39. 
excision of, ii. 227. 
fracture of, i. 895. 
resistance to aneurismal press- 
ure, i. 851. 
semilunar, displaced, ii. 114. 
Castration, ii. 598. 
Casts in urine, ii. 620. 
Cataract, iii. 254. 
aspiration or suction of, iii. 
269. 
congenital, iii. 254, 270. 
couching of, iii. 269. 
discission of, iii. 268. 
extraction of, iii. 257. 
flap, iii. 259, 264. 
linear, iii. 258, 265. 
modified linear, iii. 258, 
265. 
results of, iii. 271. 
forms of, described, iii. 254. 
reclination of, iii. 269. 
secondary, iii. 267. 
treatment of, iii. 256. 
lamellar, zonular, or con- 
genital, iii. 270. 
traumatic, iii. 270. 
Catarrh of bladder, ii. 528. 
of conjunctiva, iii. 186. 
of lachrymal sac, iii. 176. 
of middle ear, iii. 312. 
Catgut ligature, i. 47, 236. 
preparation of, i. 47. 
suture, i. 246. 
Catheter, ii. 551. 
encrusted, ii. 442. 
introduction of, ii. 552, 555. 
self-retaining, ii. 747. 
Catheterization, ii. 550. 
forced, ii. 512. 
in female, ii. 555. 
in male, ii. 550. 
of Eustachian tube, iii. 298. 
self-, ii. 543. 
syncope during, ii. 507, 555. 
Cations, iii. 723. 
Catoptric test for cataract, iii. 
256. 
Caustics in carcinoma, iii. 675, 
713. 
Cauterization, i. 225, ii. 205. 
for hemorrhoids, i. 546. 
for prolapsus ani, i. 519. 
Cautery, actual, i. 225, 546. 
electro- or galvano-, i. 225, 
iii. 725. 
Cavae, wounds of, i. 427. 
Cells, cancer, iii. 652. 
pus, i. 107, 121. 
wandering, i. 108. 
Cellulitis, diffuse, ii. 405. 
pelvic, ii. 817. 
peri-uterine, ii. 817. 
Cementum, exostosis on, ii. 937. 
Centipede-wounds, i. 285. 
Cerebral fungus, i. 369. 
symptoms in spine-injury, ii. 
857. 
syphilis, iii. 557. 
vibration, i. 344. 
Cerebro-spinal fluid, escape of, 
i. 338. 
Cerebrum, wounds of, i. 347. 
Cerumen, impacted, iii. 304. 
Cervical vertebrae, fracture of, 
i. 867. 
luxation of, ii. 41. 
Cervix uteri, elongated, ii. 780. 
lacerated, ii. 762. 
Chalazion, iii. 167. 
Chancre, iii. 507. 
concealed, ii. 469. 
contrasted with chancroid, iii. 
508. 
hard, iii. 518. 
bubo with, iii. 526. 
soft, iii. 510. 
treatment of, iii. 528. ♦ 
views concerning, iii. 507. 
with gonorrhoea, ii. 469. 
Chancroid, iii. 510. 
bubo with, iii. 512. 
in women, iii. 517. 
treatment of, iii. 514. 
Chap and crack of lip, ii. 890. 
Charbon, i. 271. 
Charpie, i. 52. 
Cheek, fissure of, ii. 903. 
Cheesy deposit in prostate, ii. 
506. 
pus, i. 166. 
Chemise, lithotomy, ii. 678. 
rectal, i. 549. 
Chemosis, iii. 204. 
Chest, drainage-tube in, i. 421. 
bandage of, i. 69, 73. 
fistulae of, i. 422. 
fractured bones of, i. 891. 
tapping of, i. 419. 
wounds of, i. 404, 407. 
hemorrhage in, i. 413. 
penetrating, i. 407, ii. 66. 
Chicken-breast, i. 1075. 
Chigoe, iii. 480. 
Chilblain, ii. 420. 
Child, lithotomy in, ii. 674, 693. 
Child, strumous nasal catarrh 
in, iii. 110. 
Chin sling, i. 61. 
Chloroform, ii. 286. 
compared with ether, ii. 290. 
Choked disk, optic, iii. 242. 
Chordee in gonorrhoea, ii. 460. 
Chorea, electricity in, iii. 723. 
from nerve-injury, iii. 429. 
of eyelids, iii. 165. 
of pharynx, ii. 1004. 
Choroid coat, detached, iii. 232. 
rupture of, iii. 233. 
tubercle of, iii. 232. 
tumors, iii. 233. 
Choroiditis, plastic, iii. 230. 
serous, iii. 229. 
suppurative, iii. 231. 
syphilitic, iii. 549, 574. 
Chronic abscess, i. 157, 165. 
ulcers, i. 180. 
Chylocele, iii. 450. 
Chyloderma, ii. 524. 
Cicatricial contraction, i. 321, 
ii. 416. 
stenosis of oesophagus, ii. 
1019. 
of pharynx, ii. 1012. 
Cicatrix, affections of, i. 320, ii. 
416. 
from electrolysis, iii. 724. 
in intestines, i. 486. 
Cicatrization, process of, i. 174, 
318, 320. 
spurious, i. 320. 
Ciliary muscle, affections of, iii. 
275. 
Circocele, ii. 562. 
Circular roller, i. 65. 
Circumcision, ii. 427. 
Circumclusion, i. 320, 661. 
Cirsoid aneurism, i. 615. 
Clavicle, dislocations of, ii. 46. 
excision of, ii. 49, 246. 
fracture of, i. 899. 
Clavus, iii. 465. 
Cleft in hard palate, ii. 979. 
Cleft palate, ii. 974. 
Clergyman’s sore throat, ii. 
1006. iii. 26. 
Clitoridectomy in epilepsy, ii. 
724. 
Clitoris, affections of, ii. 723. 
Clot as haemostatic, i. 215. 
organization of, i. 216. 
Club-foot, iii. 337. 
Club-hand, iii. 368. 
Coagulation of blood in aneu- 
rismal sac, i. 660. 
Cobra-bites, i. 287. 
Coccydynia, i. 964. 
Coccyx, dislocation of, ii. 88. 
excision of, i. 964, ii. 89. 
fracture of, i. 964. 
neuralgia of, i. 964, ii. 88. 
Coeliac axis, aneurism of, i. 722. 
Coitus, hymen preventing, ii. 
725. 
irritable testis from, ii. 595. 
penis fractured during, ii. 
436. 
Cold abscess, i. 165. 
action of, ii. 421. 
as haemostatic, i. 219. 
as local anaesthetic, ii. 291. 
in inflammation, i. 128. 
ulcers, i. 188. 
Colic, renal, ii. 707. 766 
GENERAL INDEX. 
Colles’s fracture of radius, i. 944. 
Collodion for wounds, i. 245. 
Colloid carcinoma, iii. 671. 
of breast, iii. 709. 
disease of choroid, iii. 233. 
Coloboma of choroid, iii. 232. 
of eyelids, iii. 166. 
of iris, iii. 219. 
Colon, excision of, i. 501. 
resection of, i. 450. 
stricture of, i. 486. 
wounds of, i. 444. 
Color-blindness, iii. 248. 
Colotomy, i. 498. 
Colpo-cystotomia, ii. 695. 
Coma, diagnosis of, i. 31. 
Comedones, iii. 588. 
Comminuted fractures, i. 293, 
797. 
amputation for, i. 305, ii. 294. 
Complicated dislocations, ii. 28. 
fractures, i. 796. 
Compound dislocations, ii. 28. 
fractures, i. 796. 
of leg, i. 1038. 
of skull, i. 342. 
Compresses, i. 54, 222, 243. 
Compression as a haemostatic, i. 
221. 
in cancer, iii. 674. 
in inflammation, i. 135, 137, 
147. 
in massage, iii. 742. 
of brain, i. 349, 354. 
of spinal cord, ii. 845. 
Concealed chancre, ii. 469. 
hemorrhage, i. 297. 
hernia, i. 585. 
wounds, i. 261. 
Concretions complicating lithot- 
omy, ii. 675. 
in prepuce, ii. 425. 
in urethra, ii. 453. 
Meibomian, iii. 203. 
simulating calculus, ii. 644. 
Concussion of brain, i. 343, ii. 
858. 
of joints, ii. 132. 
of spinal cord, ii. 842. 
Condyloma, i. 509, iii. 540. 
Congestion in inflammation, i. 
106. 
of retina, iii. 234. 
Congestive abscess, i. 165. 
Conical stump, ii. 321. 
trephine, i. 376. 
Conjunctiva, congestion of, iii. 
185. 
in spine-injurjq ii. 856. 
inflammation of, iii. 186. 
tumors of, iii. 200. 
Conjunctivitis, catarrhal, iii. 
186. 
exanthematous, iii. 194. 
gonorrhoeal, iii. 190. 
granular, iii. 194. 
phlyctenular, iii. 192. 
purulent, iii. 188. 
Connective-tissue corpuscles, i. 
113, 318. 
Continued sutures, i. 247, 447. 
Contraction of cicatrix, i. 321, 
ii. 419. 
of fingers, iii. 372. 
of prepuce, ii. 426. 
of punctured tendon, i. 266. 
Contractures from nerve-injury, 
iii. 429. 
Contused wounds, i. 256, 261, 
iii. 382. 
Contusions, i. 261. 
of abdomen, i. 265, 430. 
of arteries, i. 638. 
of back, ii. 850. 
of cranium, i. 326. 
of eyelids, iii. 151. 
of face, i. 386. 
of joints, ii. 131. 
of labia, ii. 716. 
of muscles, iii. 382. 
of nerves, iii. 407. 
of penis, ii. 424. 
of scalp, i. 322. 
of scrotum, ii. 515. 
Convulsions in child, from 
teeth, ii. 923. 
in phimosis, ii. 427. 
in spine-injuries, ii. 855. 
Copaiba rash, ii. 466. 
Coracoid, fracture of, i. 915. 
Cornea, affections of, iii. 204. 
opacities of, iii. 211. 
tumors of, iii. 216. 
ulcers of, iii. 208. 
Corneous growth from nail, iii. 
485. 
Corns, iii. 465. 
Cornua, iii. 467. 
Corona Veneris, iii. 533. 
Coronoid, ulnar, fractured, i. 
956. 
Corps fibreux, iii. 630. 
Corpus spongiosum, wounds of, 
ii. 439. 
Corpuscles, blood-, in inflam- 
mation, i. 107. 
clot organized by, i. 216. 
connective-tissue, i. 113, 318. 
mucus, i. 151. 
pus, i. 113. 
transudation of, i. 108. 
Corrosive sublimate poisoning, 
ii. 1033. 
Costal cartilages, fracture of, i. 
895. 
luxations, ii. 38. 
Cough, ear-, iii. 329. 
in anal fissure, i. 513. 
Cowper’s glands, inflamed, ii. 
467. 
Coxalgia, article on, ii. 162. 
Coxo-femoral amputation, ii. 
372. 
anchylosis, lordosis from, ii. 
868. 
dislocation, ii. 89. 
excision, ii. 228. 
Cramp of jaw, ii. 38. 
Cranial bones, inflamed, i. 327. 
separation of sutures of, i. 
343. 
nerves, injury of, i. 366. 
Craniotabes, i. 1085. 
Cranium, extravasated blood 
in, i. 351. 
fractures of, i. 331. 
injuries of, i. 326. 
sequelae of, i. 367, 375. 
Crepitus in arthritis, ii. 152. 
in dislocations, ii. 20. 
in fracture, i. 800. 
Crico-arytenoid juncture, an- 
chylosis of, iii. 59. 
muscles, paralysis of, iii. 57. 
Crico-thyroid muscles, paralysis 
of, iii. 56. 
Crotalus-bites, i. 287. 
Croup, iii. 33. 
anaesthetics in, ii. 283. 
spasmodic, iii. 54. 
Crural nerve, stretching of, iii. 
732. 
Crush of head, i. 361. 
Crushing of piles, i. 447. 
Cryptorches, virility of, ii. 603. 
Crystalline lens, affections of, 
iii. 253. 
cataract of, iii. 254. 
Cuboid bone, excision of, ii. 260. 
luxation of, ii. 125. 
Cuneiform bones, excision of, ii. 
260. 
luxation of, ii. 125. 
Cupping, i. 133. 
Curvatures of leg, iii. 361. 
of penis, ii. 437. 
of spine, ii. 859. 
Cutaneous cysts, iii. 596. 
parasites, iii. 479. 
redundancy, iii. 469. 
syphilis, iii. 531. 
Cylindrical epithelioma, iii. 661. 
Cyphosis, ii. 866. 
Cystic goitre, iii. 493. 
sarcoma of breast, iii. 703. 
Cysticercus in conjunctiva, iii. 
201. 
in eye, iii. 228. 
in eyelid, iii. 169. 
in vitreous humor, iii. 274. 
Cystine in urine, ii. 628. 
Cystitis, ii. 526. 
from gonorrhoea, ii. 468, 740. 
in female, ii. 827. 
Cystocele, i. 551, 608. 
vaginal, ii. 610. 
Cysto-fibroma of uterus, ii. 773. 
Cystoma, difference from cyst, 
iii. 585. 
of conjunctiva, iii. 201. 
of external canal, iii. 308. 
of larynx, iii. 63. 
of nerves, iii. 443. 
of ovary, ii. 793. 
of skin, iii. 479. 
Cystorrhcea, ii. 528. 
Cystotomy for cystitis, ii. 531. 
for enlarged prostate, ii. 505. 
Cysts, article on, iii. 585. 
blood-, i. 355, iii. 591. 
in arachnoid, i. 355. 
cutaneous or dermoid, iii. 596. 
of areola, iii. 682. 
of conjunctiva, iii. 201. 
of lachrymal gland, iii. 172. 
of ovary, ii. 813. 
of testicle, ii. 598. 
over sacrum, ii. 840. 
dentigerous, ii. 938, iii. 596. 
diagnosis of, i. 157, 660. 
from aneurism, i. 660. 
difference from cystomata, iii. 
585. 
extravasation, iii. 593. 
exudation, iii. 591. 
hydatid, iii. 594. 
of lachrymal gland, iii. 172. 
lachrymal, iii. 172. 
lactiferous, iii. 591. 
mucous, iii. 590. 
of antrum, ii. 939. 
of areola, iii. 682. 
of broad ligament, ii. 812. 
of conjunctiva, iii. 201. GENERAL INDEX. 
767 
Cysts of iris, iii. 223. 
of kidney, ii. 708. 
of lip, ii. 893. 
of lower jaw, ii. 955. 
of mamma, iii. 691-695. 
of muscle, non-parasitic, iii. 
389. 
parasitic, iii. 387. 
of ovary, ii. 793. 
of pancreas, i. 457. 
of prostate, ii. 506. 
of retina, iii. 241. 
of scrotum, ii. 520. 
of soft palate, ii. 984. 
of submaxillary gland, ii. 
995. 
of testicle, ii. 593. 
dermoid, ii. 598. 
of tongue, ii. 911. 
of tonsil, ii. 992. 
of vagina, ii. 737. 
of vulva, ii. 723. 
oil, iii. 590. 
over sacrum, ii. 840. 
parasitic, iii. 594. 
in muscle, iii. 387. 
in tonsil, ii. 985. 
piliferous, of eyelid, iii. 168. 
proliferous, iii. 596. 
salivary, iii. 590. 
sanguineous, iii. 593. 
sebaceous, iii. 587. 
seminal, iii. 590. 
synovial, iii. 591. 
umbilical, i. 475. 
urinous, i. 459. 
vascular, iii. 593. 
venous, iii. 591. 
Cystocele, i. 551, 608. 
Czerny-Lembert suture, i. 449. 
D. 
Dacryoadenitis, iii. 170. 
Dacryops, iii. 1 72. 
Dactylitis, iii. 556, 572. 
Dactylology, iii. 332. 
Dancing for tarantula-bite, i. 
285. 
Deaf-mutism, iii. 331. 
Deafness, aids for, iii. 329. 
hysterical, iii. 327. 
labyrinthic, iii. 324. 
syphilitic, iii. 557. 
Decomposition, germ-theory of, 
i. 194. 
Defecation, loss of co-ordination 
of muscles of, i. 511. 
Deformed union in fractures, i. 
798, 846, 946, 1025, 1037. 
Deformities, amputation in, ii. 
296, 420. 
chapter on, iii. 332. 
from burns, ii. 416. 
of face, i. 394. 
of foot, iii. 362. 
of lip, ii. 889, 897. 
of spine, ii. 859. 
Deformity in fractures, i. 798, 
846, 946, 1025, 1037. 
Degeneration of cartilages, ii. 
147. 
of stump, ii. 323. 
Delayed union in fractures, i. 
822. 
Delhi boil of India, iii. 489. 
Delirium, hysteroid, ii. 278. 
Delirium, nervous, ii. 377. 
traumatic, ii. 377. 
tremens, ii. 268. 
after fractures, i. 797, 821. 
Deltoid, electricity in paralysis 
of, iii. 722. 
Demarcation, line of, i. 194, 
1063. 
Demi-gauntlet, i. 67. 
Dental caries, ii. 927. 
denudation, ii. 926. 
engine, i. 1069. 
fistula, ii. 929. 
pulp, exostosis of, ii. 938. 
Dentigerous cysts, ii. 938, iii. 
596. 
osteoma, ii. 940. 
Dentine, exostosis of, ii. 938. 
Denudation of teeth, ii. 926. 
Depilatories, iii. 481. 
Depressed fractures of skull, i. 
341, 342. 
Depression of skull without frac- 
ture, i. 339, 340, 341, 342. 
Dermoid cysts, iii. 596. 
of areola, iii. 682. 
of back, ii. 840. 
of conjunctiva, iii. 201. 
of ovary, ii. 813. 
of testicle, ii. 598. 
Desault’s bandage, i. 907, 908, 
1020. 
splints, i. 1004, 1005. 
Detached retina, iii. 239. 
Diabetes, pruritus vulvse from, 
ii. 724. 
retinitis in, iii. 238. 
traumatic, i. 374. 
Diagnosis, surgical, i. 25. 
Diaphragm, wounds of, i. 379, 
854. 
Diaphragmatic hernia, i. 407. 
Diet after operations, ii. 274. 
after ovariotomy, ii. 810. 
Diffused abscess, i. 158. 
aneurism, i. 681, 717. 
Digital compression, i. 221. 
in aneurism, i. 673, 699, 702. 
in inflammation, i. 135, 137, 
147. 
Dilatation in phimosis, ii. 427. 
of arteries, i. 645. 
of pharynx, ii. 1013. 
of rectal stricture, i. 541. 
of urethral stricture, ii. 483. 
Diphtheria, compared with 
croup, iii. 33. 
diagnosis from erysipelas, ii. 
408. 
of wounds, 201, 252. 
Diphtheritic pharyngitis, ii. 
1007. 
Diploe, affections of, i. 325. 
Discoloration in luxations, ii. 
20. 
of skin, i. 801. 
Disk, optic, choked, iii. 242. 
Dislocations, ii. 17-126. 
after-treatment of, ii. 27. 
atlo-axoid, ii. 44. 
chondral, ii. 39. 
chondro-sternal, ii. 39. 
classified and defined, ii. 17. 
complicated, ii. 28. 
compound, ii. 28. 
congenital, ii. 33. 
costo-chondral, ii. 39. 
costo-vertebral, ii. 38. 
Dislocations, coxo-femoral, ii. 89. 
deformity from unreduced, iii. 
337. 
intra-uterine, ii. 33. 
metacarpo-phalangeal, ii. 86. 
occipito-atloid, ii. 43. 
of ankle, ii. 116. 
of astragalus, ii. 121. 
of carpus, ii. 78. 
separate bones of, ii. 81. 
of clavicle, ii. 46. 
at both ends, ii. 49. 
of coccyx, ii. 88. 
of costal cartilages, ii. 38. 
of crystalline lens, iii. 253. 
of elbow, ii. 70. 
compound, ii. 76. 
of ensiform cartilage, ii. 40. 
of fibula, ii. 120. 
of fingers, ii. 86. 
of foot, ii. 116. 
of forearm, ii. 67. 
of hand, ii. 78. 
of hip, ii. 89. 
accidents attending, ii. 106. 
complications of, ii. 105. 
congenital, ii. 106. 
incomplete, ii. 104. 
of humerus, ii. 53. 
complications in, ii. 64. 
congenital, ii. 67. 
diagnosis of, i. 875. 
of inferior maxilla, ii. 34. 
of knee, ii. 111. 
complicated, ii. 115. 
congenital, ii. 115. 
of metacarpus, ii. 82. 
of metatarsus, ii. 125. 
of muscles, iii. 384. 
of back, iii. 394. 
of os calcis, ii. 124. 
of os cuboides, ii. 125. 
of os cuneiforme. ii. 125. 
of os magnum, ii. 81. 
of os pisiforme, ii. 81. 
of os scaphoides, ii. 125.' 
of os semilunare, ii. 81. 
of ovary, ii. 784. 
of patella, ii. 107. 
of pelvis, ii. 87. 
of penis, ii. 437. 
of phalanges, ii. 87. 
of radius and ulna, ii. 70. 
of ribs, ii. 38. 
of scapula, ii. 50. 
of semilunar cartilages, ii. 114. 
of shoulder, ii. 46. 
of sternum, ii. 39. 
of tarsus, ii. 121. 
of teeth, ii. 926. 
of tendons, iii. 393. 
of thigh, ii. 289. 
of thumb, ii. 83. 
of toes, ii. 126. 
of ulna, ii. 70. 
of vertebrae, ii. 40. 
old, ii. 31. 
on cadaver, ii. 19. 
pathological effects of, ii. 21. 
peroneo-tibial, ii. 120. 
radio-humeral, ii. 68. 
radio-ulnar, inferior, ii. 77. 
subastragaloid, ii. 123. 
subcoracoid, ii. 54, 63. 
treatment of, ii. 23. 
with fracture, i. 820, ii. 28. 
Displacements of semilunar car- 
tilages, ii. 114. 768 
GENERAL INDEX. 
Displacements of uterus, ii. 753. 
Dissecting aneurism, i. 639, 647, 
680. 
Dissection-wound, i. 268. 
Distoina in kidney, ii. 709. 
Districhiasis, iii. 155. 
Diverticular hernia, i. 573, 608. 
Dorsal vertebrae, luxations of, 
ii. 45. 
Dorsalis pedis artery, ligation 
of, i. 792. 
Dracunculus, iii. 480. 
Drainage, i. 242. 
by horse-hair, ii. 274. 
Drainage-tube, i. 160, 242. 
in amputations, ii. 314, 373. 
in chest, i. 421. 
in excisions, ii. 213, 218, 222. 
in joint-disease, ii. 184, 190, 
192. 
in joint-injury, ii. 80, 136. 
in ovariotomy, ii. 810. 
Dressings for fractures, i. 812. 
surgical, i. 52. 
Dropsy of abdomen, i. 476. 
encysted, i. 480. 
of antrum, ii. 958. 
of Fallopian tube, ii. 812. 
of joint, ii. 138. 
of kidney, ii. 703. 
ovarian, ii. 796. 
Dry mortification, i. 197. 
Duodenum, operations on, i. 
438, 439. 
ulcer of, ii. 415. 
Dyschromatopsia, iii. 249. 
Dysmenorrhoea, ii. 765. 
Dysphagia, i. 395, 687. 
in paralysis, ii. 1027. 
nervous, ii. 1004. 
Dyspnoea from nerve-injury, i. 
402. 
from pressure of aneurism, i. 
687. 
in spine-injury, i. 866, ii. 43, 
856. 
Dysuria, ii. 425, 461. 
E. 
Ear, acuity of hearing of, iii. 287. 
affections of, iii. 287. 
external canal of, examina- 
tion, iii. 292. 
impacted cerumen in, iii. 
304. 
syringing, iii. 290. 
tumors of, iii. 308. 
foreign bodies in, iii. 304. 
hemorrhage from, i. 337. 
insects in, iii. 304. 
internal affections of, iii. 324. 
membrana tympani, view of, 
iii. 295. 
middle, catarrh of, iii. 312. 
necrosis after, iii. 321. 
inflammation of, iii. 313. 
suppurative, iii. 319. 
parasites in, iii. 306. 
wounds of, i. 388. 
Earache, iii. 329. 
Ear-cough, iii. 329. 
Ear-trumpets, iii. 330. 
Ear-vomiting, iii. 329. 
Eburnated osteoma, iii. 613. 
Eburnation, i. 824, ii. 157. 
in syphilis, iii. 552. 
Ecchymosis, i. 261. 
of conjunctiva, iii. 203. 
of eyelids, i. 386, iii. 151. 
Echinococci in kidney, ii. 709. 
in liver, i. 451. 
Ecthyma, syphilitic, iii. 535. 
Ectropion, iii. 159. 
Eczema, i. 181, 188. 
after varix, i. 635. 
of auricle, iii. 300. 
of nipple, iii. 682. 
of penis, ii. 426. 
of scrotum, ii. 515. 
Effusions in inflammation, i. 
148. 
in joints, ii. 139. 
Eiloid, iii. 477. 
Elaps-bites, i. 287. 
Elastic ligature in meningocele, 
ii. 888. 
stocking, i. 636. 
Elbow-joint, amputation at, i. 
310, ii. 76, 342. 
arthritis of, ii. 200. 
dislocations of, ii. 70, 76. 
excision of, ii. 76, 216. 
fractures of, i. 936. 
Electric apparatus, i. 225, iii. 
718. 
Electricity, article on, iii. 718. 
cases benefited by, iii. 721. 
rules for using, iii. 721. 
Electrization of larynx, iii. 59. 
Electro-cautery, article on, iii. 
725. 
Electro-galvanic cautery, i. 225. 
Electrolysis, article on, iii. 723. 
cases used in, iii. 723. 
cicatrix from, iii. 724. 
in myo-fibroma, ii. 769. 
Elephantiasis Arabum, iii. 473. 
Graecorum, iii. 473. 
of eyelid, iii. 169. 
of labia, ii. 720. 
scroti, ii. 521. 
tuberosa, iii. 474. 
verrucosa, iii. 474. 
Elongation of cervix uteri, ii. 
780. 
of uvula, ii. 981. 
Elytrotomy, ii. 823. 
Embolism, i. 191, 655, 822. 
after fracture, i. 822. 
after operations, ii. 277. 
aneurism from, i. 655. 
causing pyaemia, ii. 387. 
during shock, ii. 378. 
fat, i. 822. 
of central retinal artery, iii. 
250. 
of penis, ii. 469. 
Embryoplastic sarcoma, iii. 637. 
Embryotomy, ii. 709. 
Emesis after anaesthetics, ii. 286. 
Emigration of leucocytes, i. 109. 
Emmetropic eye, iii. 277. 
Emphysema of body, i. 409, 415, 
896. 
of conjunctiva, iii. 204. 
of eyelids, i. 386, iii. 152. 
of face, i. 835, 838. 
of scrotum, ih 517. 
Emprosthotonus, iii. 432. 
Empyema, i. 417. 
ribs excised for, i. 421. 
Enamel, abrasions of, ii. 926. 
nodules, ii. 937. 
Encanthis, iii. 200. 
Encephalitis, i. 335, 367. 
Eneephalocele, i. 369, ii. 886. 
Encephaloid carcinoma, iii. 667. 
diagnosis from abscess, i. 158. 
from aneurism, i. 659. 
of back, ii. 839. 
of bone, ii. 295. 
of jaw, lower, ii. 957. 
upper, ii. 961. 
of mamma, iii. 707. 
of prostate, ii. 506. 
of rectum, i. 528. 
of testis, ii. 590. 
of uterus, ii. 777. 
Enchondroma, amputation in, 
ii. 295. 
article on, iii. 607. 
nasal, iii. 131. 
of jaw, lower, ii. 956. 
upper, ii. 963. 
of larynx, iii. 63. 
of muscle, iii. 390. 
of ovary, ii. 814. 
of parotid, ii. 999. 
of scrotum, ii. 520. 
of submaxillary gland, ii. 995. 
of testicle, ii. 594. 
of tongue, ii. 912. 
Encysted abdominal dropsy, i. 
480. 
calculus, ii. 644. 
hernia, i. 587. 
hydrocele, ii. 560. 
rectum, i. 516. 
Endometritis, gonorrhoeal, ii. 
740. 
Endosteitis, i. 1056. 
Endothelial sarcoma, iii. 645. 
“ English disease” of bones, i. 
1072. 
Enlarged axillary glands in 
cancer, iii. 714. 
Enostoses, iii. 612. 
Ensheathing callus, i. 803. 
Ensiform cartilage, luxation of, 
ii. 40. 
Enterocele, i. 551. 
Enterotomy, i. 465. 
Entozoa in bladder, ii. 538. 
in kidney, ii. 709. 
in testis, ii. 598. 
Entropion, iii. 157. 
Enucleation of eye, iii. 284. 
Enuresis, ii. 543. 
Epicanthus, iii. 167. 
Epicystotomia, ii. 690. 
Epidermic grafting, i. 187. 
Epididymitis, ii. 581. 
gonorrhoeal, ii. 469. 
Epigastric artery ligated, i. 
778. 
Epigastrium, effect of blows 
upon, i. 440. 
Epilepsy after scalp-wounds, i. 
326. 
anaesthetics in, ii. 283. 
from brain-injury, i. 372. 
from nerve-injury, iii. 428. 
ligation of arteries for, i. 762. 
trephining for, i. 375, 377. 
Epiphyses, exfoliation of, ii. 
201. 
fracture of, i. 798, 921, 986. 
necrosis of, i. 1064. 
softening of, ii. 158. 
Epiplocele, i. 551. 
Episiorrhaphy, ii. 748. 
Epispadias, ii. 452. GENERAL INDEX. 
769 
Epistaxis, iii. 101. 
in nasal fracture, i. 873. 
Epithelial cancer, iii. 657. 
Epithelioma, article on, iii. 657. 
cylindrical, iii. 661. 
of areola, iii. 682. 
of auricle, iii. 303. 
of back, ii. 839. 
of bladder, ii. 548. 
of breast, iii. 710. 
of cicatrix, i. 320. 
of conjunctiva, iii. 202. 
of eyelid, iii. 170. 
of gum, ii. 923. 
of intestine, i. 485. 
of labia, ii. 721. 
of lip, ii. 894. 
of nose, iii. 98. 
of oesophagus, ii. 1019. 
of prepuce, ii. 432. 
of rectum, i. 527. 
of scrotum, ii. 525. 
of tongue, ii. 912. 
of tonsil, ii. 993. 
of uterus, ii. 778. 
of vagina, ii. 737. 
squamous, iii. 660. 
tubular, iii. 663. 
Epithelium in urine, ii. 620. 
Epulis, ii. 923, iii. 641. 
Equinia. See Farcy. 
Equinia mitis, i. 278. 
Equinus, talipes, iii. 345. 
Erectile tissue, iii. 621. 
tumors, i. 617, 659, 709, ii. 
839, 892, 911, 922. 
Ergot for aneurism, i. 700. 
mortification from, i. 192, 199. 
Ergotin in aneurism, i. 677. 
Ergotism, i. 91. 
Erysipelas, articles on, ii. 402, 
iii. 454. 
contagion and infection of, 
iii. 456. 
forms of, ii. 404, iii. 454. 
in pharynx, ii. 1008. 
in wounds, i. 252, 263, 303, 
403. 
of scalp, i. 325. 
treatment of, ii. 409, iii. 461. 
Erythropsine, iii. 249. 
Esmarch bandage in amputa- 
tions, ii. 313, 324, 372. 
in aneurism, i. 674. 
in excisions, ii. 211, 217, 241. 
Ether as anaesthetic, ii. 283. 
Ethidene, ii. 289. 
Ethmoid, fracture of, i. 337, 874. 
Eustachian catheterism, iii. 298. 
tube involved in ear-disease, 
iii. 315. 
Eversion of eyelids, iii. 159. 
Exanthematous ophthalmia, iii. 
194. 
Excision, article on, ii. 206. 
gunshot wounds demanding, 
i. 305. 
in arthritis, ii. 152, 162. 
of ankle, ii. 241. 
for shot wounds, i. 314. 
of astragalus, i. 1041, ii. 255. 
and calcaneum, ii. 259. 
of bone, i. 1058, 1068. 
of breast, operation, iii. 715. 
of calcaneum, ii. 256. 
of carcinoma, iii. 677, 713. 
of clavicle, ii. 246. 
of clitoris, ii. 724. 
TOL. m.—49 
Excision of coccyx, i. 964, ii. 89. 
of colon, i. 501. 
of elbow, ii. 216. 
for shot wounds, i. 309. 
of femur, ii. 253. 
of fibula, i. 315, ii. 255. 
of fistula in ano, i. 539. 
of foot, ii. 361. 
of forearm, ii. 252. 
for shot wounds, i. 310. 
of gall-bladder, i. 454. 
of gums, ii. 919, 922. 
of hand, parts of, ii. 224. 
of hip, ii. 228. 
for shot wounds, i. 312. 
of humerus, ii. 251. 
for shot wounds, i. 308. 
of jaw, lower, ii. 967. 
upper, ii. 970. 
of knee, ii. 233. 
for shot wounds, i. 314. 
of larynx, iii. 72, 75. 
of leg, for shot wounds, i. 315. 
of metacarpal bones, ii. 225. 
of metacarpus, ii. 226. 
of metatarsus, ii. 260. 
of necrosed bone, i. 1068. 
of nerves, iii. 727, 733. 
of nerves of face, i. 393. 
of parotid gland, ii. 1001. 
of patella, ii. 253. 
of phalanges, ii. 225. 
of piles, i. 547. 
of rectum, i. 532. 
of ribs and their cartilages, 
ii. 227. 
of scapula, ii. 248. 
after amputation at shoul- 
der, ii. 251. 
of shoulder, ii. 212. 
of sternum, ii. 226. 
of submaxillary gland, ii. 996. 
of tarsus, ii. 255. 
for talipes, iii. 350. 
of thumb, ii. 225. 
of tibia, i. 315, ii. 254. 
of toes, ii. 260. 
of tongue, ii. 916. 
of ungual phalanx, ii. 225. 
of uterus, ii. 780. * 
of uvula, ii. 982. 
of veins, ii. 567. 
of wrist, ii. 220. 
for shot wounds, i. 310. 
subperiosteal, ii. 242. 
Exophthalmic goitre, iii. 492. 
Exostoses, iii. 612. 
amputation for, ii. 295. 
of auditory canal, iii. 311. 
of cranium, i. 327. 
of teeth, ii. 937. 
under nail, iii. 486. 
Exploring-needle, i. 158. 
Exstrophy of bladder, ii. 611. 
Extension in dislocations, ii. 24. 
in fractures, i. 815. 
to stump, ii. 319. 
External popliteal nerve,stretch- 
ing of, iii. 731. 
urethrotomy, ii. 492. 
Extirpation of clavicle, ii. 247. 
of larynx, iii. 72. 
of testicle, ii. 598. 
of uterus, ii. 780. 
Extra-uterine pregnancy, ii. 829 
Extravasation cysts, iii. 593. 
of blood in fracture, i. 802. 
of urine, i. 476, ii. 440, 477. 
Exudation cysts, iii. 591. 
Eye, affections of appendages of, 
iii. 150. 
chambers of, iii. 227. 
muscles of, iii. 180. 
artificial, iii. 286. 
black, i. 386. 
blood in chambers of, iii. 227. 
blood-supply of, iii. 141. 
contusions of, iii. 216. 
deportment in disease of, iii. 
142. 
displaced by aneurism, i. 709. 
examination of, iii. 142. 
interior of, iii. 146. 
foreign bodies in, iii. 227. 
fundus of, normal, iii. 149. 
nerve-injury affecting, ii. 856. 
optic nerve or disk of, iii. 149. 
pupil altered in, iii. 220. 
refraction in, iii. 277. 
syphilis of, iii. 548, 573. 
tension of, iii. 143. 
vision of, acuity of, iii. 144. 
field of, iii. 144. 
Eyeball, enucleation of, iii. 284. 
Eyebrows, affections of, iii. 151. 
Eyelash, malposition of, iii. 155. 
Eyelids, adhesions of, iii. 161. 
affections of, iii. 151. 
ecchymosis of, i. 386. 
excurvation of, iii. 163. 
fissure of, iii. 157, 166. 
congenital, iii. 166. 
muscular defects of, iii. 163. 
tumors of, iii. 167. 
versions of, iii. 157. 
F. 
Face, contusions of, i. 386. 
deformities of, ii. 889, 897. 
fractures of, i. 872. 
wounds of, i. 387, 888. 
Facial aneurism, i. 702. 
nerves, iii. 733. 
neuralgia, i. 393. 
paralysis, electricity in, iii. 
722. 
traumatic, i. 393. 
Faecal accumulation, i. 484, 514, 
579. 
fistula, i. 462, 505. 
impaction, ii. 768. 
Fallopian dropsy, ii. 812. 
tubes, syphilis of, iii. 561. 
False anchylosis, ii. 141. 
aneurism, i. 647, 680. 
joint, i. 824, ii. 21, 32. 
passage in urethra, ii. 440. 
Farcy, i. 276. 
Fascia lata in fractured femur, 
i. 976. 
Fatty carcinoma, iii. 671. 
change in stump, ii. 323. 
tumors, i. 158, 264, 589, 597, 
600, 619, ii. 838. 
Fauces, affections of, ii. 981. 
erysipelas of, ii. 406, 1008. 
Felon, iii. 487. 
Felt splints, i. 813, 935. 
: Female, chancre in, iii. 523. 
chancroid in, iii. 517. 
diseases of genitals of, ii. 716. 
hernia in, i. 587. 
irritable bladder of, ii. 828. 
lacerated perineum of, ii. 726. 770 
GENERAL INDEX. 
Female, uterine disease in, ii. 
750, 782. 
vesico-vaginal fistula in, ii. 
740. 
Femoral aneurism, i. 727. 
artery, ligation of, i. 728, 784. 
bursa, iii. 401. 
hernia, i. 584. 
vein, ligation of, i. 625. 
Femur, amputation of, ii. 368. 
caries of, ii. 169. 
excision of, ii. 253. 
fracture of, i. 293, 311, 971, ii. 
106, 143. 
non-union in, i. 836, 841, 
844. 
separated head of, ii. 170. 
Fermentation, germ-theory of, 
i. 44. 
Fever in inflammation, i. 107, 
ii. 384. 
pysemic, ii. 385. 
surgical, i. 101, ii. 384. 
traumatic infective, ii. 383. 
urethral, ii. 444. 
Fibrin, i. 110. 
Fibro-angioma of gum, ii. 922. 
Fibroid rectal polypus, i. 520. 
Fibroma, article on, iii. 600. 
glio-, iii. 648. 
nasal, iii. 125. 
of areola, iii. 682. 
of auricle, iii. 302. 
of back, ii. 836. 
of bladder, ii. 546. 
of conjunctiva, iii. 202. 
of external auditory canal, 
iii. 308. 
of eyelid, iii. 168. 
of gums, ii. 921. 
of jaw, lower, ii. 955. 
upper, ii. 962. 
of larynx, iii. 62. 
of lip, ii. 894. 
of mamma, iii. 696. 
of muscle, iii. 389. 
of nerves, iii. 442. 
of oesophagus, ii. 1025. 
of 'ovary, ii. 813. 
of scrotum, ii. 520. 
of soft palate, ii. 985. 
of stump, ii. 323. 
of synovial membranes, ii. 
147. 
of testicle, ii. 595. 
of tongue, ii. 911. 
of tonsil, ii. 992. 
of uterus, ii. 766. t 
of vagina, ii. 737. 
of vulva, ii. 722. 
over parotid, ii. 1000. 
Fibro-myomatous polypus of 
uterus, ii. 773. 
Fibrous goitre, iii. 493. 
Fibula, excision of, i. 315, 844, 
ii. 255. 
fractures of, i. 1035. 
Pott’s, i. 1036. 
luxations of, ii. 120. 
Figure-of-eight rollers, i. 71, 73, 
74, 905, 910. 
Filaria medinensis, iii. 480. 
Fingers, amputation of, ii. 333. 
supernumerary, ii. 296. 
contraction of, iii. 372. 
dislocation of, ii. 86. 
excision of, ii. 225. 
fracture of, i. 960. 
Fingers, locked, iii. 375. 
Fissure of anus, i. 512. 
of lower lip, ii. 903. 
of nipple, iii. 681. 
of palate, ii. 974. 
of tongue, ii. 908. 
of vagina, ii. 736. 
Fistula, abdominal, i. 460. 
aerial, i. 399. 
after lithotomy, ii. 681. 
after wounds, i. 460. 
dental, ii. 929. 
faecal, i. 462, 505. 
horseshoe, i. 536, 539. 
in ano, i. 536. 
inguinal, ii. 537. 
lachrymal, i. 393, iii. 171. 
of antrum, ii. 959. 
of cornea, iii. 211. 
of gall-bladder, i. 401. 
of larynx, i. 399, iii. 44. 
of oesophagus, ii. 1018. 
of pharynx, ii. 1011. 
of stomach, i. 401, 439. 
of thorax, i. 422. 
of vagina, ii. 743. 
ovarian, i. 476. 
parotid, i. 390. 
perineo-anal and rectal, i. 536. 
recto-vesical, ii. 536. 
salivary, i. 390, ii. 998. 
stereoraceous, i. 476. 
umbilical, i. 476. 
urethral, ii. 446. 
urethro-rectal, ii. 449. 
urinary, i. 476. 
utero-vesical, ii. 749. 1 
vesico-pubic, ii. 537. 
vesico-utero-vaginal, ii. 750. 
vesico-vaginal, ii. 740. 
Fistulous tracts, i. 165. 
Flat-foot, iii. 363. 
Flea-bites, i. 289. 
Flexed toes, iii. 367. 
Flexion of thigh, iii. 353. 
of uterus, ii. 759. 
Floating kidney, i. 458, ii. 696. 
spleen, i. 456. 
Fluctuation, i. 156, 477. 
Foetal tumors, ii. 598, 840. 
Follicular adenoma, iii. 631. 
pharyngitis, ii. 1006, iii. 26. 
urethritis, ii. 467. 
vulvitis, ii. 719. 
Foot, amputations of, ii. 353. 
deformities of, iii. 362. 
dislocations of, ii. 116. 
excision of, ii. 361. 
flat- or splay-, iii. 363. 
fractures of, i. 1040. 
wounds of, i. 614. 
Foot and mouth disease, i. 275. 
Foot-drop, i. 852. 
Forearm, amputations of, ii. 341. 
dislocations of, ii. 67. 
excision of, i. 310, ii. 252. 
fractures of, i. 937. 
Foreign bodies in air-passages, 
iii. 44. 
in bladder, i. 469. 
in brain, i. 364. 
in ear, iii. 304, 305. 
in eye, iii. 227. 
in frontal sinus, iii. 117. 
in lip, ii. 894. 
in nose, iii. 105. 
in oesophagus, ii. 1014. 
in pharynx, ii. 1012. 
Foreign bodies in rectum, i. 514. 
in stomach, i. 434. 
in tonsils, ii. 985. 
in urethra, ii. 453. 
in wounds, i. 241. 
Fracture, i. 794. 
after-treatment of, i. 816. 
amputation for, ii. 294. 
anchylosis after, i. 821. 
callus in, i. 803. 
morbid changes of, i. 851. 
dislocations with, i. 797, ii. 
28, 65. 
intra-uterine, ii. 33. 
necrosis after, i. 392, 821. 
repair of, i. 801. 
shortening in, i. 799, 847. 
signs of, i. 798. 
treatment of, i. 809. 
union of, delayed, i. 822. 
vicious, i. 846. 
Fractures, special, i. 862. 
of acetabulum, i. 968. 
of alveolar process, i. 879. 
of astragalus, i. 1040. 
of carpus, i. 958. 
of cartilage, i. 889. 
costal, i. 895. 
of clavicle, i. 899. 
ununited, i. 841, 903. 
of coccyx, i. 964. 
of cranium, i. 331. 
epilepsy from, i. 372. 
of elbow-joint, i. 936. 
of femur, i. 971. 
complicated, i. 293, 311, 
981. 
extracapsular, i. 980. 
in children, i. 1009. 
intracapsular, i. 972. 
of lower end, i. 999. 
of shaft, i. 987. 
of upper end, i. 973, 990. 
ununited, i. 836, 841, 844. 
of fibula, i. 1035. 
ununited, i. 836, 841. 
of fingers, i. 960. 
of foot, i. 1040. 
of forearm, i. 937. 
of hand, i. 958, 961. 
of humerus, i. 918. 
of lower end, i. 928, 933. 
of shaft, i. 925. 
of upper end, i. 918. 
ununited, i. 832, 841. 
of hyoid bone, i. 888. 
of ilium, i. 965. 
of innominate bones, i. 965. 
of ischium, i. 968. 
of knee-cap, i. 1012. 
of larynx, i. 889. 
of leg, i. 1023. 
compound, i. 1038. 
of lower extremity, i. 971. 
of malar bone, i. 877. 
of maxilla, inferior, i. 879. 
ununited, i. 840. 
superior, i. 875. 
of metacarpal of thumb, i. 
959. 
of metacarpus, i. 958. 
of metatarsus, i. 1045. 
of nasal bones, i. 873. 
of odontoid process, i. 868, 
870. 
of olecranon, i. 953. 
of os calcis, i. 1041. 
of ossa innominata, i. 965. GENERAL INDEX. 
771 
Fractures of patella, i. 1012. 
ununited, i. 836, 841. 
of pelvis, i. 962. 
of penis, ii. 436. 
of phalanges, carpal, i. 960. 
tarsal, i. 1045. 
of pubis, i. 966. 
of radius, i. 937, 941. 
Barton’s, i. 943. 
Colles’s, i. 944. 
ununited, i. 832, 841. 
of radius and ulna, i. 937. 
ununited, i. 832, 844. 
of ribs, i. 891. 
of sacrum, i. 962. 
of scapula, i. 911-917. 
of skull, i. 331. 
base of, i. 336. 
depressed, i. 339, 341, 360. 
punctured, i. 343. 
of sternum, i. 896. 
of sustentaculum tali, i. 1044. 
of tarsus, i. 1040. 
of teeth, ii. 926. 
of tibia, i. 1032. 
ununited, i. 836-839, 841. 
of tibia and fibula, i. 1023. 
ununited, i. 836-839. 
of trachea, i. 889. 
of ulna, i. 937, 951. 
ununited, i. 832, 835, 841, 
844. 
of vertebra?, i. 864, 870. 
arches of, i. 864. 
bodies of, i. 864. 
cervical, i. 867. 
dorsal, i. 866. 
lumbar, i. 865. 
of zygoma, i. 877. 
Fragilitas ossium, i. 1081. 
Frambcesia, iii. 477. 
French rhinoplasty, iii. 139. 
Frictions in massage, iii. 739. 
Frigorific mixture, ii. 291. 
Frog-face, iii. 126. 
Fromotopneea, i. 409. 
Frontal sinus, affections of, iii. 
116. 
Frost-bite, ii. 420. 
Fungoid arthritis, ii. 154. 
neoplasm, inflammatory, iii. 
649. 
Fungous ulcer, i. 177. 
Fungus about eye, iii. 180. 
cerebri, i. 369. 
haematodes, iii. 669. 
malignant, i. 371. 
of bladder, ii. 547. 
of testicle, ii. 589. 
Furunculus, ii. 397. 
of auricle, iii. 307. 
of back, ii. 837. 
of nose, iii. 95. 
Fusiform aneurism, i. 648. 
G. 
Galactocele, iii. 691. 
Gall-bladder, fistula of, i. 461. 
excision of, i. 454. 
wounds of, i. 450. 
Galvano-cautery, i. 225, ii. 915. 
article on, iii. 725. 
Galvano-puncture, i. 617, 676, 
706. 
Ganglions, iii. 395. 
Gangraena contagiosa, i. 201. 
Gangraena nosocomialis, i. 201. 
Gangrene, i. 189. 
amputation for, i. 196, 200, 
ii. 296. 
hospital, i. 201. 
moist, i. 193. 
of bladder, ii. 533. 
of hard palate, ii. 979. 
of nose, iii. 95. 
of penis, ii. 435. 
of toes and feet, i. 197, ii. 
296. 
of vulva, ii. 718. 
senile, i. 197, ii. 296. 
Gastrectomy, i. 437. 
Gastric fistula, i. 441, 461. 
tinnitus, iii. 328. 
Gastrocele, i. 551. 
Gastro-hysterotomy, ii. 820. 
Gastrotomy, i. 435. 
in extra-uterine foetation, ii. 
834. 
Gelatinoid polypus, iii. 620. 
of nose, iii. 121. 
Genital function, disorders of, 
ii. 600. 
Genitalia, malformed, female, ii. 
611, 716, 732. 
male, ii. 426, 450, 611. 
parasites on, ii. 516. 
Genito-urinary organs, chapter 
on, ii. 424. 
in diagnosis, i. 42. 
Genu extrorsum curvatum, iii. 
359. 
Genu valgum, iii. 353. 
Germ-tissue, i. 316. 
Giant-celled myosarcoma, i. 631. 
sarcoma, iii. 641. 
Glanders, i. 276. 
Glandular hypertrophy, iii. 629. 
Glaucoma, iii. 250. 
Gleet, ii. 470. 
Glenoid fracture, i. 916. 
Glio-fibroma, iii. 648. 
Glioma, article on, iii. 648. 
of retina, iii. 241. 
Glio-myxoma, iii. 648. 
Glio-sarcoma, iii. 648. 
of nerves, iii. 443. • 
Glossitis, ii. 907. 
mercurial, ii. 907. 
syphilitic, iii. 546. 
Glottis, functions of, suspended, 
iii. 56. 
oedema of, iii. 23. 
Gluteo-femoral groove in cox- 
algia, ii. 163. 
Goitre, article on, iii. 490. 
Gonorrhoea, ii. 460. 
bacteria of, ii. 461. 
bubo after, ii. 469. 
in female, ii. 738. 
inflamed testis in, ii. 469. 
irritable bladder from, ii. 475. 
ophthalmia in, ii. 474, iii. 
190. 
rheumatism in, ii. 474. 
sicca, ii. 466. 
warts from, ii. 438, 721. 
Gracilis, bursa of, iii. 403. 
Granular gleet, ii. 471. 
lids, iii. 194. 
vaginitis, ii. 740. 
Granulation-cell sarcoma, iii. 
637. 
tissue, i. 173, 176, 316. 
in arthritis, ii. 150. 
Gravel, ii. 623, 705. 
Graves’s disease, iii. 492. 
Great occipital nerve, stretching 
of, iii. 729. 
sciatic nerve, stretching of, 
iii. 730. 
toe, fracture of, i. 1045. 
ingrown nail of, iii. 486. 
“Green-stick” fracture, i. 796. 
Guinea-worm, iii. 480. 
Gullet, affections of, ii. 1014. 
Gum-boil, ii. 928. 
Gumma, iii. 545, 547, 569. 
of nerves, iii. 443. 
of soft palate, ii. 983. 
of tongue, ii. 912. 
Gummatous syphiloderm, iii. 
536. 
Gums, affections of, ii. 919-923. 
Gunshot wounds, i. 290. 
Gut ligatures, i. 47. 
Gutta-percha splints, i. 886. 
Gypsum bandage, i. 814, 1034. 
H. 
Habits in diagnosis, i. 28. 
Haematocele, diagnosis from 
hernia, i. 588. 
hydro-, ii. 580. 
of spermatic cord, ii. 561. 
of tunica vaginalis testis, ii. 
579. 
peri-uterine, ii. 815. 
pudendal, ii. 717. 
upon back, ii. 837. 
Hsematuria, ii. 537. 
in spine-injury, ii. 841, 854. 
renal, ii. 708, 711. 
Haemostatic, hot water as a, ii. 
273. 
Haemostatics, i. 219. 
comparison of, i. 237. 
Haemothorax, i. 414. 
Hair, affections of, iii. 481. 
drains, i. 243. 
loss of, from eyebrows, iii. 151. 
on lip of female, ii. 891. 
Hairy moles, ii. 891. 
Hand, abscess of, i. 611. 
amputation of, ii. 338. 
dislocation of, ii. 78. 
excision of, ii. 224. 
fracture of, i. 96, 958. 
wounds of, i. 610. 
Handkerchief dressings, i. 78. 
Hare-eye, iii. 163. 
Hare-lip, ii. 897. 
double, ii. 901. 
single, ii. 898. 
suture, i. 248. 
with cleft palate, ii. 974. 
Head, bandages of, i. 57, 74. 
injuries of, i. 322, 326, 356. 
sequelae of, i. 372. 
malformation of, ii. 885. 
spasmodic extension of, iii. 
379. 
wounds of, i. 356. 
Healing of wounds, i. 316. 
Heart, syphilis of, iii. 562. 
Heat, effects of, ii. 412. 
in inflammation, i. 130. 
Hectic fever, i. 101, ii. 136, 160, 
392, 394. 
Hematoid cancer of breast, iii. 
708. 772 
GENERAL INDEX. 
Hemiopia, iii. 245. 
Hemorrhage after amputation, 
ii. 318. 
secondary, ii. 320. 
after fractures, i. 819. 
arrest of, i. 215, 219, ii. 313. 
agents compared, i. 237. 
concealed, i. 297. 
from aneurismal sac, i. 716. 
from carcinoma, iii. 675. 
from nose, iii. 101. 
from wounds, i. 214, 297, 299. 
internal, i. 297. 
into vitreous humor, iii. 274. 
prevention of, ii. 264, 273. 
reactionary, ii. 277. 
secondary, i. 253, 297, 819, ii. 
278, 320. 
transfusion in, i. 239. 
treatment of, i 134, 165, 219, 
224, 226, 239, 406, ii. 318. 
venous, i. 625. 
vesical, ii. 537, 548. 
Hemorrhagic cysts, iii. 593. 
retinitis, iii. 236. 
Hemorrhoids, i. 540. 
internal, i. 541. 
urethral, ii. 826. 
Hepatic abscess, i. 451. 
Hernia, i. 550. 
cerebri, i. 369. 
concealed, i. 570, 585. 
congenital, i. 586. 
diaphragmatic, i. 606. 
diverticular, i 593, 608. 
femoral, i. 593. 
hydrocele in sac of, ii. 577. 
incarcerated, i. 565. 
in females, i. 552. 
infantile, i. 557, 586. 
inguinal, i. 584. 
irreducible, i. 565. 
ischiatic, i. 606. 
lumbar, i. 604. 
obturator, i. 604. 
of bladder, i. 608, ii. 610. 
of lung, i. 415. 
omental, i. 581, 587. 
perineal, i. 607. 
pudendal, i. 606. 
radical cure of, i. 557. 
reduction of, i. 571. 
sacro-rectal, i. 607. 
scrotal, i. 586. 
seat of stricture in, i. 567, 
570. 
sloughing of gut in, i. 581. 
strangulated, i. 567. 
operation for, i. 571. 
taxis in, i. 571. 
testis, ii. 589. 
thyroid, i. 605. 
treatment of, i. 555. 
truss for, i. 555, 590, 601. 
umbilical, i. 599. 
vaginal, i. 606. 
ventral, i. 604. 
vitality of intestine in, i. 580. 
volvulus in, i. 580. 
Hernial aneurism, i. 647. 
Herniotomy, i. 574. 
Herpes, conjunctival, iii. 192. 
of penis, ii. 425. 
of prepuce, ii. 469. 
Hey’s foot-amputation, ii. 356. 
Hip, amputation at, ii. 372. 
anchylosis of, ii. 144. 
disease of, ii. 162. 
Hip, dislocations of, ii. 89. 
excision of, i. 312, ii. 228. 
osteo-arthritis of, ii. 155. 
Histoid tumors, ii. 813. 
Hordeolum, iii. 153. 
Hornet-stings, i. 289. 
Horns, iii. 467. 
on eyelid, iii. 169. 
Horse-foot, iii. 345. 
Horse-hair in aneurism, i. 678. 
drainage, i. 243, ii. 274. 
Hospital gangrene, or mortifica- 
tion, i. 201. 
Hot water as a haemostatic, ii. 
273. 
House-maid’s knee, iii. 398. 
Howard’s artificial respiration, 
iii. 89. 
Humerus, absorption of, i. 824. 
amputation of, i. 307, ii. 346. 
dislocations of, ii. 53. 
excision of, i. 307, 308, ii. 251. 
fracture of, i. 426, 930. 
ununited, i. 832, 842. 
Hunterian chancre, iii. 507, 518. 
Hyalitis, iii. 273. 
Hydatid cysts, iii. 594. 
electrolysis for, iii. 724. 
in eye, iii. 228. 
of mamma, iii. 695. 
Hydrarthrosis, ii. 138. 
Hydrated testicle, ii. 593. 
Hydrocele, congenital or infan- 
tile, ii. 576. 
diagnosis from hernia, i. 588. 
electrolysis for, iii. 724. 
encysted, ii. 571, 577. 
in female, ii. 577. 
in tunica vaginalis testis, ii. 
570. 
inguinal, ii. 577. 
of broad ligament, ii. 814. 
of hernial sac, ii. 577. 
of spermatic cord, ii. 559. 
Hydrocephalus externus, ii. 886. 
internus, ii. 885. 
Hydronephrosis, ii. 703. 
Hydrophobia, i. 278. 
Hydrops articuli, ii. 138. 
pericardii, i. 425. 
renalis, ii. 703. 
tubarum, ii. 812. 
Hydrorachis, ii. 851. 
Hydrosalpinx, ii. 812. 
Hydrothorax, i. 417. 
Hymen closing vagina, ii. 
733. 
diseases of, ii. 725, 733. 
Hymenoptera, sting of, i. 289. 
Hyoid bone, fracture of, i. 888. 
Hyperaesthesia after contusions, 
i. 263. 
after spine-injury, ii. 855. 
of larynx, iii. 53. 
of mamma, iii. 684. 
of pharynx, ii. 1003. 
Hypermetropia, iii. 279. 
Hyperostosis of auditory canal, 
iii. 311. 
Hypertrophy, dermoid and sub- 
dermoid, iii. 464. 
from nerve-injury, iii. 429. 
glandular, iii. 629. 
of bladder, ii. 533. 
of bone, i. 1083. 
of clitoris, ii. 723. 
of cranial bones, i. 327. 
of fingers, iii. 372. 
Hypertrophy of gams, ii. 919. 
of hard palate, ii. 978. 
of heart from atheroma, i. 
646. 
of labia, ii. 719. 
of larynx, glandular, iii. 26. 
of lip, ii. 890. 
of mamma, iii. 682. 
of nerves, iii. 440. 
of nose, iii. 94. 
of ovaries, ii. 783. 
of prepuce, ii. 426. 
of prostate, ii. 499. 
of teeth, ii. 937. 
of testicle, ii. 597. 
of toes, iii. 367. 
of tongue, ii. 905. 
of tonsil, ii. 987. 
of uvula, ii. 981. 
of veins, i. 630. 
Hypoglossal nerve, injury of, i. 
401. 
Hypospadias, ii. 450. 
Hysteria from anal fissure, i. 
513. 
Hysterical deafness, iii. 327. 
delirium, ii. 278, 286. 
joints, ii. 203. 
retention of urine, ii. 511. 
Hysterotomy, ii. 820. 
I. 
Ichor, i. 171. 
Ichthyocolla plaster, i. 245. 
Ichthyol, iii. 463. 
Ichthyosis linguae, ii. 908. 
Ileum, rupture of. i. 443. 
Iliac abscess, ii. 875. 
arteries, aneurism of, i. 723, 
725. 
ligation of, i. 726, 776, 778, 
779. 
dislocation, ii. 91. 
Ilium, fracture of, i. 965. 
Immediate union, i. 316. 
Immobilization in excisions, ii. 
218, 235, 242. 
in joint-wounds, i. 831, ii. 135. 
Immovable dressings, i. 813. 
Impacted cerumen, iii. 304. 
faeces, i. 514. 
fractures, i. 797, 919, 974, 
981, 1000. 
Imperforate anus, i. 505. 
hymen, ii. 733. 
vagina, ii. 733. 
Impetigo, syphilitic, iii. 535. 
Impotence, ii. 600. 
electricity in, iii. 722. 
Incised wounds, i. 254, 430, 
640. 
Incisions, forms of, ii. 264. 
into joints, ii. 129. 
Incomplete anchylosis, ii. 141. 
dislocations, ii. 17. 
fractures, i. 796. 
Incontinence of urine, ii. 543. 
Incurvated toe-nail, iii. 486. 
India, Delhi boil and myceto- 
ma of, iii. 489. 
Indian rhinoplasty, iii. 136. 
Indurated chancre, iii. 507, 518. 
Induration of bone, i. 1059. 
Infantile hernia, i. 557, 586. 
hydrocele, ii. 576. 
paralysis, iii. 441. GENERAL INDEX. 
773 
Inferior maxilla, disease of, ii. 
946. 
dislocation of, ii. 34. 
fractures of, i. 842, 879. 
laryngotomy, iii. 77. 
thyroid artery, ligation of, i. 
763. 
Inflammation, i. 89. 
acute, i. 96. 
adhesive, i. 316. 
blood in, i. 92, 110. 
blood-vessels in, i. 104. 
chronic, i. 90, 143, 165. 
complicating wounds, i. 251. 
constitutional symptoms of, 
i. 100, 144, 156. 
definition of, i. 103. 
extension of, i. 95. 
history of causes and nature 
of, i. 115. 
leucocytes in, i. 107, 127. 
metastasis of, i. 127. 
nature of, i. 103. 
nerve-agency in, i. 94, 103, 
125. 
of antrum, ii. 957. 
of bladder, ii. 526. 
of bone, i. 114, 1050. 
of brain, i. 367. 
of bursae, iii. 396. 
of choroid, iii. 229. 
of conjunctiva, iii. 186. 
of cornea, iii. 204. 
of Cowper’s glands, ii. 467. 
of cranial bones, i. 327. 
of ear, external, iii. 307. 
middle, iii. 312. 
of frontal sinus, iii. 116. 
of iris, iii. 221. 
of joints, ii. 150. 
of kidney, ii. 698. 
of lachrymal gland, iii. 
170. 
of lachrymal sac, iii. 175. 
of larynx, iii. 21. 
of lymph-glands, iii. 451. 
of mamma, iii. 685. 
of muscle, iii. 384. 
of nasal septum, iii. 119. 
of nerves, iii. 405. 
of nose, follicular, iii. 95. 
of ovary, ii. 782. 
of parotid, ii. 997. 
of penis, ii. 434. 
of periosteum, i. 1047. 
of pharynx, ii. 1005. 
of prostate, ii. 495. 
of retina, iii. 235. 
of sclerotica, iii. 218. 
of scrotum, ii. 518. 
of soft, palate, ii. 983. 
of spermatic cord, ii. 557. 
of stump, ii. 318. 
of synovial membranes, ii. 
137. 
of tendons, iii. 394. 
of testicle, ii. 581. 
of tongue, ii. 907. 
of ungual matrix, iii. 484. 
of urethra, ii. 459. 
of veins, i. 627. 
of vitreous humor, iii. 273. 
of vulvo-vaginal glands, ii. 
718. 
results of, i. 148. 
terminations of, i. 127. 
treatment of acute, i. 145. 
of chronic, i. 143. 
Inflammatory fever, i. 101, ii. 
385. 
fungoid neoplasm, iii. 649. 
Infraorbital nerve, stretching 
of, iii. 727. 
Ingrown toe-nail, iii. 486. 
Inguinal glands, inflamed, ii. 
469, 739, iii. 512, 526. 
hernia, i. 584. 
hydrocele, ii. 577. 
Injections for cancer, iii. 676. 
In-knee, iii. 353. 
Innominate artery, aneurism of, 
i. 690. 
ligation of, i. 738. 
bones, fracture of, i. 924. 
Insects in ear, iii. 304. 
wounds by, i. 289. 
Instruments, disinfection of, ii. 
262. 
Intercostal artery, ligation of, 
i. 406. 
Intermediate union, i. 319. 
Internal carotid artery, aneu- 
rism of, i. 702. 
ligation of, i. 755. 
hemorrhage, i. 297. 
iliac, ligation of, i. 778. 
mammary artery, ligation of, 
i. 763. 
piles, i. 541. 
urethrotomy, ii. 490. 
Interrupted sutures, i. 246. 
Intestines, fistula in, i. 462. 
foreign bodies in, i. 484. 
mortification of, i. 192, 380. 
obstruction of, i. 481. 
rupture of, i. 442. 
sloughing of, i. 380. 
strangulation of, i. 463, 483. 
sutures in, i. 447. 
syphilis of, iii. 551. 
wounds of, i. 444. 
with protrusion, i. 446. 
I Intracapsular fractures, i. 978, 
982, 984. 
Intracranial abscess, 328. 
aneurism, i. 707. 
| extravasations, i. 351. 
i Intraorbital aneurism, i.,709. 
: Intra-thoracic cesophagotomy, 
ii. 1029. 
I Intra uterine amputation, ii. 
326. 
dislocations, ii. 33. 
fractures, i. 341. 
Intubation, iii. 41, 43. 
| Intussusception of intestines, i. 
; 481. 
Invagination of intestines, i. 
481. 
| Inversion of eyelids, iii. 157. 
of uterus, ii. 763. 
Involucrum, i. 1063. 
Iridectomy, iii. 224. 
Irideremia, iii. 219. 
Irido-choroiditis, iii. 228. 
Irido-cyclitis, iii. 228. 
Iridodesis, iii. 226. 
Iridodialysis, iii. 227. 
j Iridodonesis, iii. 220. 
Iris, affections of, iii. 219. 
operations on, iii. 224. 
tremulous, iii. 220. 
tumors of, iii. 223. 
Iritis, iii. 221. 
sequels of, iii. 223. 
I syphilitic, iii. 548, 569, 573. 
Irrigation in compound luxa- 
tions, ii. 29, 120. 
in inflammation, i. 47, 129, 
544. 
of wounds, i. 303. 
Irritable bladder, ii. 475. 
in female, ii. 828. 
joints, ii. 133. 
rectum, i. 516. 
testicle, ii. 595. 
ulcer, i. 177. 
Ischaemia, iii. 235. 
Ischiatic aneurism, i. 779. 
dislocations, ii. 93. 
hernia, i. 606. 
Ischio-rectal abscess, i. 535, ii. 
818. 
Ischium, bursa over, iii. 402. 
fractures of, i. 968. 
Isinglass plaster, i. 245. 
Issues, i. 147. 
Italian rhinoplasty, iii. 138. 
Itching of anus, i. 509. 
of vulva, ii. 724. 
J. 
Jaw, cramp of, ii. 38. 
diseases of, ii. 946. See Max- 
illa. 
dislocations of, ii. 34. 
excision of, ii. 965. 
fracture of lower, i. 879. 
of upper, i. 875. 
noisy movements of, ii. 37. 
Joints, amputation at, ii. 338, 
342, 346, 358, 365, 372. 
anchylosis of, ii. 140, 147. 
cartilage, degeneration in, ii. 
147. 
contusions of, ii. 131. 
diseases of, ii. 127. 
dropsy of, ii. 138. 
excision of, ii. 206. 
false, i. 824. 
fibroid formations in, ii. 147. 
hysterical, ii. 203. 
inflammation of, ii. 137, 150. 
involved in fractures, i. 820. 
irritable, ii. 133. 
movable bodies in, ii. 127. 
nervous disease of, ii. 203. 
osteo-arthritis of special, ii. 
155. 
sprains of, ii. 131. 
strumous disease of, ii. 150, 
158. 
swollen after nerve - injury, 
iii. 411. 
wounds of, ii. 134. 
Jugular vein, arterio-venous 
aneurism of, i. 713. 
ligation of, i. 625. 
K. 
Keloid, i. 320, iii. 469, 603. 
Keratitis, iii. 204. 
interstitial, iii. 207. 
Keratoglobus, iii. 213. 
Kidney, ablation of, ii. 713. 
abscess of, ii. 701. 
anomalies of, ii. 696. 
calculus in, ii. 705. 
carcinoma of, ii. 710. 
cystic, ii. 70S. 774 
GENERAL INDEX. 
Kidney, dropsy of, ii. 703. 
floating or movable, i. 458, ii. 
696. 
hemorrhage from, ii. 708. 
inflamed, i. 460, ii. 698. 
operations on, ii. 713. 
parasites in, ii. 709. 
sarcoma of, ii. 713. 
syphilis of, iii. 561. 
tuberculosis of, ii. 710. 
wounds of, i. 458. 
Kneading in massage, iii. 741. 
Knee, amputation at, i. 314, ii. 
365. 
anchylosis of, ii. 145. 
disease of, ii. 186. 
dislocations of, ii. 28, 111, 115. 
excision of, i. 314, ii. 233. 
house-maid’s, iii. 398. 
osteo-arthritis of, ii. 156. 
shot wounds of, i. 313. 
Knee-cap, fractures of, i. 1012, 
1018. 
Knife, manner of using, ii. 261. 
Knock-knee, iii. 353. 
Knot, reef and surgeon’s, i. 235. 
Kolpokleisis, ii. 748. 
L. 
Labia majora, affections of, ii. 
'716. 
angeioma of, i. 624. 
Labial hernia, i. 606. 
Labyrinthic deafness, iii. 324. 
Lacerated wounds, i. 256, 610, 
ii. 424. 
Laceration of arteries, i. 797. 
of cervix uteri, ii. 762. 
of perineum, ii. 726. 
of urethra, ii. 440. 
Lachrymal fistula from wounds, 
i. 393. 
gland, affections of, iii. 170. 
removal of, iii. 172. 
passages, affections of, iii. 173. 
point, deviations of, iii. 173. 
obliteration of, iii. 175. 
probes, rules for passing, iii. 
173. 
sac, catarrh of, iii. 176. 
inflamed, iii. 175. 
Lacteal cysts, iii. 691. 
obstruction, iii. 695. 
Lactiferous cysts, iii. 591. 
Lagophthalmus, iii. 163. 
Laparo-elytrotomy, ii. 823. 
Laparotomy, i. 429, 445, 494. 
for diseased ovaries, ii. 785. 
for uterine fibroids, ii. 772. 
in extra-uterine foetation, ii. 
834. 
rules for, i. 429. 
statistics of, i. 493, 494. 
Laryngismus stridulus, iii. 54. 
Laryngitis, iii. 21. 
chronic, iii. 25. 
syphilitic, iii. 30. 
tuberculous, iii. 28. 
Laryngoscopy, iii. 19. 
Laryngotomy, iii. 68. 
divisions of, iii. 75. 
in retropharyngeal abscess, ii. 
1010. 
in throat erysipelas, ii. 412, 
1008. 
Laryngo-tracheitis, iii. 33. 
Laryngo-tracheotomy, iii. 83. 
Larynx, contusions of, i. 889. 
diseases of, iii. 17. 
electrization of, iii. 59. 
excisions of, iii. 72, 75. 
extirpation of, iii. 72. 
fistula in, i. 399, iii. 44. 
foreign bodies in, iii. 44. 
fracture of, i. 889. 
incisions into, iii. 68. 
necrosis of, i. 403. 
neurosis of, iii. 53. 
partial excision of, iii. 75. 
stricture of, iii. 42. 
syphilis of, iii. 546, 569. 
tumors of, iii. 60. 
malignant, iii. 70. 
treatment of, iii. 63, 71. 
wounds of, i. 394, 399, 400. 
Lateral curve of spine, ii. 860. 
lithotomy, ii. 666. 
Leech, artificial, i. 134. 
Leeching, i. 134. 
Leg, amputation of, i. 311, 314, 
ii. 362. 
curvatures of, iii. 361. 
excision of bones of, i. 315, ii. 
254. 
fractures of, i. 1023. 
wounds of, i. 310, 311, 313, 
613. 
Leiomyoma, iii. 606. 
Lepra of eyelid, iii. 169. 
of iris, iii. 223. 
of larynx, iii. 31. 
Leptothrix, iii. 180. 
Leucsemic retinitis, iii. 238. 
Leucocytes in inflammation, i. 
107, 121, 317. 
Leucoma, iii. 211. 
Lice on eyelids, iii. 157. 
Lids, ecchymosis of, i. 386, iii. 
151. 
Ligamentous union of fracture, 
i. 954, 979. 
Ligamentum patellae, bursa of, 
iii. 401. 
fracture of, ii. 110. 
Ligation, i. 234, 236, 700, 715. 
exposure of vessel in, i. 234. 
for aneurism, i. 662, 664, 669, 
694, 700, 715. 
on distal side of, i. 700. 
in cancer, iii. 677. 
of arteries, i. 234, 700, 715, 
734, ii. 313. 
of hemorrhoids, i. 545. 
of nerves, iii. 407. 
of special vessels, i. 734. 
abdominal aorta, i. 783. 
axillary, i. 764, 770. 
brachial, i. 770. 
carotid, common, i. 703, 
747. 
external, i. 749. 
internal, i. 755. 
dorsalis pedis, i. 792. 
epigastric, i. 778. 
facial, i. 753. 
femoral, i. 784. 
gluteal, i. 779. 
iliac, common, i. 779, 783. 
external, i. 776. 
internal, i. 778. 
innominate, i. 738. 
internal mammary, i. 763. 
ischiatic, i. 779. 
lingual, i. 751. 
Ligation, occipital, i. 754. 
peroneal, i. 790. 
radial, i. 772. 
subclavian, i. 756. 
temporal, i. 755. 
thyroid, inferior, i. 762. 
superior, i. 750. 
tibial, anterior, i. 791. 
posterior, i. 788. 
ulnar, i. 775. 
vertebral, i. 762. 
of veins, i. 625. 
subcutaneous, i. 622. 
Ligature, animal, i. 236, ii. 313. 
for hemorrhage, i. 232, ii. 313. 
metallic, i. 237. 
method of tying, i. 234. 
Lightning-stroke, ii. 423. 
Limb, artificial, ii. 327, 350, 365. 
mortified, ii. 411. 
Line of demarcation, i. 194, 
1063. 
Lingual abscess, ii. 909. 
artery, ligation of, i. 751. 
Lint, i. 52. 
Lip, angeioma of, i. 623. 
carbuncle on, ii. 892. 
deformities of, ii. 889, 897, 
903. 
epithelioma of, ii. 894. 
foreign bodies in, ii. 894. 
hair on female, ii. 891. 
hare-, ii. 897. 
hypertrophy of, ii. 890. 
restoration of lower, ii. 895. 
of upper, ii. 896. 
tumors of, ii. 892. 
ulcer of, ii. 890. 
wounds of, i. 388, ii. 891. 
Lipoma, article oir, iii. 597. 
of back, ii. 838. 
of conjunctiva, iii. 200. 
of eyelid, iii. 169. 
of larynx, iii. 63. 
of lip, ii. 894. 
of mamma, iii. 696. 
of scrotum, ii. 520. 
of tongue, ii. 911. 
of vulva, ii. 722. 
Lipomatous sarcoma, iii. 643. 
Listerism, i. 44. 
in amputations, compared 
with ordinary dressing, ii. 
315. 
in compound dislocations, ii. 
28, 29. 
in oophorectomy, ii. 785. 
in ovariotomy, ii. 807. 
Lister’s method of excision of 
wrist, ii. 221. 
Lithectasy, ii. 693. 
Lithiasis, iii. 203. 
Lithic acid calculus, ii. 623. 
Litholapaxy, ii. 657. 
Lithotomy, ii. 662. 
accidents during, ii. 676. 
following, ii. 679. 
after-treatment, ii. 675. 
bilateral, ii. 688. 
causes delaying extraction in, 
ii. 674. 
contra-indications for, ii. 665. 
in children, ii. 674. 
in female, ii. 693. 
urethral, ii. 694. 
lateral, ii. 666. 
median, ii. 684. 
medio-lateral, ii. 687. GENERAL INDEX. 
775 
Lithotomy, patient prepared for, 
ii. 665. 
recto-vesical, ii. 690. 
supra-pubic, ii. 690. 
vaginal, ii. 695. 
Lithotrity, ii. 651. 
cases suited for, ii. 653. 
complication in, ii. 660. 
in female, ii. 694. 
Liver, abscess of, i. 451. 
syphilis of, iii. 564, 573. 
wounds of, i. 451. 
Local anaesthetics, ii. 291. 
Lock-finger, iii. 375. 
Lockjaw, iii. 432. 
Longitudinal fractures, i. 798. 
Lordosis, ii. 868. 
Lumbar abscess, i. 158, ii. 872, 
875. 
colotomy, i. 499. 
hernia, i. 604. 
nephrectomy, ii. 714. 
Lung, hernia of, i. 415. 
syphilis of, iii. 548, 573. 
wounds of, i. 408. 
emphysema after, i. 409. 
Lupus of larynx, iii. 31. 
of nose, iii. 96. 
erythematosus, iii. 99. 
Luxations, ii. 17. See Disloca- 
tions. 
Lymph, i. 111. 
Lymphadenoid sarcoma, iii. 
639. 
Lymphadenoma of testes, ii. 
593. 
Lymphangiectasis, iii. 449. 
Lymphangiomata, article on, 
iii. 618. 
Lymphangitis, iii. 445. 
Lymphatics, affections of, iii. 
444. 
pus absorbed by, ii. 386. 
Lymph-glands, amyloid disease 
of, iii. 453. 
inflamed, iii. 451. 
syphilis of, iii. 564. 
Lymph-oedema, iii. 448. 
Lymphoma, article on, iii. 615. 
of tonsil, ii. 992. 
over parotid, ii. 999. 
Lymphorrhagia, iii. 449. 
Lymph-scrotum, ii. 524. 
Lymph - vessels, varicose, iii. 
448. 
wounds of, iii. 447. 
M. 
MacBride’s yoke, i. 502, 533. 
Macewen’s hernia operation, i. 
563. 
osteotomy, iii. 358. 
Mackintosh cloth, i. 48. 
Macrochilia, iii. 618. 
Macroglossia, iii. 618. 
Macromelia, iii. 618. 
Macrostoina, ii. 903. 
Madura foot, iii. 364. 
Maggots in wounds, i. 254. 
Malacosteon, i. 1077. 
Malar bone, fracture of, i. 877. 
Malarial influences, i. 30. 
Male, diseases of mamma of, iii. 
714. 
Malformations, chapter on, iii. 
332. 
Malformations of abdomen, i. 
553. 
of anus and rectum, i. 505. 
of auricle, iii. 299. 
of bladder, ii. 610. 
of head from effusion, ii. 885. 
of lips, ii. 889, 891, 897. 
of oesophagus and pharynx, 
ii. 1003. 
of palate, ii. 974. 
of urethra, ii. 450, 825. 
of vagina, ii. 732. 
Malignant pustule, i. 271. 
Malum senile coxae, ii. 154. 
Mamma, abnormalities of, iii. 
680. 
abscess of, iii. 687. 
cold, iii. 690. 
interlobular, iii. 688. 
post-, iii. 690. 
subcutaneous, iii. 688. 
adenoma of, iii. 700. 
affections of nipple of, iii. 680. 
anatomy of, iii. 679. 
atrophy of, iii. 683. 
bandage for, i. 62. 
carcinoma of, iii. 704. 
chronic tumor of, iii. 630. 
cysts of, iii. 691-695. 
excision, operation of, iii. 715. 
female, affections of, iii. 682. 
fibroma of, iii. 696. 
hyperaesthesia of, iii. 684. 
hypertrophy of, iii. 682. 
inflammation of, iii. 685. 
in mumps, ii. 997. 
lipoma of, iii. 696. 
male, diseases of, iii. 714. 
myxoma of, iii. 699. 
neuralgia of, iii. 684. 
sarcoma of, iii. 701. 
scirrhus of, iii. 705. 
syphilis of, iii. 564. 
Mammary artery, internal, liga- 
tion of, i. 763. 
gland, iii. 679. See Mamma. 
Mania a potu after fracture, i. 
821. 
after operations, ii. 278. 
Manipulation for aneurism, i. 
676, 700. 
for diagnosis of aneurism, i. 
656. 
for inflammation, i. 135, 147. 
Marriage, syphilis in relation 
to, iii. 575. 
Marshall Hall’s artificial respi- 
ration, iii. 88. 
Massage, article on, iii. 734. 
cases benefited by, iii. 736. 
compression in, iii. 742. 
directions for, iii. 736. 
divisions of, iii. 737. 
frictions in, iii. 739. 
in inflammation, i. 135. 
in joint-injury, ii. 133. 
in joint-neuroses, ii. 205. 
in spinal curvature, ii. 859. 
kneading in, iii. 741. 
modus operandi of, iii. 737. 
movements in, iii. 744. 
percussion in, iii. 743. 
rolling in, iii. 741. 
Masseur, qualifications for, iii. 
736. 
Mastitis, iii. 685. 
Mastoid disease, iii. 322. 
trephining in, iii. 323. 
Matrixitis, iii. 484. 
Maxilla, abscess of, ii. 950. 
anchylosis of, ii. 946. 
deformities of, ii. 946. 
excision of, ii. 965. 
inferior, diseases of, ii. 946. 
dislocation of, ii. 34. 
fracture of, i. 879. 
noisy movements of, ii. 37. 
resection of, ii. 967. 
tumors of, ii. 955. 
necrosis of, i. 392, 1061, ii. 
950. 
osteitis of, ii. 949. 
periostitis of, ii. 948. 
phosphor-necrosis of, ii. 951. 
superior, diseases of, ii. 957. 
excision of, ii. 970. 
fracture of, i. 875. 
tumors of, ii. 960. 
behind, ii. 974. 
osseous, ii. 964. 
Maxillae, excision of both, ii. 
972. 
Median laryngotomy, iii. 76. 
lithotomy, ii. 684. 
nerve, stretching of, iii. 730. 
Median ventral hernia, i. 604. 
Mediastinal wound, i. 422. 
Medullary cancer of mamma, 
iii. 707. 
Melanosis of skin, iii. 478. 
Melanotic carcinoma, iii. 671. 
of back, ii. 839. 
of breast, iii. 710. 
of rectum, i. 527. 
sarcoma, iii. 641. 
Membrana pupillaris remain- 
ing, iii. 219. 
tympani, affections of, iii. 
312. 
inflation of, iii. 295. 
Membranous stricture of ure- 
thra, ii. 477. 
Meningeal syphilis, iii. 557. 
Meningitis, i. 335, 367. 
spinal, ii. 846. 
Meningocele, ii. 886. 
Menses after spaying, ii. 792. 
retained, ii. 735. 
Mercurial glossitis, ii. 907. 
poisoning, ii. 1033. 
Metacarpal bones, amputation 
of, ii. 337. 
dislocation of, ii. 82. 
excision of, ii. 225. 
fracture of, i. 958. 
Metacarpo-phalangeal amputa- 
tion, ii. 335. 
Metallic ligature, i. 237. 
suture, i. 247. 
Metastasis in cancer, iii. 654. 
in inflammation, i. 127. 
Metatarsal bones, amputation 
of, ii. 353. 
dislocation of, ii. 126. 
excision of, ii. 260. 
fracture of, i. 1045. 
Metatarso-phalangeal amputa- 
tion, ii. 352. 
arthritis, ii. 194. 
Methylene bichloride, ii. 289. 
Mickulicz’s excision of foot, ii. 
361. 
Micrococci, i. 45, 154, 1060. 
Migration of leucocytes, i. 109. 
Millet-grains, iii. 588. 
over eyelids, iii. 168. 776 
GENERAL INDEX. 
Moles, i. 624, ii. 891, iii. 468. 
Mollities ossium, i. 1077. 
Molluscuin fibrosum, iii. 470. 
of eyelid, iii. 168. 
sebaceum, iii. 470. 
Morbus coxarius, ii. 162. 
Morplioea, iii. 470. 
Mortification, i. 189. 
acute, i. 193. 
amputation in, i. 196, 200, ii. 
296. 
chronic, i. 197, 200. 
dry, i. 197. 
hemorrhage in, i. 196. 
hospital, i. 201. 
of bone, i. 1060. 
of nose, iii. 95. 
of scrotum, ii. 519. 
of stump, ii. 318. 
phagedaenic, i. 201. 
senile, i. 197. 
Mother’s mark, i. 617, iii. 621. 
Mouth and foot disease from 
animals, i. 275. 
Movable bodies in joints, ii. 127. 
Movements in massage, iii. 744. 
Moxa, i. 147. 
Mucocele, iii. 176. 
Mucous cysts, iii. 590. 
membranes, syphilis of, iii. 
539. 
patches in child, iii. 571. 
of larynx, iii. 547. 
polypus of uterus, ii. 773. 
Mulberry calculus, ii. 637. 
Multilocular ovarian cysts, ii. 
793. 
Mumps, ii. 997. 
Murrain, i. 271. 
Muscae volitantes, iii. 275. 
Muscles, affections of, iii. 381. 
atrophy of, in club-foot, iii. 
340. 
bursae on crural, iii. 403. 
degeneration of, iii. 386. 
developed by massage, iii. 
744. 
dislocation of, ii. 67, iii. 393. 
inflammation of, iii. 384. 
neuralgia of, iii. 386. 
paralysis of laryngeal, iii. 56. 
pseudo - hypertrophic, iii. 
387, 440. 
parasites in, iii. 387. 
paresis of, iii. 384. 
rupture of, iii. 382. 
syphilis of, iii. 555. 
trichina in, iii. 388. 
tumors of, iii. 389. 
wounds of, iii. 381, 383. 
Musculo - cutaneous nerve, 
stretching of, iii. 730. 
Myalgia, iii. 386. 
spinal, ii. 842. 
Mycetoma of India, iii. 489. 
Mydriasis, iii. 220. 
Myelinic neuroma, iii. 622. 
Myelitis, spinal, ii. 846. 
Myeloid sarcoma, iii. 641. 
Myelo-sarcoma of jaw, ii. 960. 
Myodesopia, iii. 275. 
Myofibroma, uterine, ii. 766. 
Myoma, article on, iii. 605. 
of skin, iii. 479. 
of testicle, ii. 594. 
Myopia, iii. 278. 
Myosarcoma of vein, i. 631. 
Myosis, iii. 220. 
Myositis, iii. 384. 
Myotomy, ii. 866, 904, 977. 
Myriapod-wounds, i. 285. 
Myxoma, article on, iii. 619. 
glio-, iii. 648. 
of external auditory canal, iii. 
309. 
of larynx, iii. 62. 
of lip, ii. 893. 
of mamma, iii. 699. 
of muscle, iii. 389. 
of nerves, iii. 443. 
of vulva, ii. 723. 
Myxo-sarcoma, iii. 643. 
N. 
Naevus, article on, i. 615, iii. 
621. 
electrolysis for, iii. 724. 
maternal, i. 616,617, 620, 622. 
of auricle, iii. 303. 
of back, ii. 839. 
of eyelid, iii. 169. 
of gums, ii. 922. 
of iris, iii. 223. 
of lip, ii. 892. 
Nails, affections of, iii. 483. 
ingrown, of toe, iii. 486. 
Nasal bones, fracture of, i. 873. 
catarrh, iii. 108. 
extension of, iii. 115. 
passages, growths in, iii. 121, 
133. 
Naso-pharyngeal polypus, iii. 
126. 
electrolysis for, iii. 724. 
Nebula of cornea, iii. 211. 
Neck, dislocations of, ii. 41. 
nerves injured in, i. 401. 
wounds of, i. 394. 
gunshot, i. 400. 
Necrosis, amputation for, ii. 295. 
after catarrhal otitis, iii. 321. 
after compound fracture, i. 
821. 
article on, i. 1060. 
divisions of, defined, i. 1062. 
from face-injury, i. 392. 
humid, i. 1062. 
in stump, ii. 320. 
multiple, i. 1062. 
of cranial bones, i. 327. 
of jaws, ii. 950. 
of larynx, i. 403. 
of teeth, ii. 927. 
phosphor-, ii. 951. 
repair after, i. 1065. 
strumous, ii. 162. 
syphilitic, iii. 553, 572. 
treatment of, i. 1067. 
varieties of, i. 1062. 
Needles, i. 266. 
removal of, i. 267. 
Neoplasms, benign or typical, 
iii. 597. 
Nephrectomy, ii. 713. 
Nephritic retinitis, iii. 237. 
Nephritis, ii. 698. 
Nephrolithotomy, ii. 715. 
Nephrorrhaphy, ii. 713. 
Nephrotomy, ii. 713. 
Nerve-agency in inflammation, 
i. 94, 103, 125. 
Nerve-section, iii. 733. 
for elephantiasis, iii. 474. 
Nerve-stretching, article on, iii. 
727. 
for neuralgia, iii. 413. 
of anterior crural, iii. 732. 
of anterior tibial, iii. 732. 
of auricularis magnus, iii. 728. 
of external popliteal, iii. 731. 
of great occipital, iii. 729. 
of great sciatic, iii. 730. 
of infraorbital, iii. 727. 
of median, iii. 730. 
of musculo-cutaneous, iii. 730. 
of peroneal, iii. 731. 
of spinal accessory, iii. 729. 
of supraorbital, iii. 727. 
of ulnar, iii. 730. 
Nerve-tumor of skin, iii. 624. 
Nerves, affections of, iii. 405. 
atrophy of, iii. 439, 
bridging of, iii. 440. 
bulbous, ii. 317. 
cranial, injured, i. 366. 
central affections from pe- 
ripheral irritation of, iii. 
428. 
excision of, iii. 727, 733. 
healing of, iii. 408. 
injury of, evil effects from, iii. 
410. 
in fractures, i. 820. 
of special sense, iii. 408. 
ligation of, i. 234, iii. 407. 
optic, diseases of, iii. 242. 
puncture of, i. 613, iii. 408. 
spinal accessory, dividing or 
stretching of, iii. 380. 
tumors of, iii. 442. 
wounds of, i. 401, 612, iii. 407. 
Nervous delirium, ii. 377. 
disease of joints, ii. 203. 
dysphagia, ii. 1004. 
enlargement of parotid, ii. 
998. 
Neuralgia, article on, iii. 411. 
electricity in, iii. 723. 
from face-injury, i. 393. 
from scalp-wounds, i. 326. 
in Pott’s disease, ii. 873. 
muscular, iii. 386. 
of bladder, ii. 534. 
of mamma, iii. 684. 
of pharynx, ii. 1005. 
of stump, ii. 321. 
of testicle, ii. 595. 
of urethra, ii. 475. 
syphilitic, iii. 557. 
Neuritis, iii. 405. 
optic, iii. 242. 
Neuroma, article on, iii. 622. 
cutis, iii. 472, 624. 
nasal, iii. 133. 
treatment of, iii. 442. 
Neuroses, nasal, iii. 133. 
of bladder, ii. 534. 
of joints, ii. 203. 
of larynx, iii. 53. 
of oesophagus, ii. 1026. 
of pharynx, ii. 1003. 
Nictitation of eyelids, iii. 165. 
Nipple, abnormalities of, iii. 
680. 
eruptions on, iii. 682. 
fissure of, iii. 681. 
retracted, iii. 681. 
syphilis of, iii. 682. 
ulceration of, iii. 681. 
Nitrate of silver poisoning, ii. 
1033. GENERAL INDEX. 
777 
Nitrous oxide, ii. 2S9, 933. 
Nodes, syphilitic, i. 1048, iii. 
552. 
Non-lacteal cysts, iii. 692. 
Nose, affections of septum of, 
iii. 118. 
affections of soft parts of, iii. 
93. 
cavities of, affections of, iii. 
101. 
catarrh of, iii. 108. 
examination of, iii. 103. 
deformities of, ii. 902, iii. 92. 
foreign bodies in, iii. 105. 
fracture of, i. 873. 
neuroses of, iii. 133. 
operations to restore, iii. 136. 
parasites in, iii. 107. 
polypi in, iii. 121, 631. 
wounds of, i. 388. 
Nuck, canal of, i. 552. 
0. 
Oakum dressings, i. 53. 
Obstruction, lacteal, iii. 695. 
of intestines, i. 481. 
to tears, iii. 173. 
syphilitic, iii. 569. 
Obturator dislocations, ii. 98. 
hernia, i. 605. 
Occipital artery, ligation of, i. 
754. 
nerves, stretching of, iii. 729. 
Occipito-atloid joint, arthritis 
of, ii. 195. 
dislocations at, ii. 43. 
Odontalgia, ii. 929. 
Odontoid process, fracture of, i. 
868, ii. 44. 
Odontomes, ii. 937. 
(Edema, lymph, iii. 448. 
of conjunctiva, iii. 204. 
of eyelids, iii. 152. 
of larynx, iii. 23. 
of penis, ii. 424. 
of scrotum, ii. 517. 
of vulva, ii. 717. 
(Edematous ulcer, i. 178. 
(Esophagismus, ii. 1026. 
(Esophagostomy, ii. 1029. 
(Esophagotomy, ii. 1028. 
(Esophagus, affections of, ii. 
1002, 1014. 
diverticula in, ii. 1023. 
morbid growths of, ii. 1025. 
neuroses of, ii. 1026. 
stenosis of, ii. 1019. 
syphilis of, iii. 551. 
varices of, ii. 1024. 
wounds of, i. 394, 398, 428. 
Ogston’s osteotomy, iii. 358. 
Oidium albicans, ii. 910. 
Oil cysts, iii. 590. 
Oiled silk, i. 54. 
Olecranon, fracture of, i. 953, 
ii. 73. 
Omentum, strangulated, i. 581. 
wounds of, i. 442, 446. 
Onychia, iii. 484. 
Oophorectomy, ii. 785. 
Opacities of cornea, iii. 211. 
of vitreous humor, iii, 274. 
Open piles, i. 541. 
Operations, article on the man- 
agement of, ii. 268. 
Ophthalmia, catarrhal, iii. 186. 
exanthematous, iii. 194. 
gonorrhoeal, ii. 474, iii. 190. 
granular, iii. 194. 
neonatorum, iii. 188. 
phlyctenular, iii. 192. 
purulent, iii. 188. 
Ophthalmoscopy, iii. 146. 
Opisthotonus, iii. 432. 
Opium-poisoning, ii. 1033. 
Optic nerve, diseases of, iii. 242. 
Orbit, pulsating tumor of, i. 
710. 
Orchitis, article on, ii. 584. 
after gonorrhoea, ii. 469. 
after lithotomy, ii. 681. 
after lithotrity, ii. 661. 
after mumps, ii. 585. 
Organic stricture of urethra, 
ii. 478. 
Organization of clot, i. 216. 
Os calcis, dislocation of, ii. 124. 
excision of, ii. 257. 
fracture of, i. 1041. 
magnum, dislocation of, ii. 81. 
Ossa carpi, dislocations of, ii. 
81, 82, 124, 125. 
excisions of, ii. 257, 260. 
innominata, fractures of, i. 
965. 
Osseous anchylosis, ii. 140. 
Ossification of callus, i. 805. 
of choroid, iii. 233. 
Osteitis, article on, i. 1050. 
strumous, ii. 158. 
Osteo-arthritis, ii. 154. 
Osteoid sarcoma, iii. 643. 
Osteoma, article on, iii. 612. 
dentigerous, ii. 940. 
of jaw, lower, ii. 956. 
upper, ii. 964. 
of muscle, iii. 390. 
of nose, iii. 131. 
Osteomalacia, i. 1077. 
Osteomyelitis, i. 1056. 
in stump, ii. 320. 
Osteophytes, i. 1050. 
Osteoporosis, i. 1060, 1083. 
Osteo-sarcoma, iii. 612. 
Osteotomy for genu valgiyn, iii. 
358. 
subcutaneous, i. 849, ii. 145, 
184. 
Otalgia, iii. 329. 
Othaematoma, iii. 301. 
Out-knee, iii. 359. 
Ovarian artery, aneurism of, i. 
609. 
fistula, i. 476. 
tumors, ii. 793. 
carcinomatous, ii. 814. 
cystic, ii. 793. 
dermoid, ii. 813. 
enchondromatous, ii. 814. 
fibromatous, ii. 813. 
sarcomatous, ii. 814. 
treatment of, ii. 800. 
Ovariotomy, ii. 802. 
Ovaritis, ii. 782. 
Ovary, cysts of, ii. 793. 
dermoid, ii. 813. 
displaced, ii. 784. 
inflammation of, ii. 782. 
removal of, ii. 785. 
syphilis of, iii. 561. 
tumors of, ii. 793. 814. 
Overlapping toes, iii. 366. 
Oxalate of lime calculus, ii. 637. 
Oxalic acid poisoning, ii. 1034. 
Oxaluria, ii. 625. 
P. 
Pachydermia lymphangiectat- 
ica, ii. 525. 
Pads, surgical, i. 814, 815, 906. 
Pain in diagnosis, i. 39. 
Painful cicatrix, i. 320, ii. 417. 
subcutaneous tubercle, iii. 624. 
Palate, cleft, ii. 974, 979. 
hard, affections of, ii. 978. 
syphilis of, iii. 554. 
soft, or velum, affections of, 
ii. 983. 
Palmar abscess, i. 611. 
arch, i. 612. 
aneurism of, i. 718. 
fascia, i. 611. 
Palpebral abscess, iii. 154. 
Pancreas, syphilis of, iii. 564. 
wounds of, i. 456. 
Pannus crassus, iii. 205. 
herpeticus, iii. 193. 
tenuis, iii. 205. 
Panophthalmitis, iii. 231. 
Paper dressings, i. 53, 54, 815. 
Papillae of tongue, diseased, ii. 
908. 
Papilloma, article on, iii. 625. 
at anus, i. 509. 
nasal, iii. 132. 
of auricle, iii. 303. 
of bladder, ii. 547. 
of gum, ii. 922. 
of larynx, iii. 62. 
of lip, ii. 893. 
of tongue, ii. 910. 
of umbilicus, i. 475. 
of urethra, ii. 459. 
of vagina, ii. 737. 
Papulo squamous syphiloderm, 
iii. 533. 
Paracentesis abdominis, i. 478. 
pericardii, i. 426. 
thoracis, i. 419. 
tympani, iii. 318. 
Paralysis after spine-lesion, i. 
865, 871, ii. 43, 845, 854. 
dislocations from, ii. 19, 54. 
electricity in, iii. 721, 722. 
facial, i. 393, ii. 1001, iii. 722. 
from callus, i. 852. 
from fractures, i. 928. 
in diagnosis, i. 40. 
infantile, iii. 441. 
nutrition in, iii. 410. 
of bladder, ii. 540. 
of ciliary muscle, iii. 276. 
of deltoid muscle, ii. 53, iii. 
722. 
of laryngeal muscles, iii. 55. 
of oesophagus, ii. 1027. 
of pharynx, ii. 1004. 
of upper extremity, iii. 368. 
pseudo-hypertrophic, iii. 387, 
440. 
reflex, i. 40. 
scrivener’s, iii. 430. 
syphilitic, iii. 557. 
Paraphimosis, ii. 430. 
chancroid with, iii. 517. 
Parasites in bladder, ii. 538. 
in muscles, iii. 387. 
in nose, iii. 107. 
in oesophagus, ii. 1025. GENERAL INDEX. 
778 
Peroneus loijgus, bursa of, iii. 
403. 
Pes equinus, iii. 345. 
Pessaries, ii. 754. 
Phagedaena gangrasnosa, i. 201. 
Phagedaenic chancroid, iii. 515. 
wounds, i. 253. 
Phalanges, amputation of, ii. 
333, 352. 
dislocations of, ii. 28, 87. 
fractures of, i. 960, 1045. 
Pharyngitis, atrophic, ii. 1006. 
diphtheritic, ii. 1007. 
erysipelatous, ii. 1008. 
follicular, ii. 1006. 
Pbaryngo-oesophageal pouches, 
ii. 1023. 
Pharynx, affections of, ii. 1002. 
neurosis of, ii. 1003. 
syphilis of, iii. 551. 
wounds of, i. 394, 398. 
Phimosis, ii. 426. 
chancroid with, iii. 516. 
Phlebectasis, i. 631. 
Phlebitis, i. 627, ii. 384. 
chronic, i. 630. 
Phleboliths, i. 631. 
Phlegmon, ii. 397. 
Phlegmonous abscess, i. 101, ii. 
397. 
erysipelas, ii. 405r. 
Phlyctenular ophthalmia, iii. 
192. 
Phosphate of lime calculi, ii. 
638. 
Phosphatic urine, ii. 627. 
Phosphor-necrosis, i. 28, 1061, 
ii. 951. 
Phosphorus-poisoning, ii. 1033. 
Pia mater, clot in, i. 355. 
Pigmented retinitis, iii. 238. 
Piles, i. 540. 
diagnosis from fissure, i. 512. 
Piliferous cyst of eyelids, iii. 
168. 
of mamma, iii. 693. 
Pinguicula, iii. 200. 
Pityriasis capitis, iii. 483. 
Placenta, removal of, in extra- 
uterine pregnancy, ii. 834. 
Plaster-of-Paris dressing, i. 814, 
ii. 191, 235. 
jacket, ii. 878. 
Plasters as dressings, i. 244, 246, 
815. 
Plastic operation on cicatrix, ii. 
419. 
on lip, ii. 895. 
Pleurisy, traumatic, i. 416. 
Pleurosthotonus, iii. 432. 
Plexiform cylindrical neuroma, 
iii. 622. 
Plica polonica, iii. 483. 
Pneumatocele of scrotum, ii. 
517. 
Pneumocele, i. 415. 
Pneumonia after lung-injury, i. 
416. 
diagnosis from traumatic 
fever, ii. 394. 
Pneumothorax, i. 409, 415. 
Podelcoma, iii. 364. 
Poisoned wounds, i. 267. 
Poisoning by alkaloids, ii. 1034. 
by minerals, ii. 1033. 
Polish plait, iii. 483. 
Polyadenoid tumor of breast, 
iii. 700. 
Polydactylism, fingers, iii. 370. 
toes, iii. 365. 
Polypus, gelatinoid or soft, iii. 
620, 631. 
nasal, i. 875. 
fibrous, iii. 125. 
gelatinous, iii. 121, 631. 
naso-pharyngeal, iii. 126. 
electrolysis for, iii. 724. 
of bladder, ii. 547. 
of conjunctiva, iii. 201. 
of external auditory canal, iii. 
308. 
of oesophagus, ii. 1025. 
of rectum, i. 520, iii. 631. 
of tongue, ii. 912. 
of urethra, ii. 459. 
of uterus, ii. 773, iii. 631. 
Popliteal aneurism, i. 651, 730. 
artery, ligation of, i. 731, 787, 
788. 
bursa, iii. 402. 
nerve, stretching of, iii. 731. 
Porro operations, iii. 822. 
Porte-moxa, i. 148. 
Posterior tibial artery, ligation 
of, i. 788. 
Posthitis, ii. 425, 467. 
Post-mammary abscess, iii. 690. 
tumors, ii. 974. 
Post-mortem wounds, i. 268. 
Pott’s disease of spine, ii. 869. 
fracture, i. 1036, ii. 117. 
Pregnancy diagnosed from as- 
cites, i. 477. 
extra-uterine, ii. 829. 
Prepuce, deformities of, ii. 426. 
diseases of, ii. 424, 469. 
epithelioma of, ii. 432. 
Presbyopia, iii. 276. 
Pressure for aneurism, i. 662, 
669, 671, 674, 696, 705. 
Priapism, ii. 437. 
after spine-injury, ii. 856. 
in hydrophobia, i. 282. 
Procidentia uteri, ii. 753. 
Profunda femoris, aneurism of, 
i. 729. 
Prolapsus ani et recti, i. 516. 
vaginae, ii. 736. 
Proliferous cysts, iii. 596. 
Prostate, calculus in, ii. 505. 
diseases of, ii. 494. 
hypertrophy of, ii. 499. 
inflammation of, ii. 495. 
operations on, ii. 505. 
wounds of, i. 471. 
Prostatitis, ii. 495. 
Prostato-cystitis, ii. 468. 
Prostatorrhcea, ii. 498. 
Prostatotomy, ii. 505. 
Prostitution, iii. 577. 
Provisional callus, i. 803, 808. 
dressings, i. 78. 
Prurigo of scrotum, ii. 515. 
Pruritus ani, i. 509. 
vulvae, ii. 724. 
Psammoma, iii. 644. 
Pseudarthritis, ii. 203. 
Pseudarthrosis, i. 822. 
Pseudo-hypertrophic muscular 
paralysis, iii. 387, 440. 
Psoas abscess, i. 158, 597, ii. 
172, 702, 872. 
Psoriasis linguae, ii. 908. 
of nipple, iii. 682. 
syphilitic, iii. 533. 
Pterygium, iii. 197. 
Parasites in tonsil, ii. 985. 
on scrotum, ii. 516. 
on skin, iii. 479. 
pruritus vulvae from, ii. 724. 
vegetable, in ear, iii. 306. 
in mouth, ii. 910. 
Parasitic cysts, iii. 594. 
Paresis after luxations, ii. 21, 32. 
of ciliary muscle, iii. 275. 
of muscle, iii. 384. 
of neck of bladder, ii. 542. 
Paronychia, iii. 487. 
Parotid gland, accessory, ii. 999. 
diseases of, ii. 997. 
extirpation of, ii. 1000. 
nervous enlargement of, ii. 
998. 
tumors of, ii. 998. 
tumors over, ii. 999. 
Parotitis, ii. 997. 
Passive motion, ii. 28, 193, 212. 
synovitis, ii. 140. 
Patella, dislocations of, ii. 107. 
excision of, ii. 235, 253, 366. 
fractures of, i. 1012. 
non-union of, i. 841, 845. 
Patellae, tendo, bursa of, iii. 401. 
rupture of, iii. 393. 
Pelvic cellulitis, ii. 817. 
Pelvis, fractures of, i. 962. 
luxations of, ii. 87. 
wounds of, i. 466. 
Pemphigus, syphilitic, iii. 535. 
Penetrating wounds, i.451, ii. 66. 
Penis, amputation of, ii. 432. 
calcification of, ii. 437. 
diseases of integument of, ii. 
424. 
dislocation of, ii. 437. 
epithelioma of, ii. 432. 
fracture of, ii. 436. 
priapism of, ii. 437. 
warts on, ii. 438. 
wounds of, ii. 424, 438. 
Percussion in massage, iii. 743. 
Perforated intestines, i. 490. 
Peri-anal abscess, i. 535. 
Pericardium, syphilis of, iii. 562. 
tapping of, i. 426. 
wounds of, i. 422. 
Perichondritis of larynx, iii. 32. 
Pericaecal abscess, ii. 875. 
Perimetritis, ii. 817. 
Perineal hernia, i. 607. 
section, ii. 492. 
Perineo-anal and rectal fistula, 
i. 536. 
Perinephritic abscess, i. 460, ii. 
701. 
Perineum, bladder punctured 
through, ii. 513. 
lacerations of,-ii. 726. 
Periosteum, bone produced 
from, ii. 208. 
preservation of, ii. 186, 302. 
Periostitis, article on, i. 1047. 
of jaw, ii. 948. 
Peri-rectal abscess, i. 535. 
Peritonitis, acute, i. 484. 
after lithotomy, ii. 681. 
after ovariotomy, ii. 811. 
in hernia, i. 611. 
traumatic, i. 432. 
Peri-uterine hasmatocele, ii. 815. 
Pernio, ii. 420. 
Peroneal nerve, stretching of, 
iii. 731. 
Peroneo-tibial luxations, ii. 120. GENERAL INDEX. 
779 
Ptosis, iii. 165. 
electricity in, iii. 722. 
Ptyalism, ii. 947. 
Pubes, fracture of, i. 966. 
Pubic dislocations, ii. 100. 
Pudendal haematocele, ii. 717. 
hernia, i. 606. 
Pulley in fractures, i. 993. 
Pulp-cavity, tumors of, ii. 921. 
Pulsating tumors, i. 659, 710. 
Punctum lacrymale, deviations 
of, iii. 173. 
obliteration of, iii. 175. 
Puncture of bladder, ii. 513. 
of ovarian cysts, ii. 800. 
Punctured fractures of skull, i. 
343. 
wounds, i. 265, 430. 
Pupils, in spine-injury, i. 350, 
ii. 856. 
irregular, iii. 220. 
Purulent ophthalmia, iii. 188. 
Pus, article on, i. 150. 
in blood, ii. 387. 
in urine, ii. 619. 
Pustule, malignant, i. 271. 
Putrid ulcer, i. 201. 
Pyaemia after lithotrity, ii. 661. 
Pyaemic fever, ii. 385. 
Pyelitis, ii. 699. 
Pyocyanine, i. 152. 
Pyogenic membrane, i. 153. 
Pyonephritis, ii. 705. 
Pyonephrosis, ii. 701. 
Pyothorax, i. 411. 
Q. 
Quiet, its therapeutic value, i. 
128. 
Quilled sutures, i. 249. 
Quinia affecting the ears, iii. 
326, 328. 
in inflammation, i. 142. 
Quinsy, ii. 985. 
R. 
Rachitis, article on, i. 1073. 
Radial artery, ligation of, i. 772. 
Radio-carpal joint, excision of, 
ii. 220. 
Radio-humeral luxation, ii. 68. 
Radio-ulnar luxation, ii. 77. 
Radius, excision of, i. 310. 
fracture of, i. 937, 941. 
non-union in, i. 832, 841, 
843. 
Radius and ulna, excision of, ii. 
310. 
fracture of, i. 937, 941. 
luxation of, ii. 70. 
Rami, pubic, fracture of, i. 996. 
Ranuli, ii. 993. 
Rattlesnake-bites, i. 286. 
Rectocele, ii. 736. 
Recto-vesical fistula, ii. 536. 
lithotomy, ii. 690. 
Rectum, abnormities of, 504. 
abscess about, i. 535. 
cancer of, i. 526. 
dilated pouches of, i. 516. 
disease of, i. 505. 
excision of, i. 532. 
fistulas in, i. 536. 
foreign bodies in, i. 514. 
Rectum, instruments for, i. 503, 
510, 529, 544, 549, 964. 
irritable, i. 516. 
polypus of, i. 520, iii. 631. 
prolapse of, i. 516. 
stricture of, i. 524. 
ulcers of, i. 522. 
wounds of, i. 472. 
Recurrent roller, i. 76. 
Recurring fibroma of jaw, ii. 955. 
Redness, inflammatory, i. 96, 
105, 155. 
Redressement brusque, iii. 358. 
Redundant callus, i. 851. 
skin, iii. 469. 
Reef-knot, i. 235. 
Reel-foot, iii. 348. 
Reeves’s osteotomy, iii. 358. 
Refraction in eye, iii. 277. 
Refraeture of bones, i. 849. 
Renal calculus, ii. 705. 
carcinoma, ii. 710. 
colic, ii. 707. 
cysts, ii. 708. 
fistulse, i. 476. 
hmmaturia, ii. 708. 
parasites, ii. 709. 
tuberculosis, ii. 710. 
wounds, i. 458. 
Repair after excisions, ii. 208. 
in fractures, i. 801, 809. 
in ulceration, i. 173, 176. 
in wounds, i. 304. 
of bone, i. 805, 822. 
of cartilage, i. 809. 
Reptiles, wounds by, i. 284. 
Resection of bones and joints, ii. 
206. See Excisions. 
Respiration, artificial, iii. 88. 
electricity for, iii. 722. 
Respiratory anaesthesia, ii. 290. 
Retention cysts of breasts, iii. 
691. 
of menses, ii. 735. 
of urine, ii. 507. 
Retina, anaesthesia of, iii. 247. 
detached, iii. 239. 
diseases of, iii. 234. 
embolism in, iii. 250. 
inflammation of, iii. 2ii5. 
tumors of, iii. 241. 
Retinitis, iii. 235. 
albuminurica, iii. 237. 
diabetic, iii. 238. 
hemorrhagic, iii. 236. 
leucaemica,, iii. 238. 
nephritica, iii. 237. 
pigmentosa, iii. 238. 
syphilitic, iii. 238, 549. 
Retracted nipple, iii. 681. 
Retroclusion, i. 230, 562. 
Retroflexion of uterus, ii. 759. 
Retro-oesophageal abscess, ii. 
1018. 
Retropharyngeal abscess, ii. 
1008. 
goitre, iii. 503. 
Retroversion of uterus, ii. 755. 
Rhabdomyoma, iii. 606. 
Rheumatic iritis, iii. 222. 
Rheumatism, gonorrhoeal, ii. 
474. 
Rheumatismus deformans, ii. 
154. 
Rheumatoid arthritis, ii. 154. 
Rhigolene, ii. 292. 
Rhinitis, iii. 108. 
Rhinoliths, iii. 105. 
Rhinoplasty, iii. 136. 
Rhus dermatitis, iii. 463. 
Ribs, dislocation of, ii. 38. 
excision of, ii. 227. 
fracture of, i. 840, 891. 
Rickets, i. 1073. 
Rigors, urethral, ii. 444. 
Ringworm, iii. 479. 
Rodent ulcer of nose, iii. 98. 
of vagina, ii. 737. 
Roller bandage, i. 49, 53, 62, 64, 
243, 904. 
Rolling in massage, iii. 741. 
Ropy pus, i. 151. 
Round-celled sarcoma, iii. 637, 
639. 
of breast, iii. 703. 
Round ligament, hydrocele of, 
ii. 814. 
Round-shouldered, ii. 867. 
Rubber sutures, i. 249. 
“ Run-round,” iii. 484. 
Rupia, syphilitic, iii. 535. 
Rupture, i. 433. See Hernia. 
of aponeurosis, iii. 404. 
of axillary artery, ii. 64. 
of bladder, i. 468. 
of choroid, iii. 233. 
of intestines, i. 442, 574. 
of muscle, iii. 382. 
of nerves, iii. 428. 
of oesophagus, ii. 1017. 
of omentum, i. 442. 
of perineum, ii. 726. 
of sac in extra-uterine preg- 
nancy, ii. 835. 
of spleen, i. 445. 
of stomach, i. 440. 
of tendon, iii. 392. 
of thoracic duct, iii. 446. 
of uterus, ii. 836. 
S. 
Sabre-wounds, i. 315, 358. 
Sac, aneurismal, i. 648. 
hernial, i. 551, 563, 568. 
Saccharine urine, ii. 622. 
Sacer ignis, i. 271. 
Sacro-iliac arthritis, ii. 196. 
Sacro-rectal hernia, i. 607. 
Sacrum, fracture of, i. 962. 
tumors over, ii. 840. 
Salivary ealculus, ii. 998. 
cysts, iii. 590. 
fistula, i. 390, ii. 998. 
glands, diseases of, ii. 993. 
syphilis of, iii. 564. 
Salivation, treatment of, ii. 920. 
Sand-flea, iii. 480. 
Sanger operation, ii. 821. 
Sanguineous cysts, iii. 593. 
Sarcocele, syphilitic, ii. 586, iii. 
570. 
Sarcoma, adeno-, of submaxil- 
lary gland, ii. 995. 
alveolar, iii. 638. 
angeiolithic, iii. 644. 
article on, iii. 633. 
central, iii. 643. 
diagnosis of, iii. 647, 672. 
embryoplastic, iii. 637. 
endothelial, iii. 645. 
giant celled, iii. 641. 
glio-, iii. 648. 
lipomatous, iii. 643. 
lymphadenoid, iii. 639. 780 
GENERAL INDEX. 
Sarcoma, melanotic, iii. 641. 
myeloid, iii. 641. 
myxo-, iii. 643. 
of auricle, iii. 303. 
of back, ii. 839. 
of bladder, ii. 549. 
of choroid, iii. 234. 
of conjunctiva, iii. 202. 
of external auditory canal, iii. 
311. 
of gum, ii. 923. 
of iris, iii. 223. 
of jaw, lower, ii. 955. 
upper, ii. 960. 
of kidney, ii. 713. 
of mamma, iii. 701. 
of muscle, iii. 390. 
of nerves, iii. 443. 
of nose, iii. 133. 
of oesophagus, ii. 1025. 
of ovary, ii. 814. 
of parotid, ii. 999. 
of rectum, i. 527. 
of retina, iii. 241. 
of skin, iii. 478. 
of testicle, ii. 592. 
of tonsil, ii. 993. 
of uterus, ii. 779. 
osteo-, iii. 612. 
osteoid, iii. 643. 
prognosis in, iii. 646. 
round-celled or granulation, 
iii. 637. 
large, iii. 639. 
spindle-celled, iii. 640. 
large, iii. 641. . 
treatment of, iii. 648. 
Sartorius, bursa of, iii. 403. 
Scab, union under, i. 319. 
Scalds, ii. 412. 
of eyelids, iii. 152. 
of pharynx, ii. 1010. 
Scalp, injuries to, i. 322. 
wounds of, i. 323. 
Scaphoid bone, excision of, ii. 
260. 
luxation of, ii. 125. 
Scapula, dislocation of, ii. 50. 
excision of, ii. 248. 
fracture of, i. 911. 
Scarpa’s triangle, anatomy of, i. 
784. 
Scars, i. 320, ii. 416, 419. 
Sciatic nerve, stretching of, iii. 
730. 
Scirrhus, iii. 663. 
diagnosis of, iii. 668, 672. 
of mamma, iii. 705. 
of rectum, i. 527. 
of umbilicus, i. 476. 
Scleroderma, iii. 477. 
Sclerosis of bone, i. 1059. 
Sclerotica, alfections of, iii. 217. 
tumors of, iii. 219. 
Sclerotitis, iii. 218. 
Scorpion-bites, i. 285. 
Screatus, iii. 135. 
Scrivener’s palsy, iii. 430. 
electricity in, iii. 723. 
Scrofulous abscess, i. 165. 
joint-disease, ii. 150, 158. 
pus, i. 151. 
Scrotal calculus, ii. 520. 
hernia, i. 586. 
Scrotum, affections of, ii. 514. 
elephantiasis of, ii. 521. 
epithelioma of, ii. 525. 
hydrocele of, ii. 570. 
Scrotum, lymph-, ii. 524. 
tumors of, ii. 519. 
wounds of, ii. 514. 
Sebaceous cyst or tumor, iii. 587. 
of areola, iii. 682. 
of auricle, iii. 303. 
of back, ii. 839. 
of eyelids, iii. 168. 
of nose, iii. 95. 
of vulva, ii. 722. 
Second intention, union by, i. 
316, 319. 
sight, iii. 277. 
Secondary amputation, i. 305, 
312, ii. 297. 
cataract, iii. 267. 
hemorrhage, i. 253, 297, 304, 
ii. 320. 
shock, ii. 378. 
Semilunar bone, luxation of, ii. 
81. 
cartilages displaced, ii. 114. 
Seminal cysts, iii. 590. 
Semitendinous muscle, bursa of, 
iii. 403. 
Senile gangrene, i. 197. 
Sensitive callus, i. 852. 
cicatrix, ii. 417. 
stump, ii. 321. 
Sepsin, i. 46, 627. 
Septicaemia, ii. 385. 
Sequestra, i. 189, 1063. 
Sequestrotomy, i. 1068. 
Sheaths of tendons, alfections 
of, iii. 391. 
Shock, anaesthetics in, ii. 283. 
article on, ii. 376. 
from wounds, i. 262, 297, 306, 
822, ii. 414, 417, 810. 
nature of, ii. 380. 
secondary, ii. 378. 
Shortening in fracture, i. 799, 
847. 
Shoulder, amputation at, i. 307, 
ii. 346. 
arthritis of, ii. 199. 
osteo-, ii. 156. 
dislocations of, ii. 28, 46. 
excision of, i. 307, ii. 212. 
Sight, second, iii. 277. 
Silicate of soda dressing, i. 814. 
Silicious concretions, ii. 640. 
Silver-fork deformity, i. 946. 
Silvester’s artificial respiration, 
iii. 88. 
Simple dislocation, ii. 18. 
fracture, i. 796. 
Simulated blindness, iii. 249. 
Sinus in joints, ii. 152, 159, 167, 
178, 191. 
in wounds, i. 254. 
Skin, callous, iii. 464. 
eruptions in syphilis, iii. 531. 
redundancy of, iii. 469. 
tumors of, iii. 478. 
Skin-cancer, iii. 657. 
Skin-grafting, i. 185, ii. 419. 
Skull, fractures of, i. 331. 
depressed, i. 339, 341. 
separation of sutures of, i. 
343. 
trephining of, i. 375. 
Slings, i. 60, 904, 925. 
Slough, i. 189. 
after wounds, i. 259, 261. 
in erysipelas, ii. 405. 
Sloughing ulcer, i. 178, ii. 920. 
Snake-bites, i. 286. 
Sneezing, iii. 134. 
Snider bullet, i. 292. 
Soft carcinoma, iii. 667. 
of breast, iii. 707. 
corns, iii. 465. 
palate, cleft in, ii. 974. 
Sounding for stone, ii. 642. 
Spanish windlass, i. 223. 
Spasm of ciliary muscle, iii. 276. 
of larynx, iii. 54. 
of oesophagus, ii. 1026. 
of orbicularis of eye, iii. 164. 
of stump, ii. 318. 
of upper extremity, iii. 368. 
Spasmodic croup, iii. 54. 
stricture, oesophageal, ii. 1019. 
rectal, i. 524. 
urethral, ii. 476. 
Spaying women, ii. 785. 
Speculum, anal, i. 503. 
vaginal, ii. 751. 
Spermatic cord, affections of, ii. 
557. 
haematocele of, ii. 561. 
hydrocele of, ii. 559. 
syphilis of, iii. 561. 
tumors of, ii. 558. 
Spermatorrhoea, ii. 604. 
Spermatozoa in urine, ii. 621. 
Sphacelus, i. 189. 
Sphincter ani, electricity in pa- 
resis of, iii. 722. 
Sphincterismus of anus, i. 511. 
Spica rollers, i. 69, 71, 72, 87. 
Spider-bites, i. 284. 
Spina bifida, ii. 851. 
Spinal abscess, ii. 837, 872, 881. 
accessory nerve, stretching of, 
iii. 729. 
column, defects of, ii. 851. 
fractures of, i. 862. 
sprains of, ii. 849. 
cord, compression of, ii. 845. 
concussion of, ii. 842. 
meningitis of, ii. 846. 
myelitis of, ii. 846. 
syphilis of, iii. 558. 
tumors of, ii. 848. 
wounds of, ii. 844, 846. 
injuries, ii. 848. 
myalgia, ii. 842. 
Spindle-celled sarcoma, iii. 640. 
large, iii. 641. 
of breast, iii. 702. 
Spine, arched, in coxalgia, ii. 
163. 
curvatures of, ii. 859. 
anterior, ii. 868. 
lateral, ii. 860. 
posterior, ii. 866. 
posterior angular, ii. 869. 
dislocations of, ii. 40. 
fractures of, i. 862. 
injuries of, ii. 848. 
phenomena following, ii. 
854. 
osteo-arthritis of, ii. 155. 
Pott’s disease of, ii. 869. 
sprains of, ii. 840, 849. 
tumors of, ii. 840. 
wounds of, i. 862. 
Splay-foot, iii. 363. 
Spleen, syphilis of, iii. 564, 573. 
wounds of, i. 456. 
Splenectomy, i. 456. 
Splints, i. 813. 
Agnew’s, i. 930. 
Ahl’s, i. 813. GENERAL INDEX. 
781 
Splints, Amesbury’s, i. 1002. 
angular, i. 924, 927, ii. 73, 
119. 
Ashhurst’s, ii. 236. 
author’s, for fractured patella, 
i. 930. 
Bavarian, i. 1034. 
Bean’s, i. 886. 
Bell’s, i. 1002. 
Bond’s, i. 950, ii. 77, 79. 
Boyer’s, i. 1004. 
Desault’s, i. 1004. 
Dupuytren’s, i. 1037. 
felt, i. 813, 935. 
for adducted thighs, iii. 353. 
for deformity after fracture, 
i. 848. 
for fracture of inferior max- 
illa, i. 886. 
for fracture of phalanges, i. 
961. 
for fractures of carpus and 
metacarpus, i. 960. 
for talipes, iii. 342. 
Gunning’s, i. 885. 
Hartshorne’s, i. 1006. 
Hays’s, i. 950. 
Hodge’s, i. 1006. 
Horner’s, i. 1007. 
interdental, i. 885. 
James’s, i. 1002. 
Kingsley’s, i. 885. 
lateral, ii. 116. 
Liston’s, i. 1003, 1031. 
Malgaigne’s, i. 1031. 
McIntyre’s, i. 1031, ii. 30. 
Nelaton’s, i. 949. 
night, for talipes, iii. 342. 
obtuse-angled, ii. 69, 169. 
of binders’ board, ii. 86. 
Packard’s, i. 1012, ii. 29, 236. 
palmar, ii. 28, 81, 222, 225. 
Physick’s, i. 1043. 
Hutchinson’s modification 
of, i. 1005. 
Pott’s, i. 1043. 
Price’s, ii. 236. 
right-angled, ii. 69. 
rubber, i. 885. 
Smith’s anterior wire, i. 997. 
steel, in coxalgia, ii. 175. 
straight, ii. 77, 80. 
tin, i. 812. 
in talipes, iii. 342. 
vulcanized rubber, i. 885. 
walking, for coxalgia, ii. 175. 
wire, i. 813, 997. 
wooden slat, i. 813. 
zinc, i. 812. 
Spongy osteoma, iii. 614. 
Spontaneous aneurism, i. 647. 
Sprains, ii. 131. 
of spine, ii. 840. 
Spray apparatus, i. 49. 
Spurious cicatrization, i. 292. 
Squamous epithelioma, iii. 660. 
Squint-eye, iii. 180. 
Stains of conjunctiva, iii. 204. 
Stammering, ii. 904. 
of bladder, ii. 511. 
Staphyloma after chorio-reti- 
nitis, iii. 231. 
of cornea, iii. 213. 
of sclerotica, iii. 217. 
posterior, iii. 217. 
Staphylorraphy, ii. 975. 
Stasis, i. 107. 
Steatoma, iii. 588. 
Steatoma of nose, iii. 95. 
Stellate fracture, i. 797, 917. 
Stenosis of larynx and trachea, 
iii. 42. 
of nares, iii. 92. 
of oesophagus, ii. 1019. 
of pharynx, ii. 1012. 
of vagina, ii. 733. 
Stercoraceous fistula, i. 476. 
vomiting, i. 482. 
Sterility, ii. 603. 
Sterno-clavicular arthritis, ii. 
198. 
Sterno-mastoid muscle, tenot- 
omy of, iii. 379. 
Sternum, excision of, ii. 226. 
fractures of, i. 896. 
luxation of, ii. 39. 
Stings of insects, i. 289. 
on eyelids, iii. 152. 
Stocking, elastic, i. 636. 
Stomach, fistula of, i. 461. 
fluids thrown into, ii. 1034. 
foreign bodies in, i. 434. 
poisons in, ii. 1033. 
syphilis of, iii. 551. 
wounds of, i. 440. 
Stomach-pump, use of, ii. 1034. 
Stone in bladder, ii. 629. 
Strabismus, convergent, iii. 180. 
divergent, iii. 184. 
electricity for, iii. 722. 
Strangulated hernia, i. 567, 583. 
Strangulation of intestines, i. 
483. 
Strangury, ii. 528. 
Stricture of intestine, i. 485. 
of larynx and trachea, iii. 42. 
of oesophagus, ii. 1019. 
of rectum, i. 524, 530. 
of tear-duct, iii. 176. 
of urethra, ii. 476. 
of vagina, ii. 734. 
Strongylus gigas, ii. 709. 
Strumous joints, ii. 150, 158. 
nasal catarrh, iii. 110. 
orchitis, ii. 587. 
ulcer of tongue, ii. 910. 
Strychnia-poisoning, ii. 1034. 
Stump, atfections of, ii. 3J8. 
conical, ii. 321. 
structure of, ii. 317. 
Stye, iii. 153. 
Styloid process of ulna, fracture 
of, i. 957. 
Styptics, i. 220, 390. 
Subastragaloid amputation, ii. 
358. 
dislocation, ii. 123. 
Subclavian artery, aneurism of, 
i. 703. 
ligation of, i. 756. 
wounds of, i. 396, 427. 
Subclavicular dislocation, ii. 54. 
Subcoracoid dislocation, ii. 54, 
63. 
Subcutaneous ligation of veins, 
i. 222. 
osteotomy, i. 849, ii. 145, iii. 
358. 
tenotomy, iii. 334. 
urethrotomy, ii. 494. 
wounds, i. 256. 
Subglenoid dislocation, ii. 53. 
Sublingual gland, diseases of, ii. 
993. 
Submaxillary gland, diseases of, 
ii. 995. 
Submaxillary gland, removal 
of, ii. 996. 
Subperiosteal excision, ii. 242. 
Subpubic dislocation, ii. 102. 
Subspinous dislocation, ii. 55. 
Sugar in urine, ii. 622. 
Suicidal wounds, i. 394, 397. 
Sulphuric acid poisoning, ii. 
1033. 
Sunburn, ii. 423. 
Superior maxilla, diseases of, ii. 
957. 
fracture of, i. 875. 
laryngotomy, iii. 77. 
thyroid, ligation of, i. 750. 
Supernumerary bladder, ii. 610. 
digits, ii. 296, iii. 370. 
testicle, ii. 568. 
Suppuration, article on, i. 150. 
constitutional signs of, i. 156. 
divisions of, i. 158. 
of bone, i. 1054. 
of cornea, iii. 206. 
of stump, ii. 318. 
Supra-cotyloid luxation, ii. 102. 
Supraorbital nerve, stretching 
of, iii. 727. 
Supra-pubic lithotomy, ii. 690, 
695. 
Suprarenal capsule, syphilis of, 
iii. 562, 573. 
wounds of, i. 458. 
Surgical diagnosis, i. 25. 
diseases of women, ii. 716. 
dressings, i. 52. 
engine, i. 1070. 
fever, ii. 384. 
Suspended animation, article on, 
iii. 84. 
Suspensory bandage, i. 77, 88. 
Sustentaculum tali, fracture of, 
i. 1044. 
Sutures, i. 246. 
cranial, i. 343. 
Symblepharon, iii. 161. 
Syncope, ii. 267, 288. 
treatment of, ii. 273. 
Synostosis, ii. 141. 
Synovial cysts, iii. 591. 
membrane, fibroids of, ii. 147. 
Synovitis, ii. 137. 
massage in false, iii. 744. 
varieties of, ii. 137-140. 
Syphilides, iii. 531. 
Syphilis, iii. 504. 
acquired, iii. 506. 
aneurism from, i. 653. 
bubo from, iii. 512, 526. 
cerebral, iii. 557. 
chancres from, iii. 507, 518. 
constitutional, iii. 529. 
gumma in, iii. 545. 
in relation to marriage, iii. 
575. 
infantile or hereditary, iii. 
570. 
late, iii. 545. 
local, iii. 518. 
mucous patches in, iii. 539. 
nodes iD, iii. 552. 
of air-passages, iii. 30, 546. 
of alimentary tract, ii. 910, 
iii. 551. 
of bones and periosteum, ii. 
954, iii. 551, 569, 572. 
of ear, iii. 550, 574. 
of eye, iii. 222, 238, 548, 
573. 782 
GENERAL INDEX. 
Syphilis of genito-urinary or- 
gans, ii. 586, iii. 559. 
of glandular organs, iii. 564. 
of locomotor system, ii. 140, 
iii. 551. 
of mucous membranes, iii.539. 
of nervous system, iii. 557. 
of nipple, iii. 682. 
of olfactory apparatus, iii. 
100, 550/554. 
of skin appendages, iii. 537. 
of special organs, iii. 545. 
of vascular system, iii. 562. 
paralysis from, iii. 557. 
secondary, iii. 529. 
skin eruptions in, iii. 531. 
stages or order of, iii. 506. 
treatment of early, iii. 541. 
of infantile, iii. 574. 
of late, iii. 566. 
tubercular, iii. 537, 553, 569. 
virus of, iii. 509. 
warts from, ii. 438, 721. 
Syphilization, iii. 541. 
Syphilodermata, iii. 531-537. 
Syringes, i. 490, 504. 
hypodermic, i. 142, 677. 
Syringing the ear, iii. 290. 
T. 
Taliacotian rhinoplasty, iii. 138. 
Talipes, iii. 337. 
calcaneo-valgus, iii. 351. 
calcaneus, iii. 346. 
equino-valgus, iii. 351. 
equino-varus, iii. 348. 
equinus, iii. 345. 
excision of tarsus for, iii. 350. 
pathological changes in, iii. 
340. 
treatment of, iii. 340. 
operative, iii. 343. 
valgus, iii. 350. 
varus, iii. 348. 
Tampon for nares, iii. 102. 
for rectum, i. 510. 
in lithotomy, ii. 678. 
Tanjore pill, i. 288. 
Tapping of abdomen, i. 478. 
of bladder, ii. 512. 
of chest, i. 419. 
of ovarian cysts, ii. 800. 
Tarantula-bites, i. 285. 
Tarso-metatarsal arthritis, ii. 
194. 
Tarsus, amputations at, ii. 353. 
excision of, ii. 255. 
fracture of, i. 1040. 
luxations of, ii. 121. 
Taxis for inverted uterus, ii. 
764. 
in hernia, i. 571, 591, 598, 
602. 
mal-use of, i. 583. 
T-bandages, i. 56. 
Tear-duct, stricture of, iii. 176. 
Tears, overflow of, iii. 173. 
Teeth, affections of, ii. 923. 
caries of, ii. 927. 
cysts with, ii. 938. 
exostosis on, ii. 937. 
extraction of, ii. 931. 
Hutchinson’s syphilitic, iii. 
572. 
wired in fracture, i. 884. 
Telangiectasis, i. 617* iii. 621. 
Telangiectatic carcinoma, iii. 
669. 
of breast, iii. 708. 
Temporal artery, ligation of. i. 
755. 
Temporo-maxiliary joint, osteo- 
arthritis of, ii. 156. 
Tendo Achillis, division of, iii. 
335, 346. 
patellae, bursa of, iii. 401. 
rupture of, iii. 393. 
Tendons, affections of, iii. 391. 
contracted, in stump, ii. 323. 
syphilis of, iii. 555. 
Tenotomy, iii. 332. 
of sterno-inastoid, iii. 379. 
of tendo Achillis, iii. 335, 346. 
Tent, i. 52. 
Testis, affections of, ii. 567. 
congenital defects of, ii. 567. 
extirpation of, ii. 598. 
fungus of, ii. 689. 
haematocele of, ii. 579. 
hydrocele of, ii. 570 
inflammation of, ii. 581. 
in gonorrhoea, ii. 469. 
irritable, ii. 595. 
syphilis of, iii. 559. 
tumors of, ii. 590. 
Tetanus after burns, ii. 415. 
after injury, i. 259, 298, 375. 
after operations, i. 668, ii. 279. 
article on, iii. 431. 
mortality in, iii. 435. 
nerve-stretching for, iii. 417. 
treatment of, iii. 438. 
Thanatophidia, i. 286. 
Thecitis, i. 259, ii. 274, iii. 394. 
Thermometry, i. 36, 101. 
Thigh, amputation of, ii. 368. 
dislocation of, ii. 89. 
excision of, ii. 253. 
fracture of, i. 971. 
Thighs, adduction of, iii. 352. 
flexion of, iii. 353. 
Thoracentesis, i. 419. 
Thoracic aneurism, i. 686, 690. 
duct, dilatation of, iii. 447. 
irregularities of, iii. 444. 
rupture of, iii. 446. 
wounds of, i. 428, iii. 446. 
Thorax, fistula of, i. 422. 
wounds of, i. 404. 
Thrombosis, i. 190, 628, 645. 
causing pyaemia, ii. 387. 
Thrombus as a hsemostatic, i. 
215. 
pudendal, ii. 717. 
vascularization of, i. 110. 
Thrush, ii. 910. 
Thumb, amputation of, ii. 336. 
bursa on, iii. 400. 
dislocation of, ii. 83. 
excision of, ii. 225. 
Thyro-arytenoid muscles, pa- 
ralysis of, iii. 56. 
Thyroid cartilage, operations 
on, iii. 68, 76. 
wounds of, i. 889. 
dislocations, ii. 98. 
gland, affections of, iii. 490. 
carcinoma of, iii. 503. 
extirpation of, iii. 499. 
hernia, i. 605. 
Thyroiditis, suppurative, iii. 
491. 
Thyrotomy, iii. 76. 
Tibia, excision of, ii. 254. 
fractures of, i. 1032. 
with fibula, i. 1023. 
Tibial nerve, stretching of, iii. 
732. 
Tibio-femoral dislocation, ii. 
111. 
Tinea circinata, iii. 479. 
Tinnitus aurium, iii. 327. 
gastric, iii. 328. 
Toe-nail, ingrown, iii. 486. 
Toes, deformities of, ii. 296, iii. 
365. 
dislocation of, ii. 126. 
excision of, ii. 260. 
fracture of, i. 1045. 
Tongue, affections of, ii. 904. 
amputation of, ii. 916. 
angeioma of, i. 624. 
tumors of, ii. 910. 
wounds of, ii. 908. 
Tongue-tie, ii. 904. 
Tonsil, affections of, ii. 985. 
excision of, ii. 989. 
hypertrophy of, ii. 987. 
tumors of, ii. 992. 
Tonsillitis, ii. 985. 
Toothache, ii. 929. 
Torsion of artery, i. 226, 230. 
Torsoclusion, i. 230. 
Torticollis, iii. 376. 
electricity for, iii. 722. 
from shot wounds, i. 403. 
nerve-operations for, iii. 380. 
posterior, iii. 379. 
tenotomy for, iii. 379. 
Tourniquet applied, i. 735. 
Trachea, diseases of, iii. 17. 
foreign bodies in, iii. 44. 
fractures of, i. 889. 
stricture of, iii. 42. 
syphilis of, iii. 547. 
tumors of, iii. 70. 
wounds of, i. 394. . 
Tracheotomy, article on, iii. 78. 
for foreign bodies, iii. 49. 
for laryngeal cancer, iii. 71. 
in croup, iii. 36. 
laryngo-, iii. 83. 
Trachoma, iii. 194. 
Transfusion, i. 239, ii. 382. 
Traumatic aneurism, i. 683. 
delirium, ii. 377. 
fever, i. 101, 195, ii. 384. 
infective, ii. 383. 
Tremulous iris, iii. 220. 
Trephining for epilepsy, i. 375. 
for fractured skull, i. 361. 
for osteomyelitis, i. 1058. 
the mastoid process, iii. 323. 
Trichiasis, iii. 155. 
Trichina spiralis in man, iii. 
388. 
Trigonocephalus-wounds, i. 286. 
Trismus, iii. 432. 
nascentium, iii. 434. 
Trochanter major, excision of, 
ii. 253. 
fractures of, i. 985. 
Trochanteric bursa, iii. 402. 
Trusses for hernia, i. 555. 
hemorrhoidal, i. 544. 
Tubal dropsy, ii. 812. 
Tube for intubation, iii. 41, 43. 
Tube-casts in urine, ii. 620. 
Tubercle, anatomical, i. 271. 
of bladder, ii. 550. 
of ovary, ii. 814. GENERAL INDEX. 
783 
Tubercle, painful subcutaneous, 
iii. 624. 
Tubercular laryngitis, iii. 28. 
orchitis, ii. 587. 
syphilis, iii. 537, 553, 569. 
ulcer of tongue, ii. 910. 
Tuberculosis of choroid, iii. 
232. 
of retina, iii. 242. 
renal, ii. 710. 
Tuberculous abscess, i. 165. 
Tubular adenoma, iii. 631. 
epithelioma, iii. 663. 
Tumid gums, ii. 919. 
Tumors, article on, iii. 579. 
benign, iii. 585, 597. 
blood, i. 371. 
classification of, iii. 580, 585. 
adenoma, iii. 629. 
angeioma, i. 615, iii. 621. 
carcinoma, iii. 650. 
cystic, iii. 585. 
dentigerous, ii. 940. 
enchondroma, iii. 607. 
epithelioma, iii. 657. 
erectile, iii. 621. 
fatty, i. 158, 589, 597, 600, 
619. 
fibroma, iii. 600. 
glioma, iii. 648. 
inflammatory fungoid, iii. 
649. 
lipoma, iii. 597. 
lymphangioma, iii. 618. 
lymphoma, iii. 615. 
myoma, iii. 605. 
myxoma, iii. 619. 
neuroma, iii. 622. 
osteoma, iii. 612. 
papilloma, iii. 625. 
sarcoma, iii. 633. 
scirrhus, iii. 663. 
diagnosis from abscess, i. 158. 
from aneurism, i. 659. 
from hernia, i. 589, 597, 
600. 
differences between benign 
and malignant, iii. 580. 
of antrum, ii. 960. 
of auricle, iii. 301. 
of bladder, ii. 546. 
of choroid, iii. 233. 
of conjunctiva, iii. 200. 
of cornea, iii. 216. 
of external auditory canal, 
iii. 308. 
of eyelids, iii. 167. 
of frontal sinus, iii. 118. 
of iris, iii. 223. 
of jaw, lower, ii. 955. 
osseous, ii. 964. 
upper, ii. 960. 
of larynx, iii. 60. 
of lip, ii. 892. 
of mamma, iii. 691. 
of muscle, iii. 389. 
of nerves, iii. 442. 
of ovary, ii. 793. 
of palate, hard, ii. 979. 
soft, ii. 983. 
of parotid gland, ii. 998. 
of pharynx, ii. 1013. 
of retina, iii. 241. 
of scalp, puffy, i. 330. 
of sclerotica, iii. 219. 
of scrotum, ii. 519. 
of skin, iii. 478. 
of spermatic cord, ii. 558. 
Tumors of spinal cord, ii. 848. 
of teeth, ii. 937. 
of tongue, ii. 910. 
of tonsil, ii. 992. 
of trachea, iii. 70. 
of urethra, ii. 458. 
of uterus, ii. 766. 
origin of, iii. 582. 
osseous, of nose, iii. 131. 
over parotid gland, ii. 999. 
post-maxillary, ii. 974. 
Tunica vaginalis testis, haema- 
tocele of, ii. 579. 
hydrocele of, ii. 570. 
Tuning-fork in deafness, iii. 
892. 
Tutamina, diseases of, iii. 161. 
Twist, intestinal, i. 482. 
Twisted sutures, i. 248. 
Tympanum in ear-disease, iii. 
315. 
incision of, iii. 318. 
paracentesis of, iii. 318. 
Tympany, bowel tapped for, i. 
491. 
Typhlitis, i. 495. 
Typical tumors, iii. 597. 
U. 
Ulceration, i. 169. 
concealed, i. 169. 
of anus and rectum, i. 522. 
of bladder, ii. 532, 647. 
of cicatrices, i. 319. 
of nipple, iii. 681. 
phagedaenic, ii. 825, iii. 515. 
repair in, i. 173, 176. 
syphilitic, iii. 517, 547. 
Ulcers, article on, i. 175. 
bone, i. 1050. 
caloric, ii. 419. 
carious, i. 1050. 
chronic, i. 180. 
concealed, i. 169. 
hypopyon, iii. 210. 
of cornea, iii. 208. 
of lip, ii. 890. • 
of nose, rodent, iii. 98. 
syphilitic, iii. 100. 
of soft palate, ii. 983. 
of tongue, ii. 909. 
of tonsil, ii. 991. 
perforating nasal septum, iii. 
120. 
perforating, of foot, iii. 365. 
rodent, of nose, iii. 98. 
of vagina, ii. 737. 
skin-grafting for, i. 175. 
sloughing, of gums, ii. 920. 
syphilitic, of nose, iii. 100. 
varicose, i. 182, 635. 
vicarious, i. 181. 
Ulcus ulcerans, iii. 98. 
Ulna, dislocation of, ii. 70. 
excision of, ii. 252. 
fracture of, i. 937, 951. 
Ulnar artery, ligation of, i. 
775. 
nerve, stretching of, iii. 730. 
Umbilical hernia, i. 599. 
Umbilicus, diseases of, i. 387. 
Undescended testis, i. 589, ii. 
568. 
Ungual matrix, corneous growth 
from, iii. 485. 
Ungual matrix, inflammation 
of, iii. 484. 
phalanx, excision of, ii. 225. 
Unilocular ovarian cyst, ii. 793. 
Union of wounds, i. 316. 
Ununited fractures, i. 882. 
Upper extremity, paralysis of, 
iii. 368. 
rachitic curvatures of, iii. 
368. 
spasm of, iii. 368. 
Uranoplasty, ii. 979. 
Urates in urine, ii. 623. 
Ureter, calculi in, ii. 684. 
wounds of, i. 459. 
Urethra, abscess around, ii. 
468. 
false passages in, ii. 440, 
487. 
female, affections of, ii. 825. 
fistula of, ii. 446. 
foreign bodies in, ii. 453. 
inflammation of, ii. 459. 
laceration of, ii. 440. 
malformations of, ii. 450. 
neuralgia of, ii. 475. 
rupture of, ii. 481. 
stricture of, article on, ii. 
476. 
electrolysis for, iii. 724. 
tumors of, ii. 458. 
wounds of, ii. 439. 
Urethral chill, ii. 485. 
fever, ii. 444, 660. 
fistula, ii. 446. 
hemorrhoids, ii. 826. 
lithotomy, ii. 694. 
Urethritis in female, ii. 825. 
non-specific, ii. 459. 
specific, ii. 460. 
Urethrocele, ii. 827. 
Urethroplasty, ii. 449. 
Urethro-rectal fistula, ii. 449. 
Urethrotomy, external, ii. 492. 
internal, ii. 490. 
subcutaneous, ii. 494. 
Urethro- vaginal fistula, ii. 743. 
Uric acid, ii. 623. 
Urinary calculus, ii. 629. 
concretions, ii. 640. 
fistula at navel, i. 476. 
Urine, albumen in, ii. 618. 
article on, ii. 615. 
bile in, ii. 623. 
blood in, ii. 619. 
deposits in, ii. 623. 
incontinence of, ii. 543. 
infiltration of, i. 470. 
pus in, ii. 619. 
retention of, ii. 507. 
spermatozoa in, ii. 621. 
sugar in, ii. 622. 
suppression of, ii. 444, 661, 
681. 
tube-casts in, ii. 620. 
Utero-vesical fistula, ii. 749. 
Uterus, affections of, ii. 750. 
anteversion of, ii. 758. 
elongated cervix of, ii. 780. 
extirpation of, ii. 780. 
flexions of, ii. 759. 
haematocele around, ii. 815. 
inversion of, ii. 763. 
lacerated cervix of, ii. 762. 
polypus of, ii. 773, iii. 631. 
procidentia of, ii. 753. 
retroversion of, ii. 755. 
rupture of, ii. 836. 784 
GENERAL INDEX. 
Uterus, syphilis of, iii. 561. 
tumors of, ii. 766. 
Uvula, elongation and hyper- 
trophy of, ii. 981. 
excision of, ii. 982. 
oedema of, ii. 981. 
V. 
Vagina, affections of, ii. 732. 
discharges from, in children, 
ii. 738. 
epithelioma of, ii. 737. 
fistulae in, ii. 743. 
prolapse of, iii. 736. 
tumors of, ii. 737. 
Vaginal hernia, i. 606. 
lithotomy, ii. 695. 
spaying, ii. 785. 
Vaginismus, ii. 725. 
Vaginitis, ii. 738, 740. 
gonorrhoeal, ii. 738. 
Varicelliform syphilide, iii. 534. 
Varices, i. 631. See Varix. 
Varicocele, ii. 562. 
diagnosis from hernia, i. 485. 
Varicose aneurism, i. 615, 647, 
684. 
lymph-vessels, iii. 448. 
ulcer, i. 182, 635. 
veins, i. 631. 
of labia, ii. 720. 
of scrotum, ii. 516. 
Varix, i. 631. 
aneurismal, i. 615, 647, 684. 
of stump, ii. 323. 
arterial, i. 615. 
capillary, i. 120, 617. 
lymph-, iii. 448. 
of bladder, ii. 537. 
of conjunctiva, iii. 203. 
of oesophagus, ii. 1024. 
of saphena magna, i. 597. 
Vascular cysts, iii. 593. 
enlargement of thyroid, iii. 
492. 
growths of conjunctiva, iii. 
203. 
of retina, iii. 242. 
of urethra, ii. 459. 
Vas deferens, anomalies of, ii. 
567. 
rupture of, ii. 557. 
Veins, affections of, i. 624. 
air in, i. 395, 626. 
inflammation of, i. 627. 
varicose, i. 631, ii. 516, 720. 
Velpeau bandage, i. 78, 904. 
Velum palati, affections of, ii. 
983. 
Venesection, i. 133, 137, ii. 265. 
Venomous snakes, i. 286. 
Venous angeiomata, i. 619, 623. 
cysts, iii. 591. 
hemorrhage, i. 675. 
obstruction, ii. 159. 
Ventral hernia, i. 604. 
Vermale’s amputation, ii. 304. 
Verruca, iii. 466. 
microgenica, i. 271. 
Vertebrae, bursa over, ii. 840. 
dislocations of, ii. 40. 
fractures of, i. 862. 
necrosis of, ii. 871. 
Vertebral artery, aneurism of, i. 
707. 
Vertebral artery, ligation of, i. 
762. 
Vertigo, aural, iii. 327. 
Vesical calculus, ii. 629. 
catarrh, ii. 528. 
hemorrhage, ii. 537. 
neurosis, ii. 534. 
wounds, i. 468. 
Vesico-uterine fistula, ii. 749. 
Vesico-utero-vaginal fistula, ii. 
750. 
Vesico-vaginal fistula, ii. 740. 
operation for, ii. 744. 
Vesicular syphiloderm, iii. 534. 
Vibration of brain, i. 344. 
Vicious union in fractures, i. 
846. 
Villous growths of urethra, ii. 
459. 
polypus of rectum, i. 520. 
Viper-wounds, i. 286. 
Viscera, wounds of abdominal, 
i. 440. 
Vitiligo, iii. 482. 
Vitreous humor, diseases of, iii. 
273. 
Volar artery, aneurism of, i. 718. 
Volvulus, i. 482, 580. 
Vomiting, ear-, iii. 329. 
from anaesthetics, ii. 286, 288. 
rupture of gullet during, ii. 
1017. 
Vulva, affections of, ii. 717. 
pruritus of, ii. 724. 
tumors of, ii. 722. 
Vulvo-vaginal glands, inflamed, 
ii. 718. 
W. 
Waldau cataract operation, iii. 
266. 
Wandering cells, i. 108. 
needles, i. 266. 
spleen, i. 456. 
Warts, iii. 466. 
of anus, i. 509. 
of auricle, iii. 303. 
of conjunctiva, iii. 201. 
on eyelid, iii. 169. 
on labia, ii. 721. 
on nose, iii. 93. 
on penis, ii. 438. 
syphilitic, of larynx, iii. 30. 
Weak ankles, iii. 362. 
Webbed fingers, iii. 371. 
toes, iii. 365. 
Wen, iii. 588. 
White swelling, ii. 186. 
Whitlow, iii. 487. 
Wild hairs, iii. 155. 
Windage of balls, i. 295. 
Windpipe, opening of, iii. 75. 
Wire ligatures, i. 237. 
Wiring of teeth, i. 884. 
Wisdom-teeth, ii. 928, 947. 
Wolfe cataract operation, iii. 
267. 
Woman, bubo in, iii. 513. 
chancroid in, iii. 517. 
surgical diseases of, ii. 716. 
Worm, Guinea-, iii. 480. 
Wounds, i. 214. 
after-treatment of, i. 251. 
approximation of, i. 243. 
arrow-, i. 364. 
by insects, i. 289. 
Wounds, by serpents, i. 286. 
complications of, i. 251. 
contused, i. 259, 261, 263. 
dissection, i. 268. 
erysipelas caused by, iii. 457. 
foreign bodies in, i. 241. 
gunshot, i. 302. 
healing of, i. 304, 316. 
hemorrhage from, i. 214, 297. 
incised, i. 254. 
inflamed, i. 251. 
lacerated, i. 259, 611. 
of abdomen, i. 430, 444. 
of anus, i. 472. 
of aponeuroses, iii. 404. 
of arm, i. 610. 
of arteries, i. 638. 
of back, ii. 837. 
of bladder, i. 468. 
of chest, i. 404, 426. 
of clitoris, ii. 723. 
of cornea, iii. 215. 
of diaphragm, i. 407. 
of eyelids, iii. 152. 
of face, i. 386, 888. 
of femur, i. 613. 
of frontal sinus, iii. 117. 
of gall-bladder, i. 450. 
of hand, i. 310, 610. 
of head, i. 356. 
of heart, i. 422. 
of intestines, i. 446. 
of joints, ii. 134. 
of knee, i. 313. 
of labia, ii. 716. 
of lip, i, 388, ii. 891. 
of liver, i. 450. 
of lungs, i. 408. 
of lymph-vessels, iii. 447. 
of mediastinum, i. 422. 
of muscles, iii. 381. 
of nails, iii. 483. 
of neck, i. 394. 
of nerves, i. 612, iii. 407. 
of nose, iii. 101. 
of oesophagus, i. 394, 398, 428, 
ii. 1017. 
of pancreas, i. 364. 
of pelvis, i. 466. 
of penis, ii. 424, 438. 
of pharynx, ii. 1010. 
of prostate, i. 471. 
of rectum, i. 472. 
of scalp, i. 323. 
of sclerotica, iii. 217. 
of scrotum, ii. 514. 
of soft palate, ii. 983. 
of spermatic cord, ii. 557. 
of spinal cord, ii. 844, 846. 
of spleen, i. 455. 
of stomach, i. 440. 
of tendons, iii. 391. 
of thoracic duct, i. 428, iii. 
446. 
vessels, i. 426. 
of tongue, ii. 908. 
of ureter, i. 457. 
of veins, i. 624. 
poisoned, i. 267. 
post-mortem, i. 208. 
punctured, i. 265. 
sabre-, i. 315. 
sinuses and fistulae in, i. 254. 
subcutaneous, i. 256, iii. 
334. 
sutures in, i. 246. 
treatment, i. 43, 219, 238, 251, 
259. GENERAL INDEX. 
785 
Wounds, union of, i. 316. 
Wrist, amputation at, ii. 338. 
dislocation of, ii. 78. 
excision of, i. 310, ii. 220. 
strumous arthritis of, ii. 
202. 
Wrist-drop after fracture, i. 852, 
928. 
due to callus, i. 852. 
Wry-neck, iii. 376. 
after shot wounds, i. 403. 
Wutzer’s hernia operation, i. 
558. 
X. 
Xanthic oxide, ii. 637. 
Xerophthalmia, iii. 199. 
Xerosis, iii. 199. 
Y. 
Yaws, iii. 477. 
Yellow-jacket, sting of, i. 289. 
Yielding bones, genu valgum 
from, iii. 355. 
Y ligament of hip, ii. 91. 
Youatt on hydrophobia, i. 279, 
283. 
Z. 
Zinc chloride in asepsis, i. 47. 
splints, i. 813. 
Zonular cataract, iii. 254. 
treatment of, iii. 270. 
Zoogloea, i. 45. 
Zygomatic arch, fracture of, i. 
877, 878. 
THE END. 
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